Immunohistochemical Expression of BCL-2 in Endometrial Carcinoma and Its Comparison With Hormone Receptor Status and Epidermal Growth Factor

BACKGROUND

Endometrial carcinoma is the most common malignant tumor of the female genital tract with increasing incidence in developed countries. In the era of targeted therapy, immunohistochemical markers play an important role in the treatment and prognosis of endometrial carcinoma. The aim of the study was to study the immunohistochemical expression of B-cell lymphoma 2 (BCL-2) in endometrial carcinoma and to study the correlation of BCL-2 expression with hormone receptor status and transforming growth factor receptors in endometrial carcinoma.

METHODS

Endometrial carcinoma reported between the period from January 2010 to December 2014 in the department of pathology of this institute was considered in the study. The study included cases of endometrial carcinoma reported on both curetting and hysterectomy specimens. In the samples where both curetting and hysterectomy were received only hysterectomy blocks were included and the curetting was excluded.

RESULTS

The total number of malignancies reported during this period was 3478. Of these 3478 malignancies, 59 were endometrial carcinomas with an incidence of 1.6%. Out of 59 endometrial carcinomas, 46 cases were diagnosed on hysterectomy specimens and 13 cases were diagnosed on endometrial curetting biopsies.

CONCLUSION

The positive expressions of estrogen receptor (ER) and progesterone receptor (PR) in endometrial carcinoma suggest that steroid receptor studies may be of potential benefit in the management of some patients with endometrial carcinoma.

A national level estimation of population need for blood in India

BACKGROUND

The population need for blood is the total volume required to transfuse all the individuals who need transfusion in a defined population over a defined period. The clinical demand will arise when people with a disease or condition who require transfusion, access healthcare services, and subsequently the clinicians request blood. Essentially, the conversion of need to demand must be maximum to avoid preventable mortality and morbidity. The study estimated the population need for blood in India.

METHODS

The methodology included a comprehensive literature review to determine the diseases and conditions requiring transfusion, the population at risk, and prevalence or incidence; and Delphi method to estimate the percentage of people requiring transfusion, and the quantum.

RESULTS

The estimated annual population need was 26.2 million units (95% CI; 17.9-38.0) of whole blood to address the need for red cells and other components after the separation process. The need for medical conditions was 11.0 million units (95% CI:8.7-14.7), followed by surgery 6.6 million (95% CI:3.8-10.0), pediatrics 5.0 million (95% CI:3.5-7.0), and obstetrics and gynecology 3.6 million units (95% CI:1.9-6.2). The gap between need and demand which depends upon the access and efficiency of healthcare service provision was estimated at 13 million units.

CONCLUSION

The study brings evidence to highlight the gap between need and demand and the importance of addressing it. It cannot be just the responsibility of blood transfusion or health systems, it requires a multi-sectoral approach to address the barriers affecting the conversion of need to clinical demand for blood.

Impact of CT-based planning and bladder volume changes on the dosimetry of vaginal vault brachytherapy

Aim:

To compare dose to target and organs at risk (OARs) in conventional plan (2D) versus computed tomography (CT)-based three-dimensional (3D) plan in vaginal cuff brachytherapy (VBT) and to compare the effect of bladder distension on target and OARs dosimetry.

Materials and methods:

Post-hysterectomy patients with an indication for VBT were included in the study. All patients underwent planning CT scans with a full bladder and an empty bladder protocol. For each CT, two plans were generated—one library-based 2D plan and another CT-based 3D plan. Dosimetric parameters were recorded for clinical target volume (CTV) and OARs.

Results:

A total of 92 observations were made from data collected from 46 patients. Difference between CTV dose in terms of 2D and 3D plans were not statistically significant for CTV (p = 0·11). Significant reduction in D0·1cc, D1cc and D2cc dose parameters were observed in bladder, rectum, sigmoid and bowel doses with the 3D plan (p < 0·001). Bladder distension showed a 20% reduction in dose for bowel (p < 0·001). Bladder distension also showed a 6·12% (p = 0·047) increase in D2cc, but there was a significant reduction in the mean dose to the bladder.

