Current issues in the management of endometrial cancer

From molecular pathogenesis to therapy: Unraveling non-coding RNAs/DNMT3A axis in human cancers

Cancer is a comprehensive classification encompassing more than 100 forms of malignancies that manifest in diverse tissues within the human body. Recent studies have provided evidence that aberrant epigenetic modifications are pivotal indicators of cancer. Epigenetics encapsulates DNA methyltransferases as a crucial class of modifiers. DNMTs, including DNMT3A, assume central roles in DNA methylation processes that orchestrate normal biological functions, such as gene transcription, predominantly in mammals. Typically, deviations in DNMT3A function engender distortions in factors that drive tumor growth and progression, thereby exacerbating the malignant phenotype of tumors. Consequently, such abnormalities pose significant challenges in cancer therapy because they impede treatment efficacy. Non-coding RNAs (ncRNAs) represent a group of RNA molecules that cannot encode functional proteins. Recent investigation attests to the crucial significance of regulatory ncRNAs in epigenetic regulation. Notably, recent reports have illuminated the complex interplay between ncRNA expression and epigenetic regulatory machinery, including DNMT3A, particularly in cancer. Recent findings have demonstrated that miRNAs, namely miR-770-5p, miR-101, and miR-145 exhibit the capability to target DNMT3A directly, and their aberration is implicated in diverse cellular abnormalities that predispose to cancer development. This review aims to articulate the interplay between DNMT3A and the ncRNAs, focusing on its impact on the development and progression of cancer, cancer therapy resistance, cancer stem cells, and prognosis. Importantly, the emergence of such reports that suggest a connection between DNMT3A and ncRNAs in several cancers indicates that this connecting axis offers a valuable target with significant therapeutic potential that might be exploited for cancer management.

Risk stratification of endometrial cancer and lymph node metastases prediction using 18F-FDG PET/CT: role of metabolic tumor volume and total lesion glycolysis

Background

Endometrial cancer is the commonest gynecologic malignancy. Pelvic lymph node metastasis is considered one of its most important prognostic factors. Surgery is considered the most important and effective treatment, still there is controversy about indication and necessity of pelvic lymph node dissection. 18F-fluorodeoxyglucose positron emission tomography/computed tomography is investigated in his study to evaluate its value in preoperative detection of lymph node metastases and risk stratification of endometrial cancer.

Results

Reviewing the records of 33 women with endometrial cancer, all 18F-FDG PET/CT studied indices, SUVmax, SUVmean, MTV and TLG, mean difference was statistically significant in all the studied risk categories (tumor grade, Myometrial invasion, lymphovascular space invasion, tumor stage, and risk stratification). SUVmax and TLG showed highest area under the curve for detection of Myometrial invasion > 50% (AUC = 0.911) with cut-off value of SUVmax > 14.55 showing 88.89% sensitivity and 86.67% specificity, and TLG > 192.653 having 88.89% sensitivity and 80% specificity. TLG showed highest AUC (0.889 and 0.921) for detection of LVSI and LNMs with 100% sensitivity and 66.67% specificity for cut-off value > 179.374 and 88.89% sensitivity and 83.33% specificity for cut-off value > 249.366, respectively. Concerning risk stratification of EC, SUVmax and TLG showed highest AUC (0.839) with cut-off value > 14.55 showing 77.27% sensitivity and 90.91% specificity, and > 192.653 having 77.27% sensitivity and 81.82% specificity, respectively.

Conclusion

The results of this study suggest that 18F-FDG PET/CT is a very valuable tool for prediction of lymph node metastases and risk stratification in endometrial cancer patients. Applying TLG cutoff values increases the accuracy and preoperative diagnosis of lymph node metastases which aids in sparing women with low-risk early stage EC unnecessary surgical risk and morbidity of lymphadenectomy.

KLF3 and PAX6 are candidate driver genes in late-stage, MSI-hypermutated endometrioid endometrial carcinomas

Endometrioid endometrial carcinomas (EECs) are the most common histological subtype of uterine cancer. Late-stage disease is an adverse prognosticator for EEC. The purpose of this study was to analyze EEC exome mutation data to identify late-stage-specific statistically significantly mutated genes (SMGs), which represent candidate driver genes potentially associated with disease progression. We exome sequenced 15 late-stage (stage III or IV) non-ultramutated EECs and paired non-tumor DNAs; somatic variants were called using Strelka, Shimmer, SomaticSniper and MuTect. Additionally, somatic mutation calls were extracted from The Cancer Genome Atlas (TCGA) data for 66 late-stage and 270 early-stage (stage I or II) non-ultramutated EECs. MutSigCV (v1.4) was used to annotate SMGs in the two late-stage cohorts and to derive p-values for all mutated genes in the early-stage cohort. To test whether late-stage SMGs are statistically significantly mutated in early-stage tumors, q-values for late-stage SMGs were re-calculated from the MutSigCV (v1.4) early-stage p-values, adjusting for the number of late-stage SMGs tested. We identified 14 SMGs in the combined late-stage EEC cohorts. When the 14 late-stage SMGs were examined in the TCGA early-stage data, only Krüppel-like factor 3 (KLF3) and Paired box 6 (PAX6) failed to reach significance as early-stage SMGs, despite the inclusion of enough early-stage cases to ensure adequate statistical power. Within TCGA, nonsynonymous mutations in KLF3 and PAX6 were, respectively, exclusive or nearly exclusive to the microsatellite instability (MSI)-hypermutated molecular subgroup and were dominated by insertions-deletions at homopolymer tracts. In conclusion, our findings are hypothesis-generating and suggest that KLF3 and PAX6, which encode transcription factors, are MSI target genes and late-stage-specific SMGs in EEC.

Clinical pathological characteristics and survival of high-grade endometrioid carcinoma

OBJECTIVE

The molecular features of high-grade endometrioid carcinoma (HGEC) are more akin to nonendometrioid high-grade carcinoma (NEHC). This study aims to explore whether HGEC also has similar clinical pathology and prognosis similar to NEHC.

METHODS

Using the SEER database (Surveillance, Epidemiology, and End Results), a retrospective study of the clinical-pathological data and prognosis was carried out.

RESULT

(1) Compared with LGEC (low-grade endometrioid carcinoma), HGEC patients were older with larger tumor size and a higher proportion of stage III-IV disease. However, the young had a lower proportion of stage III-IV disease than NEHC. (2) Postoperative pathological examination revealed that the positive rate of peritoneal cytology, pelvic lymph nodes and para-aortic lymph nodes in HGEC were significantly higher than LGEC, but lower than NEHC. LGEC, HGEC, and NEHC, all showed distant organ metastases such as brain metastases, bone metastases, liver metastases, and lung metastases. Notably, the metastasis rates between HGEC and NEHC were not significantly different but were higher than LGEC. (3) The five-overall survival rates of LGEC, HGEC, and NEHC were 95.1%, 73.2%, and 54.8%, respectively. Notably, the survival rates decreased significantly in stage IV. There were no significant differences between HGEC and NEHC in stage IV (p = 0.665) and both were associated with worsened survival. Also, HGEC survival prognosis was similar to NEHC.

CONCLUSION

HGEC presents mixed or overlapping clinical-pathological features of NEHC. Therefore, based on the unique pathological and prognostic features, HGEC could be classified as an intermediate between LGEC and NEHC.

Pathology findings among women with alterations in uterine bleeding patterns in cameroon

PURPOSE

Endometrial cancer is on the rise in high-income countries but it has not been adequately studied in low-and-middle income countries especially in sub-Saharan Africa (SSA), likely due to scarce pathology facilities. The purpose of this study was to characterize and quantify the prevalence of endometrial hyperplasia or cancer in a cohort of women with abnormal uterine bleeding (AUB) who underwent endometrial biopsy in Cameroon.

METHODS

We designed a cross-sectional study using medical records to characterize women who underwent endometrial biopsy in the Cameroon Baptist Convention Health Services (CBCHS) from 2008 to 2019. Pathologic diagnoses were classified as either endometrial hyperplasia, endometrial cancer, or no endometrial hyperplasia/cancer. We reported the overall prevalence of endometrial hyperplasia or cancer. Bivariate analyses compared patient characteristics between women with endometrial cancer, endometrial hyperplasia, and neither.

