The effect of tamoxifen therapy on the endometrium and ovarian cyst formation in patients with breast cancer

Prospective Exploratory Study of the Effects of Postoperative Endocrine Medication on the Endometrium in Breast Cancer Patients

Objective

This study aimed to investigate the pathological effects of long-term postoperative endocrine medication on the endometrium in breast cancer patients.

Methods

Data of 99 patients with primary breast cancer who underwent hysteroscopy and obtained endometrial biopsy from 1 June 2018 to 31 December 2021 at the Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital were prospectively collected.

Results

Hysteroscopy was performed followed by endometrial histopathological examination in 99 breast cancer patients, including 44 taking tamoxifen (TAM), 26 taking other endocrine drugs, and 29 not taking endocrine drugs. The endometrial thickness in the TAM group was significantly higher than that in the other endocrine drug groups and the group not taking endocrine drugs (p=0.017). The receiver operating characteristic curves for the abnormal premenopausal endometrial thickening were plotted in this study; an endometrial thickness of 15.5 mm seen on ultrasound could be used as the most accurate ultrasound diagnostic threshold for the diagnosis of abnormal premenopausal endometrial hyperplasia, with an area under the curve of 0.888 (95% CI: 0.716, 1.000), a sensitivity of 100%, and a specificity of 75%, which was consistent with the results of our previous retrospective study. An endometrial thickness of ≥5 mm in postmenopausal women with breast cancer taking TAM was still used as the cut-off value for routine ultrasound diagnosis of abnormal postmenopausal endometrial hyperplasia.

Conclusion

An ultrasound endometrial thickness (proliferative phase) of >15 mm in premenopausal patients can be used as the most accurate ultrasound diagnostic threshold for the diagnosis of abnormal endometrial hyperplasia. After menopause, an ultrasound endometrial thickness of ≥5 mm is still used as the criterion for diagnosing abnormal endometrial hyperplasia. Older patients should be monitored for signs of vaginal bleeding and fluid discharge, and hysteroscopy should be performed if necessary to ascertain the endometrial condition.

Evaluation of endometrial thickness in breast cancer patients with tamoxifen treatment - Difference between 2-dimensional ultrasonography and elastosonography

OBJECTIVE

This study aimed to confirm the clinical significance of elastographic endometrium measurement in comparison with conventional ultrasonography for tamoxifen users with breast cancer.

MATERIALS AND METHODS

In this retrospective analysis, 98 women receiving tamoxifen as postoperative breast cancer treatment were included. Patient medical charts were reviewed, and related medical, obstetric, and gynecological information and histories relevant to breast cancer were evaluated. Patient clinical imaging data included endometrial thickness measurements using both conventional ultrasonography and elastography, and the differences between these two modalities in delta values were statistically analyzed along with possible influencing factors.

RESULTS

Endometrial thickness measured using 2-dimensional ultrasonography had a mean value of 5.81 mm (standard deviation [SD] = 3.09), and elastosonography showed a mean value of 3.07 mm (SD = 1.62). A paired t-test was conducted and a significant difference between them was confirmed (P-value <0.001). Logistic regression analysis revealed that age and duration of tamoxifen treatment significantly influenced the degree of difference between endometrial thickness measurements.

CONCLUSIONS

Elastosonography may be a more successful and useful tool for measuring actual endometrial thickness than generalized 2-dimensional ultrasonography. In clinical cases with limited use of elastosonography and consequent inability for thorough evaluation of endometrial thickness, practitioners should exercise caution in deciding whether or not to adopt invasive diagnostic procedures, such as endometrial curettage, especially for young patients of reproductive age or those with prolonged treatment of breast cancer with tamoxifen.

Tamoxifen decreases ovarian toxicity without compromising cancer treatment in a rat model of mammary cancer

BACKGROUND

Premenopausal women diagnosed with breast cancer often face aggressive chemotherapy resulting in infertility. Tamoxifen (TAM) is a selective estrogen receptor modulator that was previously suggested as a protective agent against chemotherapy-induced ovarian failure. In the current study, we examined mechanisms of the protective action of TAM in the ovaries of tumor-bearing rats treated with the chemotherapy drug cyclophosphamide (CPA).

RESULTS

TAM prevented CPA-induced loss of ovarian follicular reserves. The protective TAM effect in the rat ovary partially resulted from decreased apoptosis. In addition, transcriptomic and proteomic screening also implicated the importance of DNA repair pathways as well as cell adhesion and extracellular matrix remodeling in the protective ovarian actions of TAM.