Conclusion:

Our study demonstrates the dosimetric benefits with 3D CT-based planning for VBT over 2D-based conventional planning and benefit of bladder distension in the reduction of bowel dose without compromising dose to the target volume.

Gene expression changes and promoter methylation with the combined effects of estradiol and leptin in uterine tissue of the ovariectomized mice model of menopause

Substantial epidemiological studies have shown an association of obesity with the common gynecological malignancy, endometrial cancer. The relevant interactions and contribution of estradiol and the adipose cytokine, leptin, in endometrial lesions are not completely understood. Suitable animal models to understand the physiological response of uterine tissue to the combined effects of estradiol-leptin are lacking. To investigate the effect of estradiol-leptin crosstalk on gene expression and associated altered pathways, we established an ovariectomized mouse model, treated with 17-β estradiol (0.1 µg/mouse subcutaenously., for every 12 h) and/or recombinant mouse leptin (1 μg/g Bwt intraperitoneally., for every 12 h) for 4 h, 20 h, and 40 h. Gene expressions by semi-quantitative RT-PCR, uterine tissue protein phosphorylation status by western blotting and promoter methylation were analyzed in estradiol, progesterone insufficient animals. Semi-quantitative RT-PCR demonstrated significantly increased expression of Esr, Igf1, Igfbp3, Vegfr1, and Vegf, and significantly decreased expression of Mmp9 after co-treatment with estradiol and leptin, indicating a common transcriptional network regulated by the treatments. Ovariectomy-induced histomorphological changes were only reversed by estradiol. Methylation-specific PCR, analyzing methylation of CpG sites of Vegfa, Pgr, and Igf1, revealed that transcriptional regulation after hormonal treatments is independent of methylation at the examined CpG sites. Western blot confirmed the increased expression of PSTAT-3 (Ser-727) and PERK1/2 proteins after estradiol + leptin treatment, confirming the estradiol + leptin cross-talk hypothesis. In conclusion, our in vivo studies determined specific gene expression and signaling protein changes, and further unraveled the molecular targets of estradiol + leptin that may perturb endometrial homeostasis and lead to endometrial hyperplasia development in the chronic stimulated state.

Long-Term Morbidity after Endometrial Cancer Surgery: a Comparison of Open vs. Robotic Approach

This retrospective study is looking into the long-term morbidity after endometrial cancer staging surgery and compares the long-term morbidity of patients who underwent open staging surgery vs. robotic approach. One hundred twenty-nine patients who underwent staging surgery for endometrial cancer from January 2014 until June 2017 were included in the analysis. Morbidities occurring 1 month after surgery-vault complications, incisional hernias, vault dehiscence, and lymphedema-were looked into. There were no statistically significant differences between the long-term complications in both groups (vault infection 5.1% vs. 1.4%, vaginal cuff dehiscence 1.6% vs. 0%, incisional hernia 6.8% vs. 0%, and lymphedema 11.8% vs. 10% in open vs robotic groups respectively). But as far as clinical significance was concerned, patients who underwent robotic staging surgery had a significant decrease in vaginal cuff complications and incisional hernia. Our study shows that robotic-assisted surgery can reduce even long-term morbidity in patients undergoing surgery for endometrial cancer.

Role of Positron Emission Tomography/Computed Tomography in Preoperative Assessment of Carcinoma Endometrium-a Retrospective Analysis

