High Expression of Galectin-1, VEGF and Increased Microvessel Density Are Associated with MELF Pattern in Stage I-III Endometrioid Endometrial Adenocarcinoma

The prognostic value of vascular endothelial growth factor in endometrial cancer: A protocol for systematic review and meta-analysis

BACKGROUND

A large number of studies have shown that high expression of vascular endothelial growth factor (VEGF) in cancer tissues is associated with poor prognosis of various cancers. However, this finding in endometrial cancer is controversial. Therefore, this meta-analysis aimed to explore the effects of VEGF on survival in patients with endometrial cancer.

METHODS

Four databases of PubMed, Medline, Web of Science, and China National Knowledge Infrastructure were searched to collect literature that met the inclusion criteria. The association between high VEGF expression and survival outcomes and clinicopathological features of patients with cancer was evaluated by calculating the combined hazard ratio (HR), odds ratio (OR), and 95% confidence interval (CI). The Begg test was used to assess publication bias.

RESULTS

A total of 11 studies were included, involving 1251 patients. The results showed that compared with low VEGF expression, high VEGF expression was significantly associated with shorter overall survival (HR = 2.44, 95% CI = 1.15-5.16, I2 = 80%, P = .02) and disease-specific survival (HR = 7.87, 95% CI = 1.70-36.44, I2 = 64%, P = .008) but not with disease-free survival (HR = 1.45, 95% CI = 0.70-3.02, I2 = 68%, P = .32). In addition, VEGF expression is higher in patients with advanced stage (OR = 3.70, 95% CI = 2.22-6.19, P < .001), lower histological differentiation (OR = 2.08, 95% CI = 1.22-3.55, P = .007), and lymph node metastasis (OR = 5.42, 95% CI = 2.35-5.11, P < .001).

CONCLUSION

High VEGF expression can predict poor prognosis and poor clinicopathological features in patients with endometrial cancer, and it may be a valuable new indicator to evaluate the prognosis of patients with endometrial cancer.

Association of Local and Distant Organ Metastases With MELF Pattern in Endometrial Cancer

Several types of myometrial invasion in endometrioid-type endometrial adenocarcinoma (EEC) have been identified: adenomyosis-like changes; adenoma malignum; broad front, single-cell/cell clusters; and the microcystic elongated and fragmented (MELF) pattern. This study aims to investigate the effect of the MELF pattern on recurrence type and survival rate among patients with EEC. We retrospectively reviewed the records of patients diagnosed with EEC over a 10-year period from January 2011 to January 2021. Among 108 patients with EEC, 54 had recurrence (study group), and 54 did not (control group). The MELF pattern was more common in the group with recurrence than in the group without recurrence (40.7% vs. 14.8%; P=0.002). The MELF pattern was observed in 60.0% of patients with local recurrence and 29.4% of patients with extrapelvic or distant organ metastases (P=0.027). Evaluation of 5-year disease-free survival (P=0.003) and overall survival (P=0.001) rates showed that MELF positivity was associated with decreased survival. Among patients with grade I-II EEC lacking uterine-localized myometrial invasion, the MELF pattern was less common in the nonrelapsed group than in the local relapse group (10.0% vs. 60.0%; P<0.001). The MELF pattern (odds ratio=19.4, 95% CI=1.2-31.2) was a significant independent negative predictor for local recurrence. The MELF pattern was more common in patients with recurrence, especially local recurrence. This finding suggests that the MELF pattern primarily impacts direct local invasion rather than hematogenous or lymphatic spread.

Endocervical Adenocarcinoma Showing Microcystic, Elongated, and Fragmented (MELF) Pattern of Stromal Invasion: A Single-Institutional Analysis of 10 Cases with Comprehensive Clinicopathological Analyses and Ki-67 Immunostaining

Microcystic, elongated, and fragmented (MELF) pattern of invasion has seldom been documented in endocervical adenocarcinoma (EAC). The aim of this study was to analyze the clinicopathological characteristics of EAC showing MELF pattern. We collected the clinicopathological information of 10 cases of EAC with the MELF pattern and conducted polymer-based immunostaining for Ki-67 (dilution 1:200, clone MIB-1) on these cases. Ki-67 expression was assessed using the average estimation within the hotspot method. All tumors were human papillomavirus-associated EAC with Silva pattern C. All except one tumor exceeded 3 cm in size. Five tumors involved the entire thickness of the cervical stroma, and four tumors extended into the parametrium. Lymphovascular space invasion was identified in six cases. Two patients developed metastatic recurrences in the para-aortic lymph nodes and lungs, respectively. The MELF area showed significantly lower Ki-67 labelling index than that of a conventional tumor area. We confirmed our previous observation that the MELF area displayed lower proliferative activity than the conventional tumor area of EAC. We also demonstrated that patients with EAC showing MELF pattern had several adverse clinicopathological characteristics reflecting aggressive behavior. On the other hand, since the frequencies of post-operative recurrence and disease-related mortality that occurred during the follow-up period were relatively low, further investigations are warranted to clarify the prognostic value of MELF pattern in EAC patients.

