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Ma X, Xu L, Ma F, Zhang J, Zhang G, Qiang J. Whole-tumor apparent diffusion coefficient histogram analysis for preoperative risk stratification in endometrial endometrioid adenocarcinoma. Int J Gynaecol Obstet 2024; 164:1174-1183. [PMID: 37925611 DOI: 10.1002/ijgo.15226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/15/2023] [Accepted: 10/17/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVE To investigate the application of whole-tumor apparent diffusion coefficient (ADC) histogram metrics for preoperative risk stratification in endometrial endometrioid adenocarcinoma (EEA). METHODS Preoperative MRI of 502 EEA patients were retrospectively analyzed. Whole tumor ADC histogram analysis was performed with regions of interest drawn on all tumor slices of diffusion-weighted imaging scans. Risk stratification was based on ESMO-ESTRO-ESP guidelines: low-, intermediate-, high-intermediate-, and high-risk. Univariable analysis was used to compare ADC histogram metrics (tumor volume, minADC, maxADC, and meanADC; 10th, 25th, 50th, 75th, and 90th percentiles of ADC [recorded as P10, P25, P50, P75, and P90 ADC, respectively]; skewness; and kurtosis) between different risk EEAs, and multivariable logistic regression analysis to determine the optimal metric or combined model for risk stratifications. Receiver operating characteristic curve analysis with the area under the curve (AUC) was used for diagnostic performance evaluation. RESULTS A decreasing tendency in multiple ADC values was observed from the low- to high-intermediate-risk EEAs. The (low + intermediate)-risk EEAs and low-risk EEAs had significantly smaller tumor volumes and higher minADCs, meanADCs, P10, P25, P50, P75, and P90 ADCs than the (high-intermediate + high)-risk EEAs and non-low-risk EEAs (all P < 0.05), respectively. The combined models of the (meanADC + volume) and the (P75 ADC + volume) yielded the largest AUCs of 0.775 and 0.780 in identifying the (low + intermediate)- and the low-risk EEAs from the other EEAs, respectively. CONCLUSION Whole-tumor ADC histogram metrics might be helpful for preoperatively identifying low- and (low + intermediate)-risk EEAs, facilitating personalized therapeutic planning.
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Affiliation(s)
- Xiaoliang Ma
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Limin Xu
- Department of Ultrasound, Lishui People's Hospital, Zhejiang Province, Lishui, People's Republic of China
| | - Fenghua Ma
- Department of Radiology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, People's Republic of China
| | - Jialiang Zhang
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Guofu Zhang
- Department of Radiology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, People's Republic of China
| | - Jinwei Qiang
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, People's Republic of China
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Moura MS, Costa J, Velasco V, Kommoss F, Oliva E, Le Loarer F, McCluggage WG, Razack R, Treilleux I, Mills A, Longacre T, Devouassoux-Shisheboran M, Hostein I, Azmani R, Blanchard L, Hartog C, Soubeyran I, Khalifa E, Croce S. Pan-TRK immunohistochemistry in gynaecological mesenchymal tumours: diagnostic implications and pitfalls. Histopathology 2024; 84:451-462. [PMID: 37988282 DOI: 10.1111/his.15082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/22/2023] [Accepted: 10/14/2023] [Indexed: 11/23/2023]
Abstract
AIMS NTRK-rearranged sarcomas of the female genital tract mainly occur in the uterus (more commonly cervix than corpus) and are characterized by a "fibrosarcoma-like" morphology and NTRK gene rearrangements. These neoplasms may exhibit histological overlap with other entities and can present diagnostic difficulties without molecular confirmation. Pan-TRK immunohistochemistry was developed to identify tumours harbouring NTRK rearrangements. The aim of this study was to characterize pan-TRK immunohistochemical expression in a large cohort of gynaecological mesenchymal neoplasms and investigate the utility of pan-TRK immunohistochemistry to distinguish NTRK-rearranged sarcoma from its mimics. METHODS AND RESULTS A total of 473 gynaecological mesenchymal tumours (461 without known NTRK fusions and 12 NTRK-rearranged sarcomas) were selected. Pan-TRK immunohistochemistry (EPR17341, Abcam) was performed on whole tissue sections and tissue microarrays. Molecular interrogation of pan-TRK positive tumours was performed by RNA sequencing or fluorescence in situ hybridization (FISH). Of the 12 NTRK-rearranged sarcomas, 11 (92%) exhibited diffuse (≥70%) cytoplasmic pan-TRK staining with moderate/marked intensity, while the other was negative. Eleven (2.4%) additional tumours also exhibited pan-TRK immunohistochemical expression: three low-grade endometrial stromal sarcomas, seven high-grade endometrial stromal sarcomas, and an undifferentiated uterine sarcoma. Molecular confirmation of the absence of NTRK rearrangements was possible in nine of these tumours. Of these nine neoplasms, seven exhibited focal/multifocal (<70%) pan-TRK cytoplasmic staining with weak/moderate intensity. CONCLUSION Even though pan-TRK immunohistochemical expression is not entirely sensitive or specific for NTRK-rearranged sarcomas, these neoplasms tend to exhibit diffuse staining of moderate/strong intensity, unlike its mimics. Pan-TRK should be performed in monomorphic uterine (corpus and cervix) spindle cell neoplasms that are negative for smooth muscle markers and hormone receptors and positive for CD34 and/ or S100. Ultimately, the diagnosis requires molecular confirmation.