PET/CT has made significant inroads into routine oncological practice in recent times. In our study, we aim to determine its value in preoperative assessment of endometrial carcinoma. A retrospective study between January 2011 and March 2016 was conducted; we included all cases of carcinoma endometrium with a preoperative PET/CT scan. PET/CT images were analyzed and correlated with histological findings after surgical staging. A total of 46 cases were analyzed, mean age was 59.8 years, BMI 30.8 kg/m2, and most common histology endometrioid type (69.5%). We correlated PET/CT findings with histopathology as reference standard. PET/CT had a sensitivity of 40%, moderate specificity (75%) and accuracy (71.7%), good NPV (91.2%), but poor PPV (16.7%) for lymph node involvement. A total of 10 (21.7%) cases were detected to have distant metabolically active lesions on PET/CT, seven out of these were positive for malignancy. And 90% of them were either non-endometrioid type or grade two and higher. We found that SUV of primary tumor was significantly higher in patients with deep myometrial invasion (p = 0.018), and high-risk histological type of tumor (p = 0.022), though not statistically significant when lymph nodal involvement (p = 0.9), cervical involvement (p = 0.56), or histological grade (p = 0.84) were considered. Sensitivity and specificity of PET/CT in staging endometrial cancer is not high enough to reliably tailor lymphadenectomy. Although SUV of the primary tumor was significantly higher in patients with deep myometrial invasion and high-risk histological type, it's usefulness in classifying patients into predefined risk groups seems to be limited. However, it is useful in detecting distant metastasis especially in high-grade and non-endometrioid type of tumors. Thus, implementation of PET/CT as a surrogate for surgical staging of endometrial cancer remains enigmatic and is open to further research.

CA 125 is a better marker to differentiate endometrial cancer and abnormal uterine bleeding

Background

Incidence of endometrial cancer in India is increasing due to lifestyle changes and obesity. As 5 year survival rate of cancer confined to uterus is good, there is need for serum tumor marker for early diagnosis. This study was designed to identify a tumor marker which differentiate endometrial carcinoma and abnormal uterine bleeding (AUB) because common presentation of endometrial carcinoma is AUB.

Objectives

To estimate and compare serum prolactin, Cancer Antigen 125 (CA-125), Cancer Antigen 15-3 (CA15-3), and Carcino embryonic antigen (CEA) levels in patients with endometrial cancer and abnormal uterine bleeding; To evaluate the role of these markers in diagnosing endometrial cancer.

Methodology

Thirty eight patients with endometrial cancer and 40 patients with AUB were recruited in this study. Serum prolactin, CA 125, CEA, and CA 15-3 levels were estimated in both groups.

Results

The levels of CA 15-3, CA 125, CEA, and prolactin were increased in endometrial carcinoma patients, on comparison with AUB patients. CA 125 alone was found to be a better marker to detect endometrial cancer with 52.63% sensitivity, 80.00% specificity.

Conclusion

As individual tumor marker, serum CA 125 has the ability to detect endometrial cancer in patients with abnormal uterine bleeding.

Prospective Nonrandomized Comparative Study of Laparoscopic Versus Open Surgical Staging for Endometrial Cancer in India

Laparoscopic procedures to treat endometrial cancer are currently emerging. At present, we have evidence to do laparoscopic oncologic resections for endometrial cancer as proven by many prospective studies from abroad such as LAP2 by GOG. So, we have decided to assess the safety and feasibility of such a study in our population with the following as our primary objectives: (1) to study whether laparoscopy is better compared to open approach in terms of duration of hospital stay, perioperative morbidity and early recovery from surgical trauma and (2) to study whether the laparoscopic approach is noninferior to the open approach in terms of number of lymph nodes harvested in lymphadenectomy and rate of conversion to open surgery. We did a prospective nonrandomized comparative study of open versus laparoscopy approach for surgical staging of endometrial cancer from 16th May 2013 to 15th May 2015. To prove a significant difference in the hospital stay, we needed 29 patients in each arm. Thirty patients in each arm were enrolled for the study. The median duration of stay in the open arm was 7 days and in the laparoscopy arm it was 5 days. The advantage of 2 days in the laparoscopic arm was statistically significant (P value 0.006). Forty percent of patients in the open arm had to stay in the hospital for more than 7 days whereas only 3% of patients in the laparoscopy arm required to stay for more than 7 days (P value 0.001). This difference was statistically significant. There was no significant difference between the early complication rates between the two arms (20% in open vs. 13% in laparoscopy; P value 0.730). There was a conversion rate of 10% in laparoscopy. The median number of nodes harvested in open arm was 16.50 and in the laparoscopy arm, it was 13.50. The difference was not statistically significant (P value 0.086). Laparoscopy approach for endometrial cancer staging is feasible in Indian patients and the short-term advantages are replicable with same oncologic safety as proved by randomized controlled trials.