RESULTS

The average age was 46.2 years and women had an average of 5.1 parity. We found that, 61 [(36.7% of 166 women; 95% CI (27.6-47.0%)] had endometrial hyperplasia or cancer. There were no cases of hyperplasia with atypia and 13 women had endometrial cancer. The remainder were comprised of benign or infectious pathologic findings. In bivariate analysis, mean ages were statistically different among the three groups (hyperplasia, cancer, and no hyperplasia/cancer), p < 0.001, and women with cancer had the highest age. Parity was statistically significantly different among the three groups (p = 0.002) and women with endometrial cancer had higher parity.

CONCLUSION

We found that just over 1 in 3 women with AUB who underwent endometrial biopsy at a health system in SSA were found to have pathologic findings of endometrial hyperplasia or cancer, with no cases of hyperplasia with atypia. Women with endometrial cancer had higher mean age and parity.

Comparison of Different Lymph Node Staging Schemes for Predicting Survival Outcomes in Node-Positive Endometrioid Endometrial Cancer Patients

Objective: To compare the prognostic predictive performance of six lymph node (LN) staging schemes: American Joint Committee on Cancer (AJCC) N stage, number of retrieved lymph nodes (NRLN), number of positive lymph nodes (NPLN), number of negative lymph nodes (NNLN), lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) among node-positive endometrioid endometrial cancer (EEC) patients. Methods: A total of 3,533 patients diagnosed with node-positive EEC between 2010 and 2016 from the Surveillance, Epidemiology, and End Results (SEER) database were retrospectively analyzed. We applied X-tile software to identify the optimal cutoff value for different staging schemes. Univariate and multivariate Cox regression models were used to assess the relationships between different LN schemes and survival outcomes [disease-specific survival (DSS) and overall survival (OS)]. Moreover, Akaike information criterion (AIC) and Harrell concordance index (C-index) were used to evaluate the predictive performance of each scheme in both continuous and categorical patterns. Results: N stage (N1/N2) was not an independent prognostic factor for node-positive EEC patients based on multivariate analysis (DSS: p = 0.235; OS: p = 0.145). Multivariate model incorporating LNR demonstrated the most superior goodness of fit regardless of continuous or categorical pattern. Regarding discrimination power of the models, LNR outperformed other models in categorical pattern (OS: C-index = 0.735; DSS: C-index = 0.737); however, LODDS obtained the highest C-index in continuous pattern (OS: 0.736; DSS: 0.739). Conclusions: N stage (N1/N2) was unable to differentiate the prognosis for node-positive EEC patients in our study. However, LNR and LODDS schemes seemed to have a better predictive performance for these patients than other number-based LN schemes whether in DSS or OS, which revealed that LNR and LODDS should be more helpful in prognosis assessment for node-positive EEC patients than AJCC N stage.

Upregulation of Serum lncRNA DLEU1 Predicts Progression of Premalignant Endometrial Lesion and Unfavorable Clinical Outcome of Endometrial Cancer

OBJECTIVE

Long non-coding RNAs (lncRNAs) play a critical role in tumorigenesis. Upregulation of lncRNA deleted in lymphocytic leukemia 1 (DLEU1) has been reported in endometrial cancer (EC) tissues. This prospective study aimed to determine the potential clinical significance of serum lncRNA DLEU1 in EC.

METHODS

The serum lncRNA DLEU1 level was detected in EC patients, patients with endometrial hyperplasia and healthy controls by reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Then its clinical value in EC was further evaluated.

RESULTS

Our results demonstrated that serum lncRNA DLEU1 levels were significantly increased in patients with EC, and serum lncRNA DLEU1 showed good performance for discriminating EC patients from patients with endometrial hyperplasia and healthy controls. In addition, EC patients with advanced clinicopathological features had higher circulating lncRNA DLEU1 level than those with favorable clinical characteristics. Moreover, EC patients in the high serum lncRNA DLEU1 group suffered worse overall survival and disease-free survival than those in the low serum lncRNA DLEU1 group. Furthermore, multivariate cox regression analysis displayed that the serum lncRNA DLEU1 served as an independent prognostic factor for EC.

CONCLUSIONS

Collectively, our study suggests that serum lncRNA DLEU1 is a novel and promising biomarker for prognostic estimation of EC.

Efficacy and Toxicity of Adjuvant Therapies for High-Risk Endometrial Cancer in Stage I-III: A Systematic Review and Network Meta-Analysis

Background

The use of adjuvant therapy for high-risk endometrial cancer patients (HREC) in International Federation of Gynecology and Obstetrics (FIGO) stage I–III remains debatable. This network meta-analysis was conducted to compare and rank adjuvant therapies based on efficacies and toxicities to facilitate clinical decision-making and further research.

Material/Methods

We searched 3 databases – PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials – from inception to December 9, 2019. Only randomized controlled trials that compared any of these adjuvant therapies (pelvic radiotherapy, vaginal brachytherapy, chemotherapy, and chemoradiotherapy) with each other or surgery alone were included. The network meta-analysis was performed in a frequentist framework using Stata software 15.0.

Results

Fourteen RCTs with 5872 participants were eligible. No significant difference between treatments was observed in 5-year overall survival (OS) or distant metastasis. Compared with surgery alone, adjuvant pelvic radiotherapy plus chemotherapy (pelvic RT-CT) prolonged 5-year progression-free survival (PFS) and pelvic radiotherapy (pelvic RT) (RR=0.61, 95% CI 0.39–0.96; RR=0.779, 95% CI 0.63–0.95). Compared with surgery alone, pelvic RT, the combination of pelvic RT and vaginal brachytherapy (pelvic RT-VBT), chemotherapy (CT), and pelvic RT-CT led to fewer local recurrences (RR=0.33, 95% CI 0.21–0.50; RR=0.15, 95% CI 0.03–0.74; RR=0.39, 95% CI 0.21–0.73; RR=0.17, 95% CI 0.06–0.46). Adjuvant CT was found to result in more grade III/IV late toxicities than surgery alone (RR=11.8, 95% CI 1.02–137.14). Pelvic RT-CT ranked first for OS, PFS, distant metastasis, and local recurrence.

Conclusions

Pelvic RT-CT is superior to other treatments for PFS and local recurrence rate, and associated related toxicities are tolerable, suggesting it may be an ideal adjuvant therapy for HREC patients.

Development and Validation of a Serum Metabolomic Signature for Endometrial Cancer Screening in Postmenopausal Women

IMPORTANCE

Endometrial carcinoma (EC) is the most commonly diagnosed gynecologic cancer. Its early detection is advisable because 20% of women have advanced disease at the time of diagnosis.

OBJECTIVE

To clinically validate a metabolomics-based classification algorithm as a screening test for EC.

DESIGN, SETTING, AND PARTICIPANTS

This diagnostic study enrolled 2 cohorts. A multicenter prospective cohort, with 50 cases (postmenopausal women with EC; International Federation of Gynecology and Obstetrics stage I-III and grade G1-G3) and 70 controls (no EC but matched on age, years from menopause, tobacco use, and comorbidities), was used to train multiple classification models. The accuracy of each trained model was then used as a statistical weight to produce an ensemble machine learning algorithm for testing, which was validated with a subsequent prospective cohort of 1430 postmenopausal women. The study was conducted at the San Giovanni di Dio e Ruggi d'Aragona University Hospital of Salerno (Italy) and Lega Italiana per la Lotta contro i Tumori clinic in Avellino (Italy). Data collection was conducted from January 2018 to February 2019, and analysis was conducted from January to March 2019.

MAIN OUTCOMES AND MEASURES

The presence or absence of EC based on evaluation of the blood metabolome. Metabolites were extracted from dried blood samples from all participants and analyzed by gas chromatography-mass spectrometry. A confusion matrix was used to summarize test results. Performance indices included sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and accuracy. Confirmation or exclusion of EC in women with a positive test result was by means of hysteroscopy. Participants with negative results were followed up 1 year after enrollment to investigate the appearance of EC signs.

RESULTS

The study population consisted of 1550 postmenopausal women. The mean (SD) age was 68.2 (11.7) years for participants with no EC in the training cohort, 69.4 (13.8) years for women with EC in the training cohort, and 59.7 (7.7) years for women in the validation cohort. Application of the ensemble machine learning to the validation cohort resulted in 16 true-positives, 2 false-positives, and 0 false-negatives, and it correctly classified more than 99% of samples. Disease prevalence was 1.12% (16 of 1430).