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Affiliation(s)
- Madalena Souto Moura
- Department of Pathology, Portuguese Institute of Oncology-Porto, Porto, Portugal
| | - João Costa
- Department of Pathology, Portuguese Institute of Oncology-Porto, Porto, Portugal
| | - Valérie Velasco
- Department of Biopathology, Institut Bergonié, Comprehensive Cancer Centre, Bordeaux, France
| | - Felix Kommoss
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Esther Oliva
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Francois Le Loarer
- Department of Biopathology, Institut Bergonié, Comprehensive Cancer Centre, Bordeaux, France
- Inserm U1312, Université de Bordeaux, Bordeaux, France
- Université de Bordeaux, Talence, France
| | - W Glenn McCluggage
- Department of Pathology, Belfast Health and Social Care Trust, Belfast, UK
| | - Rubina Razack
- Division of Anatomical Pathology, National Health Laboratory Service, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Academic Hospital, Cape Town, South Africa
| | | | - Anne Mills
- Department of Pathology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Teri Longacre
- Department of Surgical Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Isabelle Hostein
- Department of Biopathology, Institut Bergonié, Comprehensive Cancer Centre, Bordeaux, France
| | - Rihab Azmani
- Bioinformatics, Data and Digital Health Department, Institut Bergonié, Comprehensive Cancer Centre, Bordeaux, France
| | - Larry Blanchard
- Department of Biopathology, Institut Bergonié, Comprehensive Cancer Centre, Bordeaux, France
| | - Cécile Hartog
- Department of Biopathology, Institut Bergonié, Comprehensive Cancer Centre, Bordeaux, France
| | - Isabelle Soubeyran
- Department of Biopathology, Institut Bergonié, Comprehensive Cancer Centre, Bordeaux, France
| | - Emmanuel Khalifa
- Department of Biopathology, Institut Bergonié, Comprehensive Cancer Centre, Bordeaux, France
| | - Sabrina Croce
- Department of Biopathology, Institut Bergonié, Comprehensive Cancer Centre, Bordeaux, France
- Inserm U1312, Université de Bordeaux, Bordeaux, France
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3
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Can B, Karataşli V, Çakir İ, Sayhan S, Hansu K, Kuru O. The prognostic significance of the heterologous component in uterine carcinosarcomas. Rev Assoc Med Bras (1992) 2023; 69:e20230517. [PMID: 37729375 PMCID: PMC10508891 DOI: 10.1590/1806-9282.20230517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 06/25/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVE Uterine carcinosarcomas are aggressive, rare biphasic tumors with malignant epithelial and malignant sarcomatous components. The prognostic significance of the presence of extrauterine sarcoma (heterologous component) is controversial. Therefore, the aim of this study was to investigate the effect of heterologous components in uterine carcinosarcomas on disease-free survival, overall survival, and other prognostic factors. METHODS Clinical and histopathological data from patients treated for uterine carcinosarcoma in a tertiary cancer center in Turkey between July 2000 and January 2020 were collected. Independent risk factors affecting overall survival and disease-free survival were analyzed by univariate and multivariate Cox regression analyses. RESULTS A total of 98 patients were identified. The median follow-up was 21.8 (1.2-233.1) months. In the multivariate analysis, the median overall survival and disease-free survival were 23.8 and 20.7 months in those with homologous mesenchymal components and 17.6 and 9.7 months in those with heterologous mesenchymal components, respectively. It was found that the presence of heterologous mesenchymal components significantly reduced both overall survival and disease-free survival (odds ratio [OR], 2.861; 95% confidence interval [CI] 1.196-6.841; p=0.018 and OR, 3.697; 95%CI 1.572-8.695; p=0.003, respectively). In addition, both lymphadenectomy and adjuvant radiotherapy were found to significantly increase overall survival and disease-free survival. Age was found to increase only disease-free survival. CONCLUSION The results obtained in this study showed that the presence of heterologous components in uterine carcinosarcoma is a prognostic factor that adversely affects both overall survival and disease-free survival. Lymphadenectomy and adjuvant radiotherapy have beneficial effects on both overall survival and disease-free survival.