Expression of Estrogen Receptors (ER), Progesterone Receptors (PR) and HER-2/neu receptors in Endometrial Carcinoma and their associations with histological types, grades and stages of the tumor

Objective:

To study and detect immunohistochemical expression of Estrogen Receptors, Progestrone Receptors and HER-2/neu Receptors in Endometrial Carcinoma (EC) and to find their associations with histological types, grades and stages of the tumor.

Methods:

A cross sectional study of one year duration from January 2016 to January 2017 was conducted at Histopathology department of Army Medical College, Rawalpindi. A non-probability purposive sampling technique was used to include 56 cases of EC. The specimens were tested for ER, PR and HER-2/neu expression using immunohistochemical analysis. Data was analyzed in SPSS and the significance of association of expression of the receptors with histological types, grades and stages of the tumor was assessed.

Results:

Significant association of Her-2/neu overexpression with histological types and grades of EC was seen, whereas the association of ER and PR expression with histological types, grades and stage of EC was statistically insignificant.

Conclusion:

It is suggested that EC showing over expression of HER2/neu with immunohistochemistry may be treated with anti HER-2/neu treatment with better chances of survival and decreased post-treatment morbidity.

Sexual Dysfunction in Females after Cancer Treatment: an Unresolved Issue

Cancer besides being a leading cause of mortality also creates a myriad of morbidities in survivors whether treated or untreated. Among women surviving after gynecological malignancies sexual dysfunction is a morbidity unexplored in Indian context because of cultural barriers. With the increasing proportion of women surviving carcinoma of the cervix, quality of life has become an important clinical issue. Despite the immense distress it causes in patients, sexual dysfunction is neither screened nor treated in Indian scenario. Despite this recognition, the area is not well researched and there is a paucity of information on the impact of cancer treatment on sexual health in Indian Context. Research has shown that up to 50% of women treated for cervix cancers have sexual dysfunction as they recover and become cancer survivors. This article aims to review the phases of sexual response and how each may be affected by the physical and emotional stress of cancer diagnosis and treatment. We will then discuss existing tools for assessment of sexual function and approaches to their treatment. Finally, we will conclude with advice to health care professionals based on current research and suggest questions for future study.

Pap Smears in Endometrial Adenocarcinoma: Does It Have a Role?

Background: Historically the conventional Pap smear has been an effective screening tool for Carcinoma cervix. However the reporting of benign and malignant endometrial cells on Pap smear has remained controversial. There are very few studies addressing the utility of Pap smears in diagnosing endometrial carcinomas. Objective: To rescreen the Pap smears of patients with endometrial adenocarcinoma for the detection of normal/ atypical endometrial cells and to correlate with clinico-pathological parameters. Methods: The present study was carried out at SDM College of Medical Sciences, Dharwad, Karnataka, India for a period of 7 years. Of the 89 endometrial cancers diagnosed, Pap smear slides were available in 32 patients, which were reviewed and classified as normal cells/ atypical cells. Corresponding biopsy slides were reviewed for tumour type, nuclear grade, myometrial invasion and stage. Statistical tests of independence were applied for selected clinico-pathological parameters. Results: Cervical cytology was normal in nine patients (28.1%) and atypical in 23 patients ( 71.2%). The most common histological type was endometrioid carcinoma in 27 cases (84%). 13 cases(40.5%) had nuclear grade 1 whereas 9 cases(28%) and 10 cases(31.2%) had grades 2 and 3, respectively. Of the 22 cases assessed for invasion and stage, 12 cases had <1/2 of invasion (41.2%) and remaining 10 cases had >1/2 of invasion (58.8%). Early stages (I and II) had 17 cases (77.27%) and advanced stage (III and IV )had 5 cases (23.5 %). Significant correlation was found between post-menopausal status and higher nuclear grades (p<0.05).Conclusion: Pap smear is primarily a screening test for squamous cell carcinoma cervix. If atypical glandular cells are seen, further investigations are required to rule out neoplasia. All women with atypical endometrial cells on Pap tests need endometrial sampling irrespective of age/menstrual status.