CONCLUSIONS AND RELEVANCE

In this study, dried blood metabolomic profile was used to assess the presence or absence of EC in postmenopausal women not receiving hormonal therapy with greater than 99% accuracy.

Clinical Characteristics and Prognostic Analysis of Gynecologic Cancer with Spinal Metastases: A Single-Center Retrospective Study

Objective

The purpose of this study is to provide key information on the clinical characteristics, surgical treatment, and potential prognostic factors in patients with metastatic spinal gynecologic cancer (MSGC), with a view to their application in clinical practice.

Methods

From January 2010 to January 2020, we performed a retrospective analysis of 14 patients with MSGC who underwent surgical treatment in a single center. Surgical treatment was performed on 14 patients, and a total of 14 operations were performed. The survival time of patients after spinal surgery was analyzed by Kaplan–Meier and Cox regression analysis.

Results

The average age of patients was 51.9 years (range 25‒70). The average time from initial surgery to the discovery of spinal metastasis was 60.3 months (2‒180), and the average follow-up time was 19.2 months (2‒55). Spinal tumor progression was found in 9 patients, and 12 patients (85.7%) died during follow-up. In univariate analysis, extraosseous visceral metastasis (p = 0.024), revised Tokuhashi stage (p = 0.025), Tomita stage (p = 0.005), and number of spinal lesions (p = 0.038) were associated with overall survival (OS). Extraosseous visceral metastasis (p = 0.026), revised Tokuhashi stage (p = 0.014), Tomita stage (p = 0.001), and gynecological cancer type (p = 0.039) were associated with progression-free survival.

Conclusion

Surgical treatment is an effective treatment for MSGC and relieves pain, restores function and rebuilds stability. Based on our single-center experience, extraosseous visceral metastasis, revised Tokuhashi stage, Tomita stage, and gynecological cancer type may be potential prognostic factors for OS.

Usefulness of sentinel lymph node mapping using indocyanine green and fluorescent imaging in the diagnosis of lymph node metastasis in endometrial cancer

The lymph node status is the most important prognostic factor for endometrial cancer. This study aimed to assess whether sentinel lymph node mapping (SLNM) is applicable in endometrial cancer. A retrospective review of patients with endometrial cancer who were diagnosed and treated in Asan Medical Centre from September 2015 to December 2017 was conducted. One hundred patients underwent robotic (da Vinci®) or laparoscopic surgical treatment, including SLNM with indocyanine green (ICG) fluorescence detection using the Firefly® and NIR/ICG systems. At least one lymph node area was observed in 100% of SLNM cases. Sentinel node detection and frozen biopsy were performed in all cases, and all patients with metastasis were found on SLNM. The sensitivity and negative predictive value were both 100% in the patient-by-patient and station-by-station analyses. SLNM appears to be a feasible method to reduce the morbidity and increase the detection rate in early-stage endometrial carcinoma.What is already known on this subject? There are studies that it is safe to diagnose the possibility of lymph node metastasis through sentinel lymph node mapping in endometrial cancer.What do the results of this study add? In this study, it is shown that the accuracy of sentinel lymph node mapping is 100% accurate.What are the implications of these findings for clinical practise and/or further research? Therefore, total lymphadenectomy will not be necessary for the future.

Is ABO blood group a risk or prognostic factor for patients with endometrioid endometrial cancer? A retrospective analysis in Germany

BACKGROUND

A relationship is known to exist between gastric and pancreatic cancers and ABO antigens, caused by various immune modulations related to the ABO blood group of the patient. A similar relationship with regard to gynaecological cancers remains controversial.

MATERIALS AND METHODS

Patients who underwent surgery for endometrioid endometrial cancer in International Federation of Gynaecology and Obstetrics (FIGO) stage I, II, III or IV from 2006 to 2018 were identified. The research explored the existence of a relationship between the patients' blood group or Rhesus factor and the incidence of endometrial cancer, grade (G1, G2, G3), FIGO stage, nodal status, recurrence, menopausal status, parity, and body mass index. Statistical methods such as the chi-square test, analysis of variance and the Scheffé post-hoc test were used.

RESULTS

Two hundred and two patients with endometrioid endometrial cancer were included: 96 had blood group A, 19 blood group B, 75 blood group 0, and 12 had blood group AB. This distribution corresponds to the general blood group distribution in Germany. The vast majority of the dependent variables, such as grade, FIGO stage, nodal status or recurrence were not significantly associated with ABO blood group or Rhesus factor status. The relative frequencies of G1 and G3 endometrial cancers with respect to blood group were similar. Menopausal status, parity, and body mass index were not related to more advanced FIGO stages at initial diagnosis or to ABO blood group.

DISCUSSION

Blood group screening would probably not be helpful in the diagnosis of endometrioid endometrial carcinomas in early stages compared to the current gold standard. Furthermore, a specific blood group does not increase either the risk of recurrence or the risk of a dedifferentiated type of endometrial carcinoma.

Expression of anti-apoptotic protein survivin in human endometrial carcinoma: Clinical and pathological associations as a separate factor and in combination with concomitant PTEN and p53 expression

Endometrial carcinoma is one of the most common types of gynecological cancer. A total of 99 cases of primary endometrial carcinoma were investigated for survivin expression by immunohistochemistry. Furthermore, the association between concomitant survivin, PTEN and p53 expression, and clinicopathological parameters was examined. Immunopositivity for survivin was identified in 88% of cases. Concomitant survivin, PTEN and p53 expression (staining scores and intensity) was observed in 60% of endometrial adenocarcinomas. A significant association was identified between the sum of staining intensity and scores of survivin immunopositive cells, and patient age (P=0.028), histological grade (P<0.001), clinical stage (P=0.018) and fallopian tube and/or ovarian invasion (P=0.039). A negative tendency for correlation was observed between surivin and PTEN immunostaining scores (P=0.062; ρ=−0.238). Specimens with high scores of survivin expression tended to show decreased scores of PTEN immunostaining, and vice versa. However, in circumstances with an increased co-expression of survivin and PTEN, a statistically significant association with histological types was observed (P=0.020). A statistically significant positive correlation was identified between survivin and p53 sum co-expression (P=0.008; ρ=0.300). Furthermore, a significant association was identified between survivin and p53 concomitant sum expression and age of patients (P=0.001), histological type (P=0.020), clinical stage (P=0.037), histological differentiation (P=0.001) and presence of fallopian tube and/or ovarian invasion (P=0.026). The present findings suggested that survivin may be an indicator of unfavorable outcome in older patients with endometrial carcinoma, in specific circumstances that are dependent on different concomitant genetic alterations and different combinations of molecular signaling pathways. Increased expression levels of survivin and PTEN may serve a role in the development of more aggressive endometrial carcinoma during their interaction. In addition, protein expression levels of survivin and p53 are positively correlated and may share a common molecular pathway to promote endometrial carcinogenesis. These findings provided evidence that survivin and p53 combined may be useful markers for the prediction of tumor behavior and prognosis.

Combined pelvic and para-aortic is superior to only pelvic lymphadenectomy in intermediate and high-risk endometrial cancer: a systematic review and meta-analysis

BACKGROUND

Lymph node metastasis is a principal prognostic factor for the treatment of endometrial cancer. Added value of para-aortic lymphadenectomy to only pelvic lymphadenectomy for intermediate/high-risk endometrial cancer patients remains controversial.

OBJECTIVE

A systematic review and meta-analysis was performed to assess the impact of combined pelvic and para-aortic lymph node dissection (PPALND) compared to only pelvic lymph node dissection (PLND) on survival outcomes of intermediate and/or high-risk patients.

STUDY DESIGN

The systematic review and meta-analysis adhered to the PRISMA guidelines for meta-analyses of interventional studies. Pubmed, Scopus, EMBASE and Cochrane were searched up to April 20, 2018. Included studies were those comparing high-risk endometrial cancer patients that had performed pelvic and para-aortic lymph node dissection (PPALND) vs. only pelvic lymph node dissection (PLND) apart from standard procedure (total hysterectomy with bilateral salpingo-oophorectomy, TAHBSO). Primary outcomes of the study were overall survival and disease-free survival rates. Methodological quality of the included studies was assessed using the ROBINS-I tool. Overall quality of the evidence for the primary and secondary outcomes was evaluated as per GRADE guideline using the GRADE pro GD tool.