Determining the level of stromal and epithelial cells activity in normal and hyperplastic endometrium of late reproductive and perimenopausal women

Hyperplastic processes of the endometrium (HPE) are a group of benign endometrial and stromal cells that have undergone altered growth. This study aimed to investigate the potential role of hypoxia (as indicated by Hif-1α) and apoptosis markers (p53 and BCL-2) in the development of hyperplastic processes of the endometrium (HPE). Results showed that endometrial cells with atypical hyperplasia had increased levels of Hif-1ɑ, which indicates the presence of endometrial hypoxia and may trigger pathological manifestations. Though this result was not statistically significant, it could be the cause of atypia hyperplasia in the late reproductive period (Hif-1ɑ=1.89±0.09 units) and the perimenopausal period (Hif-1ɑ=2.09±0.07 units). Additionally, the study found that p53 markers were elevated in epithelial cells in the late reproductive period, and similar patterns were observed in the perimenopausal period, with the biggest expression in atypical hyperplasia. The study also found that the high expression of BCL-2 indicator (+++) was less common in late reproductive period women with atypia than those without it (χ²=7.2 p=0.01). A similar situation was observed in women in the perimenopausal period (χ²=4.2 p=0.04). These findings suggest that hypoxia may play a role in the development of HPE, as well as changes in apoptotic markers present in the endometrial tissue.

Role of adipocytokines in endometrial cancer progression

Endometrial cancer is considered a significant barrier to increasing life expectancy and remains one of the most common malignant cancers among women in many countries worldwide. The increasing mortality rates are potentially proportional to the increasing obesity incidence. Adipose tissue secretes numerous adipocytokines, which may play important roles in endometrial cancer progression. In this scenario, we describe the role of adipocytokines in cell proliferation, cell invasion, cell adhesion, inflammation, angiogenesis, and anti-apoptotic action. A better understanding of the mechanisms of these adipocytokines may open up new therapeutic avenues for women with endometrial cancer. In the future, larger prospective studies focusing on adipocytokines and specific inhibitors should be directed at preventing the rapidly increasing prevalence of gynecological malignancies.

Clinicopathologic association and prognostic impact of microcystic, elongated and fragmented pattern invasion, combined with tumor budding in endometrioid endometrial cancer

AIM

As a special invasive pattern seen in low-grade endometrial carcinoma, microcystic, elongated and fragmented (MELF) pattern is related to lymph node metastasis. Tumor budding (TB) is another histological marker in many cancers associated with tumor aggressiveness. Herein, we evaluated the impact of MELF pattern combined with TB about clinicopathological features and prognosis in endometrioid endometrial cancer (EEC). To verify the relationship between the two morphological markers and microsatellite status in EEC, the primary mismatch repair (MMR) proteins were detected by immunohistochemistry.

METHODS

One hundred and seventy-two cases of ECC diagnosed between 2011 and 2016 were reviewed with a median follow up of 47.5 months. MELF pattern and TB were examined on all H&E-stained slides. Primary MMR proteins (MLH1, MSH2, MSH6, and PMS2) were also detected.

RESULTS

Based on MELF pattern and TB, 172 patients were divided into the following four groups: MELF(-)/TB(+) (n = 41), MELF(+)/TB(-) (n = 15), MELF(+)/TB(+) (n = 20), and MELF(-)/TB(-) (n = 96). Adverse pathological features were observed in the MELF(+)/TB(+) group: 70% presented deep muscular infiltration, 65% were lymphovascular space invasion, and 25% suffered lymph node metastasis. The proportion of MMR deficient in MELF(+)/TB(-) group was the highest (66.7%). The progression-free survival (PFS) and overall survival (OS) among the four groups were significantly different. MELF(+)/TB(+) group showed the worst PFS and OS. As univariate and multivariate survival analyses revealed, the combination of MELF pattern and TB was confirmed as an independent predictor of poor prognosis.

CONCLUSIONS

Our research demonstrates that MELF pattern combined with TB, as an independent predictor of adverse outcome, is associated with adverse pathological features, which facilitates better understanding of EEC tumor behavior and more precise prognosis without additional medical expense.

VEGF Immunoexpression in Endometrioid Endometrial Carcinomas

Vascular endothelial growth factor (VEGF) is the most important stimulator of endometrial tumor angiogenesis, a mechanism that may be a therapeutic target in the context of an incidence and persistent mortality of endometrial endometrial carcinomas (EEC). In this study, VEGF immunoexpression was analyzed for 50 cases of EEC in relation to the histopathological parameters of tumor aggressiveness. High VEGF scores have been associated with the high grade and advanced stage of EEC, but unrelated to the depth of myometrial invasion, the pattern of tumor invasion, or vascular invasion. VEGF may be useful for assessing EEC aggression, but also for tumor angiogenic potential, which recommends it as a possible mark for specific antitumor therapy.

Advances in Anti-Cancer Immunotherapy: Car-T Cell, Checkpoint Inhibitors, Dendritic Cell Vaccines, and Oncolytic Viruses, and Emerging Cellular and Molecular Targets

Unlike traditional cancer therapies, such as surgery, radiation and chemotherapy that are typically non-specific, cancer immunotherapy harnesses the high specificity of a patient’s own immune system to selectively kill cancer cells. The immune system is the body’s main cancer surveillance system, but cancers may evade destruction thanks to various immune-suppressing mechanisms. We therefore need to deploy various immunotherapy-based strategies to help bolster the anti-tumour immune responses. These include engineering T cells to express chimeric antigen receptors (CARs) to specifically recognise tumour neoantigens, inactivating immune checkpoints, oncolytic viruses and dendritic cell (DC) vaccines, which have all shown clinical benefit in certain cancers. However, treatment efficacy remains poor due to drug-induced adverse events and immunosuppressive tendencies of the tumour microenvironment. Recent preclinical studies have unveiled novel therapies such as anti-cathepsin antibodies, galectin-1 blockade and anti-OX40 agonistic antibodies, which may be utilised as adjuvant therapies to modulate the tumour microenvironment and permit more ferocious anti-tumour immune response.