CONCLUSIONS

Tamoxifen shielded the ovary from the side effects of chemotherapy without lessening the tumoricidal actions of mammary cancer treatment.

Uterine metastasis from invasive ductal breast carcinoma: A case report with literature review

Breast cancer is the leading cause of cancer death in women, and most breast cancer related deaths are due to metastases. Uterine metastases from breast cancer are uncommon and rarely reported in the literature. We described the case of a 50 years-old-woman who developed a uterine metastasis, 6 years after the diagnosis of an invasive ductal breast carcinoma. Indeed, although the patient was asymptomatic, the monitoring imaging examinations, particularly the computed tomography (CT) and the positron emission tomography/computed tomography (PET/CT), showed a myometrial lesion. Non-conservative total hysterectomy was performed. The anatomo-pathological examination revealed a myometrial metastasis from an invasive ductal breast carcinoma. Seventeen months after surgery, the patient had no pelvic recurrence, but lungs and bones metastases progressed despite chemotherapy. In the lack of guidelines of uterine metastases from breast cancer's management, we reviewed the existing literature with the aim to provide a rational framework for clinical presentation, diagnostic approach, histological findings and treatment of this rare and heterogeneous pathology. Uterine metastases of breast cancer are frequently revealed with metrorrhagia. They occur preferentially in tumours with initial lobular carcinoma, initial lymph node involvement and positive hormonal receptors.

The evaluation of laparotomy results in breast cancer patients with gynecological pathologies

AIM

The aim of the study was to evaluate the results of the laparotomies due to gynecological pathologies in breast cancer patients and to assess the distribution of gynecological pathologies and the clinical and laboratory findings contributing to the diagnosis.

METHODS

This study was conducted between years 2002 and 2011 at Hacettepe University Hospital. We obtained information about 86 consecutive breast cancer patients, including age, time of diagnosis and pathology of breast cancer, hormone receptor status, history of endocrine therapy, presenting symptoms, ultrasonography findings, CA 125 levels, endometrial biopsy results, type of gynecological surgery and pathology results. Data were analyzed with the use of SPSS software.

RESULTS

Twenty-one (24.4%) out of 86 patients had endometrial pathology, and 24 (27.9%) had adnexal pathology. Fourteen patients (16.2%) had malignant pathology, and of them, 11 had ovarian cancer 3 had endometrial cancer. There were five abnormal cytological findings: 2 ASCUS, 1 LSIL, 1 ASC-H and 1 adenocarcinoma. The patient with the cytology report of adenocarcinoma had the final diagnosis of endometrial cancer. Of the patients, 67 (77.9%) used tamoxifen, whereas 19 (22.1%) did not. Thirty-three patients (38.4%) with gynecological pathologies were detected incidentally during routine follow-up of breast cancer.

CONCLUSION

This study supports the increase of the gynecological pathology incidence in breast cancer patients and the recommendation of close gynecological follow-up in these patients. Asymptomatic patients might also develop genital cancer. The ultrasonographic appearance of the adnexal masses or endometrial thickness and any abnormal vaginal bleeding or high CA 125 levels are important parameters for evaluating breast cancer patients.

A prospective, randomized study of Toremifene vs. tamoxifen for the treatment of premenopausal breast cancer: safety and genital symptom analysis

BACKGROUND

Toremifene (TOR) is a selective oestrogen receptor modulator (SERM) and has comparable efficacy to that of tamoxifen (TAM) in breast cancer patients. Herein, we compared the safety of TOR to that of TAM in the adjuvant treatment of premenopausal breast cancer.

METHODS

This was a prospective randomized and open-label clinical study. Premenopausal patients with hormonal receptor (HR)-positive early breast cancer were randomly assigned (1:1) to receive TOR) or TAM treatment. The follow-up period was 1 year. The primary end point was the incidence of ovarian cysts, and secondary end points were the incidence of endometrial thickening, changes in female hormones, the incidence of fatty liver, changes in the modified Kupperman index (mKMI) and changes in quality of life.

RESULTS

There were 92 patients in the final analysis. The incidences of ovarian cysts were 42.6% in the TOR group and 51.1% in the TAM group (p = 0.441). Forty-one patients (87.2%) in the TOR group and 36 patients (80.0%) in the TAM group experienced endometrial thickening (p = 0.348). The proportions of patients with fatty liver were 31.9% in the TOR group and 26.7% in the TAM group (p = 0.581). No significant differences in the mKMI or quality of life were observed between the two groups.