RESULTS

There were 13 studies identified with 7349 patients included. All studies were retrospective observational as no RCTs or prospective studies adhering to inclusion criteria were retrieved. Combined pelvic and para-aortic lymphadenectomy was associated with 46% decreased risk for death (HR 0.54, 95% CI 0.35-0.83, I² = 62.1%) and 49% decreased risk for recurrence (HR 0.51, 95% CI 0.28-0.93). It was also associated with increased 5-year OS rate (RR 1.13, 95% CI 1.04-0.24, I² = 57.3%) and increased 5-year DFS rate (RR 1.23, 95% CI 1.14-1.31, I² = 85.5) compared with only pelvic lymphadenectomy.

CONCLUSION

Combined pelvic and para-aortic lymphadenectomy is associated with improved survival outcomes compared with only pelvic lymphadenectomy in women with intermediate/high-risk endometrial cancers. Further prospective studies should be performed.

Endometrial Cytology as a Method to Improve the Accuracy of Diagnosis of Endometrial Cancer: Case Report and Meta-Analysis

More and more researchers have reported that dilatation and curettage (D&C) or Pipelle had low accuracy, high misdiagnosis, and insufficient rate. Endometrial cytology is often compared with histology and seems to be an efficient method for the diagnosis of endometrial disorders, especially endometrial cancer. We report a case of misdiagnosed endometrial cancer by D&C, but with a positive cytopathological finding. Following that, a meta-analysis including 4,179 patients of endometrial diseases with cyto-histopathological results was performed to assess the value of the endometrial cytological method in endometrial cancer diagnosis. The pooled sensitivity and specificity of the cytological method in detecting endometrial atypical hyperplasia or cancer was 0.91[95% confidence interval (CI) 0.74-0.97] and 0.96 (95% CI 0.90-0.99), respectively. The pooled positive likelihood ratio and negative likelihood ratio was 25.4 (95% CI 8.1-80.1) and 0.10 (95% CI 0.00-0.30), respectively. The diagnostic odds ratio which was usually used to evaluate the diagnostic test performance reached 260 (95% CI 36-1905). So we recommend that D&C and Pipelle are still practical procedures to evaluate the endometrium, cytological examinations should be utilized as an additional endometrial assessment method.

Survival in clinical stage I endometrial cancer with single vs. multiple positive pelvic nodes: results of a multi-institutional Italian study

OBJECTIVE

To investigate survival outcomes in endometrioid endometrial cancer (EEC) patients with single vs. multiple positive pelvic lymph nodes.

METHODS

We performed a retrospective evaluation of all consecutive patients with histologically proven International Federation of Gynecology and Obstetrics (FIGO) stage IIIC1 EEC who underwent primary surgical treatment between 2004 and 2014 at seven Italian gynecologic oncology referral centers. Patients with pre- or intra-operative evidence of extra-uterine disease (including the presence of bulky nodes) and patients with stage IIIC2 disease were excluded, in order to obtain a homogeneous population.

RESULTS

Overall 140 patients met the inclusion criteria. The presence of >1 metastatic pelvic node was significantly associated with an increased risk of recurrence and mortality, compared to only 1 metastatic node, at both univariate (recurrence: hazard ratio [HR]=2.19; 95% confidence interval [CI]=1.2-3.99; p=0.01; mortality: HR=2.8; 95% CI=1.24-6.29; p=0.01) and multivariable analysis (recurrence: HR=1.91; 95% CI=1.02-3.56; p=0.04; mortality: HR=2.62; 95% CI=1.13-6.05; p=0.02) and it was the only independent predictor of prognosis in this subset of patients. Disease-free survival (DFS) and disease-specific survival (DSS) were significantly longer in patients with only 1 metastatic node compared to those with more than 1 metastatic node (p=0.008 and 0.009, respectively).

CONCLUSION

The presence of multiple metastatic nodes in stage IIIC1 EEC represents an independent predictor of worse survival, compared to only one positive node. Our data suggest that EEC patients may be categorized according to the number of positive nodes.

No. 291-Epidemiology and Investigations forSuspected Endometrial Cancer

OBJECTIVE

To review the evidence relating to the epidemiology of endometrial cancer and its diagnostic workups.

OPTIONS

Women with possible endometrial cancer can undergo an endometrial evaluation by office biopsy, hysteroscopy, or dilatation and curettage. To assist in treatment planning, pelvic ultrasound, CT scan, or MRI may be considered.

OUTCOMES

The identification of optimal diagnostic tests to evaluate patients with possible endometrial cancer.

EVIDENCE

Published literature was retrieved through searches of PubMed, CINAHL, and The Cochrane Library, using appropriate controlled vocabulary (e.g., endometrial neoplasms) and key words (e.g., endometrium cancer, endometrial carcinoma). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 31, 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, national and international medical specialty societies, and recent conference abstracts.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

This document is intended to guide the development of a standardized cost-effective investigation of patients with suspected endometrial cancer.

VALIDATION

The guideline was reviewed for accuracy by experts in pathology, radiation oncology, and medical oncology. Guideline content was also compared with relevant documents from the American Congress of Obstetricians and Gynecologists.

RECOMMENDATIONS

Patient-Derived Xenograft Models for Endometrial Cancer Research

Endometrial cancer (EC) is the most common malignancy of the genital tract among women in developed countries. Recently, a molecular classification of EC has been performed providing a system that, in conjunction with histological observations, reliably improves EC classification and enhances patient management. Patient-derived xenograft models (PDX) represent nowadays a promising tool for translational research, since they closely resemble patient tumour features and retain molecular and histological features. In EC, PDX models have already been used, mainly as an individualized approach to evaluate the efficacy of novel therapies and to identify treatment-response biomarkers; however, their uses in more global or holistic approaches are still missing. As a collaborative effort within the ENITEC network, here we describe one of the most extensive EC PDX cohorts developed from primary tumour and metastasis covering all EC subtypes. Our models are histologically and molecularly characterized and represent an excellent reservoir of EC tumour samples for translational research. This review compiles the information on current methods of EC PDX generation and their utility and provides new perspectives for the exploitation of these valuable tools in order to increase the success ratio for translating results to clinical practice.

Precocious Solitary Cervical Metastasis from Endometrial Cancer Presenting as Cervical Radicular Pain

BACKGROUND

Bone metastases from endometrial cancer are rare. To our knowledge, only 2 cases of solitary vertebral metastases from endometrial cancer presenting with osseous and/or neurologic symptoms before the diagnosis of the primary endometrial cancer have been reported; however, in both cases, the metastases were thoracic. Thus, cervical vertebral metastases are extremely rare.

CASE DESCRIPTION

We describe the case of a 55-year-old woman who presented with right C6 radicular and neck pain. Neurologic imaging showed destruction of the C6 vertebral body by an extradural mass with kyphotic changes in the cervical spine. Fluorodeoxyglucose positron emission tomography showed increased uptake in the enlarged body of the uterus as well as the C6 vertebral body. Additional pelvic magnetic resonance images and endometrial biopsy confirmed endometrial cancer. The patient underwent excision of the cervical tumor with anterior reconstruction and posterior fixation followed 1 month later by semiradical hysterectomy and bilateral salpingo-oophorectomy with pelvic and para-aortic lymph node dissection. The cervical and endometrial histopathologic findings were similar, and the final diagnosis made was cervical metastatic adenocarcinoma originating from an endometrial cancer.

CONCLUSIONS

We describe an extremely rare case of a precocious solitary cervical metastasis from an endometrial cancer presenting as cervical radicular pain. In our review of published reports, we found that solitary spinal metastases are significantly associated with longer overall survival than are multiple lesions. Resection of the spinal lesion with rigid spinal reconstruction followed by radical hysterectomy may be beneficial in such patients.

Added Value of Estrogen Receptor, Progesterone Receptor, and L1 Cell Adhesion Molecule Expression to Histology-Based Endometrial Carcinoma Recurrence Prediction Models: An ENITEC Collaboration Study

Objectives

Endometrial carcinoma mortality is mainly caused by recurrent disease, and various immunohistochemical markers to predict recurrences have been studied. Loss of the estrogen receptor (ER) and progesterone receptor (PR) and the presence of the L1 cell adhesion molecule (L1CAM) are promising markers, but their combined value has not been studied.