Sociodemographic and Clinical Profile of Cervical Cancer Patients Visiting in a Tertiary Care Hospital in India

Context

Cancer of the cervix is the most common genital tract malignancy in the female and is a major public health problem in the developing countries. Study of the sociodemographic and clinical profile of patients is the first step in planning control measures and treatment facilities.

Aims

The aims of the study were to determine the sociodemographic and clinical profile of cervical cancer patients and study their association with other tumor-related factors.

Settings and Design

This is a record-based retrospective study from a single institution.

Subjects and Methods

The data on sociodemographic and clinical factors of 765 cervical cancer patients visited and treated at tertiary care cancer hospital in Mumbai in 1 year period were analyzed.

Statistical Analysis

Data were analyzed using descriptive statistics. Kruskal-Wallis and Chi-square test were used to assess relationship between variables.

Results

The median age of the cohort was 54 years and interquartile range was 16 years. Nearly 53.6% of patients were illiterate. About 88.10% of patient's had squamous cell carcinoma. Only 13% of cases had early stage disease and 77% of patient's had not taken any treatment before coming to the hospital. Of the total, about 26% patients also had concomitant comorbidities, of which hypertension was found to be the leading comorbid condition. Stage of disease was found to be significantly (P < 0.05) associated with age and educational status.

Conclusion

This study highlights certain important baseline characteristics of cervical cancer patients. This basic information on profile of patients can help plan and optimum utilization of hospital services, especially in resource-poor countries like India.

Imaging in endometrial carcinoma

Endometrial carcinoma (EC) is the most common gynecologic malignancy in the United States. Prognosis depends on patient age, histological grade, depth of myometrial invasion and/or cervical invasion, and the presence of lymph node metastases. Although EC is staged surgically according to the International Federation of Gynecology and Obstetrics (FIGO) system, preoperative imaging can assist in optimal treatment planning. Several imaging techniques such as transvaginal ultrasonography (TVUS), computed tomography (CT), and magnetic resonance imaging (MRI) have been used as diagnostic tools for preoperative staging of EC. Recently, positron emission tomography (PET), PET/CT, and PET/MRI have also been used in staging these patients. In this article, we review the value of imaging in diagnosis, staging, treatment planning, and detection of recurrent disease in patients with EC.

Hospital-based study of epithelial malignancies of endometrial cancer frequency in lahore, pakistan, and common diagnostic pitfalls

The current study was conducted to see the frequency of epithelial malignancies of endometrium with focus on the common diagnostic pitfalls and identify morphological and immunohistochemical markers helpful in the differential diagnosis between different subtypes. It is a retrospective descriptive study carried out on 52 specimens of endometrial tumors received in Fatima Memorial Hospital, Lahore, Pakistan, during three years (2010–2012). Patients were divided into 5 age groups: <40, 41–50, 51–60, 61–70, and >70 yrs. Tissues were fixed in 10% formalin and processed and stained with haematoxylin-eosin. Stained slides were examined to determine the histological types by WHO classification, and immunohistochemistry for WT1, p53, ER/PR, and MIB1 was done in cases where morphology alone was not helpful in making a confirmed diagnosis. 80% of specimens were of endometrioid adenocarcinomas, 11% of serous tumors, 4% of clear cell carcinoma, and 4% of squamous cell carcinomas involving both cervix and endometrium. Most of the patients (28.84%) with endometrial carcinomas fall in the age range of 51–60 yrs. Endometrioid adenocarcinoma is the most common type of epithelial endometrial malignancies. Morphology is the keystone in the evaluation of these tumors, but immunohistochemistry can also be helpful in establishing the correct diagnosis.