CONCLUSIONS

TOR and TAM have similar side effects on the female genital system and quality of life in premenopausal early breast cancer patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02344940. Registered 26 January 2015 (retrospectively registered).

Effects of ‎tamoxifen on the reproductive system of female breast cancer patients: an ultrasound-based cohort study

Background: Tamoxifen (TMX) is regarded as standard treatment for breast cancer (BC) patients‎. In recent years, several studies have reported gynecological side effects and due to TMX's estrogenic effects. Here, we evaluate the side effects of TMX on the ‎endometrium and ovaries of female BC patients. Methods: This was an ultrasound-based cohort study conducted in three oncology centers in Baghdad, Iraq. A total of ‎‎255 female patients were included, 140 premenopausal (PreM) and 115 postmenopausal (PostM), with estrogen receptor (ER)-positive BC using TMX adjuvant hormonal treatment for at least three months after surgery and adjuvant ‎chemo/radiotherapy.‎ Ultrasound (US) on the endometrium and ovaries of the women following ‎BC surgery/chemotherapy (baseline) and at 3, 6, 12, and 24 months following was performed‎. Data collected included age, menopausal status, co-morbid chronic illness and medications, including duration of TMX treatment. Results: Presence of ovarian cyst was significantly higher in the PreM ‎compared to PostM ‎women, while there were no significant differences for other gynecological findings.‎ At ‎baseline, endometrial thickness (ET) was significantly higher in the PreM compared to the PostM women. In both groups, women with increased ET became more frequent from baseline to 3 ‎months, from 3 to 6 ‎months, from 6 to 12 months, and from 12 ‎ to 24 months. At all time periods, ‎women with increased ET was ‎significantly higher in the PostM compared PreM women, resulting ‎in a risk of ET increase by 6 folds (ranging from 3 – ‎‎11 folds) ‎in PostM compared to PreM women. Conclusions: Longer duration of TMX is associated with increased ET. Duration of TMX did not appear to increase the risk of various gynecological outcomes, for example endometrial cancer rate was low. Finally, there was an increase in ET, which appeared to be six-folds higher in PostM compared to PreM women.‎

Ovarian hyperstimulation closely associated with resumption of follicular growth after chemotherapy during tamoxifen treatment in premenopausal women with breast cancer: a multicenter retrospective cohort study

Background

We previously reported that tamoxifen (TAM)-induced ovarian hyperstimulation (OHS) is associated with high serum concentrations of estradiol in premenopausal women with breast cancer. To investigate risk factors for TAM-induced OHS, we performed a retrospective multicenter study.

Methods

Premenopausal patients who received surgical therapy for endocrine-dependent breast cancer (n = 235) were recruited in this study and classified into 4 groups: group A, treated with TAM alone; group B, TAM treatment after 2-year-combined therapy with a gonadotropin-releasing hormone (Gn-RH) agonist; group C, TAM treatment after chemotherapy; group D, 5-year-combined therapy with TAM and a Gn-RH agonist. A serum estradiol value of more than 300 pg/mL or mean follicular diameter of more than 30 mm was defined as OHS.

Results

The incidence of OHS in group A (n = 13/26, 50.0%) was significantly higher than those in group B (n = 17/63, 27.0%), group C (n = 20/110, 18.2%), and group D (n = 0/36, 0%). The incidence of OHS was significantly correlated with aging, and the median serum concentration of estradiol in the presence of OHS was 823.0 pg/mL. The incidence of OHS (less than 47 years old) was 62.5% in group A, 48.6% in group B, and 28.2% in group C, respectively. Notably, the incidence rate of OHS following amenorrhea in group C (n = 13/20, 65.0%) was significantly higher than that in group B (n = 1/17, 5.9%).

Conclusions

These findings indicate that the onset of OHS following amenorrhea was common in the post-chemotherapeutic group, while its ratio was low in the group after Gn-RH analog treatment, suggesting that combined treatment-based management involving TAM therapy is necessary for premenopausal patients with breast cancer.

Menopause hormone therapy: latest developments and clinical practice

Menopause hormone therapy (MHT) is the most efficient treatment for symptoms of acute climacteric syndrome and for efficient prevention of long-term estrogen deficiency. Vaginal administration of low doses of estrogen is a therapy of choice for treatment and prevention of urogenital atrophy and its consequences. Systemic treatment may include estrogen, but an equally efficient alternative is tibolone. Nonhormonal therapy relies on phytoestrogens, black cohosh extract, and serotonin reuptake inhibitors.