Materials and Methods

Expression of ER, PR, and L1CAM was immunohistochemically determined in 293 endometrial carcinomas from 11 collaborating European Network for Individualized Treatment of Endometrial Cancer centers. Estrogen receptor, PR, or L1CAM staining was considered positive or negative when expressed by greater than or equal to 10% or less than 10% of the tumor cells, respectively. The association between these markers and clinicopathological markers, and their combined value in predicting survival were calculated, both in the entire cohort and in a selected groups of stage I endometrioid and low-risk stage I endometrioid carcinomas.

Results

Estrogen receptor and PR were negative in 19% and 28% of the cases, respectively, and L1CAM was positive in 18%. All 3 were associated with advanced stage, high-grade, nonendometrioid histology, lymphovascular space invasion (LVSI), and reduced disease-free survival. Only advanced stage, loss of PR, and LVSI were associated with reduced disease-free survival in multivariate analysis. A prognostic model including these 3 markers was superior to 1 including only the 3 immunohistochemical markers, which was superior to the traditional model. In both the stage I endometrioid and the low-risk stage I endometrioid groups, only loss of PR was associated with reduced disease-free survival.

Conclusions

Loss of ER and PR, and the presence of L1CAM are associated with high risk characteristics, and loss of PR is the strongest predictor of recurrent disease. Although a combination of these 3 markers is slightly superior to the traditional histological markers, a prognostic model including stage, PR expression, and LVSI is the most promising model in the identification of high risk carcinomas. In the stage I endometrioid carcinomas, PR immunohistochemistry appears to be of additional value in predicting recurrences.

Rural-urban differences in surgical treatment, regional lymph node examination, and survival in endometrial cancer patients

PURPOSE

Endometrial cancer (EC) is the most common gynecological malignancy and one of few cancers with an increasing US mortality rate. Rural patients may have less access to specialty care affecting their receipt of surgery and adequate lymphadenectomy (AL). We sought to assess rural-urban differences in EC surgery, lymphadenectomy, and survival.

METHODS

We analyzed data from the Surveillance Epidemiology and End Results database on EC patients (2004-2013). We performed univariate analyses to compare rural and urban patients on demographic and clinical characteristics and receipt of nodal examination and AL. We assessed rural-urban differences in trends of receipt of AL, performed logistic regression to evaluate differences in receipt of surgery, nodal examination, and AL, and performed survival analysis.

RESULTS

Rural patients were less likely to have any lymph nodes removed, had a smaller median number removed, and a smaller proportion had AL. Even after controlling for established risk factors, rural patients had lower odds of lymph node examination and adequate AL than urban patients and also had poorer survival.

CONCLUSIONS

Future research should continue to assess the association between access to care and disparities in surgical care and the effect of these disparities on survival.

Preoperative risk stratification using 18F-FDG PET/CT in women with endometrial cancer

The aim of this study is to evaluate the usefulness of 18F-FDG PET/CT for preoperative stratification of high-risk and low-risk carcinomas in patients with endometrial cancer. Patients, methods: 60 women (mean age 53.8 ± 9.9 years) with endometrial cancer, who underwent 18F-FDG PET/CT for preoperative staging work-up, followed by primary cytoreductive surgery, were enrolled in this study. Maximum and mean standardized uptake values (SUVmax, SUVmean) of endometrial tumors were measured, and compared with the various clinicopathologic findings obtained after surgery. Tumour aggressiveness was classified as high-risk and low-risk carcinomas. Patients with stage I or II, endometrioid adenocarcinoma, histologic grade 1 or 2, invasion of less than half of the myometrium, maximum tumor size less than 2.0 cm, and absence of cervical invasion and lymphovascular space involvement (LVSI) were classified as the lowrisk carcinoma group. The remaining patients were classified as the high-risk carcinoma group. Results: In univariate analysis, SUVmax of the primary endometrial tumor was significantly higher in patients who were in a postmenopausal state (p = 0.047), large (> 2 cm) primary tumor (p <0.001), nonendometrioid subtype (p = 0.024), invasion of more than half of the myometrium (p = 0.020), or LVSI (p = 0.004). SUVmax differed significantly according to FIGO stage (p = 0.013) and histologic grade (p <0.001). In multivariate analysis, FIGO stage, histologic grade, LVSI, and maximum tumor size demonstrated a significant association with SUVmax (p <0.001; r = 0.843, r2 = 0.711). SUVmean showed similar results. Forty-one (68.3%) patients were diagnosed postoperatively as high-risk and 19 patients (31.7%) as low-risk carcinoma. Patients with high-risk carcinoma (12.1 ± 6.1) showed significantly higher SUVmax than patients with low-risk carcinoma (5.8 ± 2.8, p <0.001). The optimal SUVmax cut-off value of 8.7, determined by ROC analysis, revealed 75.6% sensitivity, 89.5% specificity, and 81.7% accuracy for risk stratification. Conclusion: High-risk endometrial cancer might be differentiated by means of higher SUVmax from low-risk endometrial cancer. 18F-FDG FDG PET/CT can be applied preoperatively for stratification of risk in patients with endometrial cancer.

Prognostic Impact of ABO Blood Group on Type I Endometrial Cancer Patients- Results from Our Own and Other Studies

Objectives: The ABO blood group antigens were found on most epithelial cells and in secretions. In the normal endometrium there is a variable expression of histo-blood group and related antigens suggesting a hormonal regulation. A relationship between ABO blood groups and endometrial cancer has been investigated with contradictory results. In this study we investigated the influence of blood types on clinical and pathological characteristics of endometrial cancer patients.

Method: Retrospective cohort study. Clinical and pathological data were extrapolated and their association with blood groups were assessed.

Results: A total of 203 type I endometrial cancer patients were included in the final analysis. Univariate analysis indicated that a lower frequency of G3 undifferentiated tumors was observed in patients with A blood group (P=0.027). Multivariate analysis, including also clinical features such as Age, BMI, parity, hypertension and diabetes confirmed that patients with A group present a lower risk of G3 tumors in comparison with not A patients. (OR=0.32, P=0.011).

Conclusions: Patients with A genotype have a lower risk to develop G3 type I endometrial cancer. ABO blood group might represent a useful, easy access and cheap biomarker for patients' selection and for management personalization of endometrial cancer patients.

Is There Any Association between Glutathione S-transferases M1 and Glutathione S-transferases T1 Gene Polymorphisms and Endometrial Cancer Risk? A Meta-analysis

Epidemiological evidence on the association between genetic polymorphisms in glutathione S-transferases M1 (GSTM1) and T1 (GSTT1) genes and risk of endometrial cancer (EC) has been inconsistent. In this meta-analysis, we seek to investigate the relationship between GSTM1 and GSTT1 polymorphisms and the risk of EC. We searched Medline, PubMed, Web of Science, Embase, Chinese National Knowledge Infrastructure database, and Chinese Biomedical Literature database to identify eligible studies. The pooled odds ratios (ORs) with 95% confidence intervals (CIs) for the association were determined using a fixed- or random-effect model. Tests for heterogeneity of the results and sensitivity analyses were performed. A total of six case-control studies were included in the final meta-analysis of GSTM1 (1293 cases and 2211 controls) and GSTT1 (1286 cases and 2200 controls) genotypes. Overall, GSTM1 null genotype was not significantly associated with an increased risk of EC (OR = 1.00, 95% CI = 0.76-1.30, P = 0.982). Similarly, for GSTT1 deletion genotype, we observed no association under the investigated model in the overall analysis (OR = 0.91, 95% CI = 0.64-1.30, P = 0.619). Subgroup analysis also showed no significant association between the GSTM1 null genotype and EC risk in hospital-based design (OR = 1.26, 95% CI = 0.93-1.71, P = 0.131) and no relationship between GSTT1 null genotype with EC risk in population-based design (OR = 1.18, 95% CI = 0.79-1.76, P = 0.407). However, GSTM1 null genotype contributed to an increased EC risk in population-based design (OR = 0.76, 95% CI = 0.60-0.97, P = 0.027), while null GSTT1 in hospital-based studies (OR = 0.70, 95% CI = 0.52-0.93, P = 0.015). The present meta-analysis suggested that GSTs genetic polymorphisms may not be involved in the etiology of EC. Large epidemiological studies with the combination of GSTM1 null, GSTT1 null, and design-specific with the development of EC are needed to prove our findings.