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Affiliation(s)
- Behzat Can
- Necip Fazil City Hospital, Department of Gynecological Oncology – Kahramanmaraş, Turkey
| | - Volkan Karataşli
- Şanlıurfa State Hospital, Department of Gynecological Oncology – Sanlıurfa, Turkey
| | - İlker Çakir
- Buca Seyfi Demirsoy Training and Research Hospital, Department of Gynecological Oncology – İzmir, Turkey
| | - Sevil Sayhan
- İzmir Tepecik Training and Research Hospital, Department of Pathology – İzmir, Turkey
| | - Kemal Hansu
- Necip Fazil City Hospital, Department of Obstetrics and Gynecology – Kahramanmaraş, Turkey
| | - Oğuzhan Kuru
- Istanbul University, Cerrahpasa Faculty of Medicine, Department of Gynecological Oncology – Istanbul, Turkey
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Yalciner M, Bölek H, Berna Köksoy E. Clinical Features and Prognostic Factors in Patients With Uterine Leiomyosarcoma: A Single-Center Experience. Cureus 2023; 15:e43681. [PMID: 37724232 PMCID: PMC10505264 DOI: 10.7759/cureus.43681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/20/2023] Open
Abstract
Background Uterine leiomyosarcomas (LMS) are associated with more recurrence and higher mortality compared to other uterine cancers. Considering the limited number of case series in the literature, the limited effectiveness of standard treatment methods, and the inadequacy of molecular biomarkers, we planned to investigate the effects of treatment methods and survival outcomes in these patients. Methodology The study was designed retrospectively, and the records of patients who were followed up and treated at Ankara University Faculty of Medicine, Medical Oncology Clinic, between January 1, 2011, and December 31, 2021, were reviewed. Patients over 18 years of age with a pathological diagnosis of uterine LMS were included. Demographic, clinical, and pathological data were recorded using the hospital database. The International Federation of Gynecology and Obstetrics (FIGO) staging was reassessed for each patient in accordance with the AJCC Cancer Staging Manual, Eighth Edition (2017). Tumor size, location, and grade were also evaluated. Types of treatments, protocols, and adverse effects were recorded. Relapsed patients, relapse localization, and treatments given at relapse were recorded and compared. Results Twenty-eight patients were included. The mean age of the patients was 53.7 years. The median follow-up time was 39.3 months. The localization of LMS could be detected in 22 (78.57%) patients, among them 20 (90.9%) patients had intramural, 1 (4.5%) had submucosal, and 1 (4.5%) had subserosal LMS. All patients (26, 92.8%) underwent primary surgery, except for 2 (7.14%) patients who were metastatic at the time of diagnosis. Adjuvant treatment suggestion was made for 7 (25%) patients with a high risk of recurrence in the multidisciplinary tumor council. Partial response was observed in 1 (3.5%) of the 2 (7.1%) metastatic patients, and stable disease was observed in the other. Recurrence was detected in 22 (84.6%) patients . Fifteen (53.6%) patients died during the follow-up period. Survival was better in premenopausal patients (99.2 versus 51.6 months, P = 0.056). No significant difference was found when the survival of patients who received and did not receive adjuvant treatment were compared. In relapsed patients, there was no significant difference in survival between patients who underwent and did not undergo surgical treatment. Conclusions Uterine LMS is a rare and aggressive malignancy with limited diagnostic methods, frequent recurrences, high mortality, and limited use of nonsurgical treatments. The positive effect of adjuvant treatment on survival has not been demonstrated. Further studies are needed to investigate the effect of hormone receptor status on prognosis and new biomarkers.