Lower Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Promotes the Proliferation and Migration of Endometrial Carcinoma

Background

The incidence and death rates of endometrial cancer are alarmingly increasing. The diagnosis and treatment of endometrial cancer is crucial to decreasing mortality. Cystic fibrosis transmembrane conductance regulator (CFTR) belongs to the adenosine triphosphate (ATP)-binding cassette transporter family and plays an essential role in anion regulation and tissue homeostasis of various epithelia. This study explored the expression of CFTR in endometrial carcinoma and the role of CFTR in proliferation and migration of endometrial carcinoma cells.

Material/Methods

Immunohistochemistry and real-time (RT)-PCR were used to test the expression of CFTR in normal endometrium and endometrial carcinoma. CFTR inhibitor was used to restrain the expression of CFTR on the endometrial carcinoma, the effects on the proliferation and migration of endometrial carcinoma cells were also studied. RT-PCR was performed to test the expression of mir-125b after restraining CFTR. Proliferation and migration capability of endometrial carcinoma cells were detected after transfection of endometrial carcinoma cells with mir-125b mimic.

Results

Compared with cells from normal endometrium, the expression of CFTR was significantly upregulated in endometrial carcinoma cells. After adding CFTR(inh)172, the capability for proliferation and transfer of endometrial carcinoma cells was strengthened, the expression of mir-125b was reduced, and after transfection with mir-125b mimics entering the endometrial carcinoma cells, the ability of the proliferation and transfer of endometrial carcinoma cells was also reduced.

Conclusions

The high expression of CFTR in the endometrial carcinoma cells played a pivotal role in restraining the proliferation and transfer of endometrial carcinoma cells.

Fertility-preservation in endometrial cancer: is it safe? Review of the literature

Almost 5% of women with endometrial cancer are under age 40, and they often have well-differentiated endometrioid estrogen-dependent tumors. Cancer survival rates have improved over the last decades so strategies to avoid or reduce the reproductive damage caused by oncologic treatment are needed. We reviewed the published literature to find evidence to answer the following questions: How should we manage women in reproductive age with endometrial cancer? How safe is fertility preservation in endometrial cancer? Can pregnancy influence endometrial cancer recurrence? What are the fertility sparing options available? Progestins may be prescribed after careful evaluation and counseling. Suitable patients should be selected using imaging methods and endometrial sampling since surgical staging will not be performed. Conservative treatment should only be offered to patients with grade 1 well-differentiated tumors, absence of lymph vascular space invasion, no evidence of myometrial invasion, metastatic disease or suspicious adnexal masses, and expression of progesterone receptors in the endometrium. The presence of co-existing ovarian metastatic of synchronous cancer should be investigated and ruled out before the decision to preserve the ovaries. The availability of Assisted Reproductive Technology (ART) has made it possible for women with endometrial cancer to give birth to a child without compromising their prognoses. Gamete, embryo or ovarian tissue cryopreservation techniques can be employed, although the latter remains experimental. Unfortunately, fertility preservation is rarely considered. Current recommendations for conservative management are based on the overall favorable prognosis of grade 1 minimally invasive tumors. Selected patients with endometrial cancer may be candidates to a safe fertility-preserving management.

Inter-observer reproducibility of endometrial cytology by the Osaki Study Group method: utilising the Becton Dickinson SurePath™ liquid-based cytology

OBJECTIVE

The purpose of the present study was to evaluate the reproducibility of the cytological diagnosis of endometrial lesions by the Osaki Study Group (OSG) method of new cytological diagnostic criteria using BD SurePath^™ (SP)-liquid-based cytology (LBC).

METHODS

This cytological classification using the OSG method consists of six categories: (i) normal endometrium (NE), (ii) endometrial glandular and stromal breakdown (EGBD), (iii) atypical endometrial cells, cannot exclude atypical endometrial hyperplasia or more (ATEC-A), (iv) adenocarcinoma including atypical endometrial hyperplasia or malignant tumour (Malignancy), (v) endometrial hyperplasia without atypia (EH) and (vi) atypical endometrial cells of undetermined significance (ATEC-US). For this study, a total 244 endometrial samplings were classified by two academic cytopathologists as follows: 147 NE cases , 36 EGBD cases , 47 Malignant cases, eight ATEC-A cases, two EH cases and four ATEC-US cases. To confirm the reproducibility of the diagnosis and to study the inter- and intra-observer agreement further, a second review round followed at 3-month intervals, which included three additional cytopathologists.

RESULTS

The inter-observer agreement of NE classes improved progressively from 'good to fair' to 'excellent', with values increasing from 0.70 to 0.81. Both EGBD and Malignancy classes improved progressively from 'good to fair' to 'excellent', with values increasing from 0.62-0.63 to 0.84-0.95, respectively. The overall intra-observer agreement between the first and the second rounds was 'good to fair' to 'excellent', with values changing from 0.79 to 0.85. All kappa improvements were significant (P < 0.0001).

CONCLUSION

In this study, it seemed that the use of the OSG method as the new diagnostic criteria for SP-LBC preparation, may be a valid method to improve the precision (reproducibility) of endometrial cytology.

Tumor progression, metastasis, and modulators of epithelial-mesenchymal transition in endometrioid endometrial carcinoma: an update

Endometrioid endometrial carcinoma (EEC), also known as type 1 endometrial cancer (EC), accounts for over 70-80% of all cases that are usually associated with estrogen stimulation and often develops in a background of atypical endometrial hyperplasia. The increased incidence of EC is mainly confined to this type of cancer. Most EEC patients present at an early stage and generally have a favorable prognosis; however, up to 30% of EEC present as high risk tumors, which have invaded deep into the myometrium at diagnosis and progressively lead to local or extra pelvic metastasis. The poor survival of advanced EC is related to the lack of effective therapies, which can be attributed to poor understanding of the molecular mechanisms underlying the progression of disease toward invasion and metastasis. Multiple lines of evidence illustrate that epithelial-mesenchymal transition (EMT)-like events are central to tumor progression and malignant transformation, endowing the incipient cancer cell with invasive and metastatic properties. The aim of this review is to summarize the current knowledge on molecular events associated with EMT in progression, invasion, and metastasis of EEC. Further, the role of epigenetic modifications and microRNA regulation, tumor microenvironment, and microcystic elongated and fragmented glands like invasion pattern have been discussed. We believe this article may perhaps stimulate further research in this field that may aid in identifying high risk patients within this clinically challenging patient group and also lead to the recognition of novel targets for the prevention of metastasis - the most fatal consequence of endometrial carcinogenesis.

Clinicopathological significance of increased ZIC1 expression in human endometrial cancer

Zinc finger of the cerebellum (ZIC1), one of ZIC family genes, has been shown to play important roles in many cancers such as gastric cancer and breast cancer. However, there is little known about the expression and significance of ZIC1 in endometrial cancer. The aim of this study was to determine the expression pattern and clinicopathological significance of ZIC1 in endometrial cancer. The mRNA and protein expression of ZIC1 in endometrial cancer tissues was detected using the reverse-transcription polymerase chain reaction and Western blotting, respectively. Immunostaining of ZIC1 in 99 endometrial cancer samples was examined and its associations with clinicopathological parameters were analyzed. Hec-1-B cells were transfected with ZIC1-shRNA or sc-shRNA, and cell proliferation was assayed. Hec-1-B cells stably transfected with ZIC1-shRNA or sc-shRNA were subcutaneously inoculated into nude mice, and the tumor weight was measured. A significantly increased expression of ZIC1 mRNA and protein was observed in endometrial cancer tissues compared to that in normal endometrial tissues (P<0.05). Immunohistochemical analysis showed that strong cytoplasmic immunostaining of ZIC1 was observed in almost all endometrial cancer samples (90/99) while light and moderate immunostaining of ZIC1 was only detected in 17 of 30 (56.7%) normal tissues. Moreover, up-regulation of ZIC1 was significantly correlated with age, disease stage, TNM stage and FIGO stage (P<0.05). The down-regulated expression of ZIC1 contributed to the inhibition of cell proliferation, and inhibited the growth of tumor. It was concluded that ZIC1 is over-expressed in endometrial cancer tissue but not in normal tissue, and positively correlated to the malignant biological behavior of endometrial carcinogenesis.