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Affiliation(s)
- Merih Yalciner
- Medical Oncology, Ankara University School of Medicine, Ankara, TUR
| | - Hatice Bölek
- Medical Oncology, Ankara University School of Medicine, Ankara, TUR
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Biswas J, Dasgupta S, Datta M, Datta M, Saha S, Pradhan P. Effect of single-dose methotrexate injection to prevent neoplastic changes in high risk complete hydatidiform mole: A randomised control trial. J Family Med Prim Care 2022; 11:6036-6041. [PMID: 36618146 PMCID: PMC9810940 DOI: 10.4103/jfmpc.jfmpc_208_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/11/2022] [Accepted: 04/14/2022] [Indexed: 11/11/2022] Open
Abstract
Background Complete hydatidiform mole affects women in their reproductive age. About 15-20% develops persistent molar gestational trophoblastic neoplasia (GTN), which is linked with delayed (beyond 56 days) normalization of serum βHCG after surgical evacuation. Objective The objective of the article is to shorten the duration of normalization time of βHCG with single-dose methotrexate injection in women with high risk complete hydatidiform mole (CHM) after suction evacuation. Methods Total 76 women with CHM were randomized into intervention and control groups. In the intervention arm (n = 34) women received single dose 100 mg intramuscular methotrexate injection post evacuation and the control group (n = 42) had standard care. Surveillance was done in both groups at two weeks intervals for next six months and duration of normalization of βHCG level was recorded. Results Total 94.7% women completed follow-up. Mean of normalization time was significantly lower in the intervention group compared to controls (9.7 weeks versus 14.7 week; P < 0.01). Time to event curve showed significantly earlier cumulative normalization time for the intervention group. Conclusion Single-dose 100 mg methotrexate injection is a low-cost, simple intervention to help one out of three women with CHM with high-risk features to achieve normalization of βHCG within 56 days. This might be helpful for people in resource-poor countries where adherence to prolonged surveillance is poor.
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Affiliation(s)
- Jhuma Biswas
- Department of Obstetrics and Gynaecology, Calcutta National Medical College and Hospital, West Bengal, India
| | - Shyamal Dasgupta
- Department of Obstetrics and Gynaecology, R. G. Kar Medical College and Hospital, West Bengal, India
| | - Mallika Datta
- Department of Obstetrics and Gynaecology, Calcutta National Medical College and Hospital, West Bengal, India
| | - Mousumi Datta
- Department of Community Medicine, Medical College and Hospital, Kolkata, West Bengal, India,Address for correspondence: Dr. Mousumi Datta, 2/4/3B VYOM, 49A Manmohan Banerjee Road, Behala Buroshibtolla, Kolkata - 700 038, West Bengal, India. E-mail:
| | - Santa Saha
- Department of Biochemistry, Regional Institute of Ophthalmology, Medical College and Hospital, Kolkata, West Bengal, India
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Schiemer R, Furniss D, Phang S, Seddon AB, Atiomo W, Gajjar KB. Vibrational Biospectroscopy: An Alternative Approach to Endometrial Cancer Diagnosis and Screening. Int J Mol Sci 2022; 23:ijms23094859. [PMID: 35563249 PMCID: PMC9102412 DOI: 10.3390/ijms23094859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 01/27/2023] Open
Abstract
Endometrial cancer (EC) is the sixth most common cancer and the fourth leading cause of death among women worldwide. Early detection and treatment are associated with a favourable prognosis and reduction in mortality. Unlike other common cancers, however, screening strategies lack the required sensitivity, specificity and accuracy to be successfully implemented in clinical practice and current diagnostic approaches are invasive, costly and time consuming. Such limitations highlight the unmet need to develop diagnostic and screening alternatives for EC, which should be accurate, rapid, minimally invasive and cost-effective. Vibrational spectroscopic techniques, Mid-Infrared Absorption Spectroscopy and Raman, exploit the atomic vibrational absorption induced by interaction of light and a biological sample, to generate a unique spectral response: a “biochemical fingerprint”. These are non-destructive techniques and, combined with multivariate statistical analysis, have been shown over the last decade to provide discrimination between cancerous and healthy samples, demonstrating a promising role in both cancer screening and diagnosis. The aim of this review is to collate available evidence, in order to provide insight into the present status of the application of vibrational biospectroscopy in endometrial cancer diagnosis and screening, and to assess future prospects.