Characterization of precursor lesions in the endometrium and fallopian tube epithelium of early-stage uterine serous carcinoma

To determine if selected cases of uterine serous carcinoma (USC) arise from tubal rather than endometrial epithelium. Bilateral fallopian tubes from 38 women with pure USC were entirely submitted for histopathologic examination using the protocol Sectioning and Extensively Examining the FIMbria (SEE-FIM). Non-neoplastic endometrium was extensively sampled. Immunohistochemistry for p53 was performed on all paraffin blocks of fallopian tube and non-neoplastic endometrium. Endometrial intraepithelial carcinoma (EIC) was present in 22 cases (58%). Endometrial p53 foci were identified in 3 patients. There were 11 cases (29%) with fallopian tube involvement; 9 of 11 had tubal wall invasion or lymphatic involvement without serous tubal intraepithelial carcinoma (STIC) and were, therefore, classified as metastatic from the endometrium. STIC was identified in 3 patients (8%). There were 3 cases with tubal p53 foci in non-neoplastic epithelium. EIC was present in 58% of patients, further supporting EIC as a precursor lesion to USC. STIC was present in 8%, suggesting that the fallopian tube may in fact represent the primary lesion in a minority of patients with USC. This finding may account for the early multifocal disease distribution observed in these patients.

Sentinel lymph node procedure in endometrial cancer: A systematic review and proposal for standardization of future research

OBJECTIVES

Sentinel lymph node (SLN) procedure could be an attractive solution to the debate on lymphadenectomy in endometrial cancer; however challenges to interpreting the literature include marked heterogeneity across studies, a wide variety of injection techniques and a lack of uniformly accepted definitions for important outcomes. We aim to critically appraise the published literature and streamline terminology and methodology for future studies in this field.

METHODS

We conducted a PubMed search and included all original research of endometrial cancer patients having undergone SLN procedure with an n>30. Data collected included injection technique, unilateral, bilateral, and para-aortic detection rates, and ultrastaging results. When different definitions were used for reporting outcomes, we recalculated the original study results according to our proposed definitions. Data was analyzed using descriptive statistics.

RESULTS

Seventeen studies met our inclusion criteria. Injection sites were categorized into cervical versus corporeal. Overall detection rates ranged from 60 to 100%; studies with n>100 all had overall detection rates of >80%. Bilateral detection rates were higher with a combination of two injection agents. Para-aortic mapping was most frequent after corporeal injection techniques (39%), and was higher after deep vs. standard cervical injection (17% vs. 2%). The proportion of metastatic lymph nodes diagnosed through ultrastaging was high (around 40%) and ultrastaging of SLN upstaged approximately 5% of patients. Retrospectively applying a surgical algorithm revealed a sensitivity of 95%, a negative predictive value of 99%, and a false negative rate of 5% (with only 9 false negative cases remaining in total).

CONCLUSION

Results of SLN research for endometrial cancer are promising. We believe that in future studies, uniform reporting is needed to improve our understanding of the safety and feasibility of SLN in EC. We propose 2 strategies: a checklist of elements to include in future reports and the standardization of key definitions.

EMMPRIN in gynecologic cancers: pathologic and therapeutic aspects

The highly glycosylated transmembrane protein extracellular matrix metalloproteinase inducer (EMMPRIN) is associated with several pathological conditions, including various types of cancers. In different gynecological malignancies, such as ovarian, cervical, and endometrial cancers, EMMPRIN plays significant roles in cell adhesion modulation, tumor growth, invasion, angiogenesis, and metastasis by inducing the production of various molecules, including matrix metalloproteinases and vascular endothelial growth factor. Because of its high level of expression, EMMPRIN can possibly be used as a diagnostic marker of gynecological cancers. Recent studies have showed that targeting EMMPRIN, especially by RNA interference (RNAi) technology, has promising therapeutic potential in basic research on gynecological cancer treatments, which make a platform for the future clinical success. This review study focused on the association of EMMPRIN in gynecological cancers in the perspectives of pathogenesis, diagnosis, and therapeutics.

Second-line dovitinib (TKI258) in patients with FGFR2-mutated or FGFR2-non-mutated advanced or metastatic endometrial cancer: a non-randomised, open-label, two-group, two-stage, phase 2 study

BACKGROUND

Activating FGFR2 mutations are found in 10-16% of primary endometrial cancers and provide an opportunity for targeted therapy. We assessed the safety and activity of dovitinib, a potent tyrosine-kinase inhibitor of fibroblast growth factor receptors, VEGF receptors, PDGFR-β, and c-KIT, as second-line therapy both in patients with FGFR2-mutated (FGFR2(mut)) endometrial cancer and in those with FGFR2-non-mutated (FGFR2(non-mut)) endometrial cancer.

METHODS

In this phase 2, non-randomised, two-group, two-stage study, we enrolled adult women who had progressive disease after first-line chemotherapy for advanced or metastatic endometrial cancer from 46 clinical sites in seven countries. We grouped women according to FGFR2 mutation status and gave all women dovitinib (500 mg per day, orally, on a 5-days-on and 2-days-off schedule) until disease progression, unacceptable toxicity, death, or study discontinuation for any other reason. The primary endpoint was proportion of patients in each group who were progression-free at 18 weeks. For each group, the second stage of the trial (enrolment of 20 additional patients) could proceed if at least eight of the first 20 treated patients were progression free at 18 weeks. Activity was assessed in all enrolled patients and safety was assessed in all patients who received at least one dose of dovitinib. The completed study is registered with ClinicalTrials.gov, number NCT01379534.

FINDINGS

Of 248 patients with FGFR2 prescreening results, 27 (11%) had FGFR2(mut) endometrial cancer. Between Feb 17, 2012, and Dec 13, 2013, we enrolled 22 patients in the FGFR2(mut) group and 31 patients in the FGFR2(non-mut) group. Seven (31·8%, 95% CI 13·9-54·9) patients in the FGFR2(mut) group and nine (29·0%, 14·2-48·0) in the FGFR2(non-mut) group were progression-free at 18 weeks. On the basis of predefined criteria, neither group continued to stage two: seven (35%) of the first 20 patients in the FGFR2(mut) group were progression free at 18 weeks, as were five (25%) of the first 20 in the FGFR2(mut) population. Rates of treatment-emergent adverse events were similar between groups and events were most frequently gastrointestinal. Overall, the most common grade 3 or 4 adverse events suspected to be related to the study drug were hypertension (nine patients; 17%) and diarrhoea (five; 9%). The most frequently reported serious adverse events suspected to be related to study drug were pulmonary embolism (four patients; 8%), vomiting (four; 8%), dehydration (three; 6%), and diarrhoea (three; 6%). Only one death was deemed to be treatment-related: one patient in the FGFR2(non-mut) group died from cardiac arrest with contributing reason of pulmonary embolism (grade 4, suspected to be study drug related) 4 days previously.

INTERPRETATION

Second-line dovitinib in FGFR2(mut) and FGFR2(non-mut) advanced or metastatic endometrial cancer had single-agent activity, although it did not reach the prespecified study criteria. Observed treatment effects seemed independent of FGFR2 mutation status. These data should be considered exploratory and additional studies are needed.

FUNDING

Novartis Pharmaceuticals.

Preoperative risk stratification using metabolic parameters of (18)F-FDG PET/CT in patients with endometrial cancer

PURPOSE

To evaluate the usefulness of metabolic parameters obtained by (18)F-FDG PET/CT for preoperative stratification of high-risk and low-risk endometrial carcinomas.

METHODS

Preoperative (18)F-FDG PET/CT was performed in 56 women with endometrial cancer. Maximum standardized uptake values (SUVmax), metabolic tumour volume (MTV) and total lesion glycolysis (TLG) of primary tumours were compared with clinicopathological features of surgical specimens. Diagnostic performance in terms of differentiation of low-risk disease (endometrioid histology, histological grade 1 or 2, invasion of less than half of the myometrium, and FIGO stage I) from high-risk disease was assessed.

RESULTS

MTV and TLG were significantly higher in patients with higher histological grade (p = 0.0026 and p = 0.034), larger tumour size (p = 0.002 and p = 0.0017), lymphovascular space involvement (LVSI; p = 0.012 and p = 0.0051), myometrial invasion (p = 0.027 and p = 0.031), cervical stromal invasion (p = 0.023 and p = 0.014), ovarian metastasis (p = 0.00022 and p = 0.00034), lymph node metastasis (p < 0.0001 and p < 0.0001), and higher FIGO stage (p = 0.0011 and p = 0.00048). SUVmax was significantly higher in patients with larger tumour size (p = 0.0025), LVSI (p = 0.00023) and myometrial invasion (p < 0.0001). The areas under the ROC curves (AUCs) for distinguishing high-risk from low-risk carcinoma were 0.625, 0.829 and 0.797 for SUVmax, MTV and TLG, respectively. AUCs for both MTV and TLG were significantly larger than that for SUVmax (p = 0.0049 and p = 0.021). The optimal TLG cut-off value of 70.2, determined by ROC analysis, was found to have 72.0% sensitivity and 74.2% specificity for risk stratification.

CONCLUSION

MTV and TLG of primary endometrial cancer show better correlations with clinicopathological features and are more useful for differentiating high-risk from low-risk carcinoma than SUVmax.

Endometrial histology in severely obese bariatric surgery candidates: an exploratory analysis

BACKGROUND

Endometrial pathology risk has been linked to obesity; however, little is known of its prevalence in severely obese women not seeking care for endometrial pathology associated symptoms. This pilot study was designed to explore the frequency and risk factors associated with endometrial pathology in cancer-free, severely obese, bariatric surgery candidates using the Pipelle endometrial sampling technique (SureFlex Preferred Curette, Bioteque America, Inc, New Taipei City, Taiwan).

METHODS

Twenty-nine severely obese bariatric surgery candidates with intact uteruses and no history of endometrial cancer or endometrial ablation were included in this subanalysis from a larger cohort of 47. Endometrial samples were obtained using a Pipelle endometrial suction curette at a single time point before surgery. Logistic regression was used to assess the relationship between body mass index and endometrial pathology when adjusting for age and race.

RESULTS

Of the 29 successful biopsies, 8 (27.6%) were classified as abnormal endometrium: 1 was classified as complex atypical hyperplasia, 1 was classified as hyperplasia without atypia, 4 samples were identified with endometrial polyps, and 2 samples were identified with metaplasia. None presented with cancer. Increasing body mass index was significantly associated with higher risk of abnormal endometrium (OR = 1.19, 95% CI [1.03-1.36], P = .01).

CONCLUSIONS

The findings in this sample suggest that obesity may be associated with increased risk of having undiagnosed endometrial pathology. More thorough examination of relationships between levels of obesity and endometrial pathology are needed to better characterize high cancer risk groups who may benefit from introducing new screening measures.

ZEB1 expression in endometrial biopsy predicts lymph node metastases in patient with endometrial cancer

Purpose. The purpose of this study was to analyze the expression of zinc-finger E-box-binding homeobox 1 (ZEB1) in endometrial biopsy and its correlation with preoperative characteristics, including lymph node metastases in patient with endometrial cancer. Methods. Using quantitative RT-PCR, ZEB1 expressions in endometrial biopsy from 452 patients were measured. The relationship between ZEB1 expression and preoperative characteristics was analyzed. Results. ZEB1 expressions were significantly associated with subtype, grade, myometrial invasion, and lymph node metastases. Lymph node metastases could be identified with a sensitivity of 57.8% at specificity of 74.1% by ZEB1 expression in endometrial biopsy. Based on combination of preoperative characteristics and ZEB1 expression, lymph node metastases could be identified with a sensitivity of 62.1% at specificity of 96.2% prior to hysterectomy. Conclusion. ZEB1 expression in endometrial biopsy could help physicians to better predict the lymph node metastasis in patients with endometrial cancer prior to hysterectomy.

Surgical and systemic management of endometrial cancer: an international survey

PURPOSE

To ascertain the spectrum of clinical management of endometrial carcinoma (EC) the largest international survey was conducted to evaluate and identify differences worldwide.

METHODS

After validation of a 15-item questionnaire regarding surgical and adjuvant treatment of EC in Germany, an English-adapted questionnaire was put online and posted to all the major gynecological cancer Societies worldwide for further distribution commencing in 2010 and continued for 26 months.

RESULTS

A total of 618 Institutions around the world participated: Central Europe (CE), Southern Europe (SE), Northern Europe (NE), Asia and USA/Canada/UK. Both a therapeutic and staging value was attributed to systematic pelvic and paraaortic lymph node dissection (LND) in CE (74.6%) and in Asia (67.2%), as opposed to USA/UK where LND was mainly for staging purposes (53.5%; p < 0.001). LND was performed up to the renal veins in CE in 86.8%, in Asia in 80.8%, in USA/UK in 51.2% and in SE in 45.1% (p < 0.001) of cases. In advanced disease, centers from Asia were treated most with adjuvant chemotherapy alone (93.6%), as opposed to centers in SE, CE and UK/USA that employed combination chemo-radiotherapy in 90.9% (p < 0.001) of cases. Paclitaxel/carboplatin was mostly used followed by doxorubicin/cisplatin (75 vs. 23.3%; p < 0.001). In total, 94% of all participants supported the concept of treating EC patients within appropriate clinical trials.

CONCLUSIONS

There is broad range in both the surgical and adjuvant treatment of EC across different countries. Large-scale multicenter prospective trials are warranted to establish consistent, evidence-based guidelines to optimize treatment worldwide.

Role of epithelial to mesenchymal transition proteins in gynecological cancers: pathological and therapeutic perspectives

Gynecorelogic cancers like ovarian, cervical, and endometrial cancers are among the major threats to modern life, especially to female health. Like some other types of cancers, all of these gynecological cancers have found to be associated with the developmental stage epithelial to mesenchymal transition (EMT). More specifically, the aberrant expression of major EMT markers, such as lower expressions of E-cadherin and alpha-catenin, and overexpressions of N-cadherin, beta-catenin, vimentin, and matrix metalloproteinases, have been reported in ovarian, cervical, and endometrial cancers. The transcription factors, such as Twist, Snail, Slug, and Zeb, which regulate these EMT mediators, are also reported to be overexpressed in gynecological cancers. In addition to the over/lower expression, the promoter methylation of some of these genes has been identified too. In the era of target-specific cancer therapeutics, some promising studies showed that targeting EMT markers might be an interesting and successful tool in future cancer therapy. In this study, we have reviewed the recent development in the research on the association of EMT markers with three major gynecological cancers in the perspectives of carcinogenesis and therapeutics.

Semiquantitative perfusion combined with diffusion-weighted MR imaging in pre-operative evaluation of endometrial carcinoma: results in a group of 57 patients

PURPOSE

To evaluate the semiquantitative DCE and quantitative DWI parameters in endometrial cancer, in order to assess the presence of neoplastic tissue and normal myometrium and to ascertain a potential relationship with tumor grade.

METHODS AND MATERIALS

A total of 57 patients with biopsy-proven endometrial adenocarcinoma who underwent MR imaging examination for staging purposes were retrospectively evaluated. Imaging protocol included multiplanar T1- and T2-weighted TSE, DCE T1-weighted (THRIVE; 0, 30, 90 and 120seconds after intravenous injection of gadolinium) and DWIBS sequences (b values=0 and 1000mm(2)/s). Color perfusion and ADC maps were automatically generated on dedicated software. Relative enhancement (RE, %), maximum enhancement (ME, %), maximum relative enhancement (MRE, %), time to peak (TTP, s) and mean apparent diffusion coefficient (ADC) were calculated by manually drawing a region of interest (ROI) both on the neoplastic tissue and the normal myometrium. Histopathology was used as reference standard.

RESULTS

Histopathological analysis confirmed the presence of endometrial carcinoma in all patients. Neoplastic tissue demonstrated significantly lower (P<0.001) values of RE (%) 63.92±35.68; ME (%) 864.91±429.54 and MRE (%) 75.97±38.26 as compared to normal myometrium (RE (%) 151.43±55.99; ME (%) 1800.73±721.32; MRE (%) 158.28±54.05). TTP was significantly higher (P<0.05) in tumor lesion (385.51±1630.27 vs 195.44±78.69). Mean ADC value of neoplastic tissue (775.09±?220.73×10(-3)mm(2)/s) was significantly lower (P<0.05) than in myometrium (1602.37±378.54×10(-3)mm(2)/s). The analysis of perfusion and diffusion parameters classified according to tumor grades, showed a statistically significant difference only for RE (P=0.043) and ME (P=0.007).

CONCLUSIONS

Perfusion parameters and mean ADC differ significantly between endometrial cancer and normal myometrium, potentially reflecting the different microscopical features of cellularity and vascularity; however a significant relationship with tumor grade was not found in our series.