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Affiliation(s)
- Roberta Schiemer
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham NG5 1PB, UK;
- Correspondence:
| | - David Furniss
- Mid-Infrared Photonics Group, George Green Institute for Electromagnetics Research, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, UK; (D.F.); (S.P.); (A.B.S.)
| | - Sendy Phang
- Mid-Infrared Photonics Group, George Green Institute for Electromagnetics Research, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, UK; (D.F.); (S.P.); (A.B.S.)
| | - Angela B. Seddon
- Mid-Infrared Photonics Group, George Green Institute for Electromagnetics Research, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, UK; (D.F.); (S.P.); (A.B.S.)
| | - William Atiomo
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai P.O. Box 505055, United Arab Emirates;
| | - Ketankumar B. Gajjar
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham NG5 1PB, UK;
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Meixner E, Lang K, König L, Sandrini E, Lischalk JW, Debus J, Hörner-Rieber J. Postoperative Radiotherapy for Endometrial Cancer in Elderly (≥80 Years) Patients: Oncologic Outcomes, Toxicity, and Validation of Prognostic Scores. Cancers (Basel) 2021; 13:6264. [PMID: 34944884 DOI: 10.3390/cancers13246264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/10/2021] [Accepted: 12/12/2021] [Indexed: 01/23/2023] Open
Abstract
Endometrial cancer is a common malignancy in elderly women that are more likely to suffer from limiting medical comorbidities. Given this narrower therapeutic ratio, we aimed to assess the oncologic outcomes and toxicity in the adjuvant setting. Out of a cohort of 975 women, seventy patients aged ≥ 80 years, treated with curative postoperative radiotherapy (RT) for endometrial cancer between 2005 and 2021, were identified. Outcomes were assessed using Kaplan-Meier-analysis and comorbidities using the Charlson Comorbidity Index and G8 geriatric score. The overall survival at 1-, 2- and 5-years was 94.4%, 82.6%, and 67.6%, respectively, with significant correlation to G8 score. At 1- and 5-years, the local control rates were 89.5% and 89.5% and distant control rates were 86.3% and 66.9%, respectively. Severe (≥grade 3) acute toxicity was rare with gastrointestinal (2.9%), genitourinary (1.4%), and vaginal disorders (1.4%). Univariate analysis significantly revealed inferior overall survival with lower RT dose, G8 score, hemoglobin levels and obesity, while higher grading, lymphangiosis, RT dose decrease and the omission of chemotherapy reduced distant control. Despite older age and additional comorbidities, elderly patients tolerated curative treatment well. The vast majority completed treatment as planned with very low rates of acute severe side-effects. RT offers durable local control; however, late distant failure remains an issue.
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Kasius JC, Pijnenborg JMA, Lindemann K, Forsse D, van Zwol J, Kristensen GB, Krakstad C, Werner HMJ, Amant F. Risk Stratification of Endometrial Cancer Patients: FIGO Stage, Biomarkers and Molecular Classification. Cancers (Basel) 2021; 13:cancers13225848. [PMID: 34831000 PMCID: PMC8616052 DOI: 10.3390/cancers13225848] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 11/11/2021] [Indexed: 12/24/2022] Open
Abstract
Endometrial cancer (EC) is the most common gynaecologic malignancy in developed countries. The main challenge in EC management is to correctly estimate the risk of metastases at diagnosis and the risk to develop recurrences in the future. Risk stratification determines the need for surgical staging and adjuvant treatment. Detection of occult, microscopic metastases upstages patients, provides important prognostic information and guides adjuvant treatment. The molecular classification subdivides EC into four prognostic subgroups: POLE ultramutated; mismatch repair deficient (MMRd); nonspecific molecular profile (NSMP); and TP53 mutated (p53abn). How surgical staging should be adjusted based on preoperative molecular profiling is currently unknown. Moreover, little is known whether and how other known prognostic biomarkers affect prognosis prediction independent of or in addition to these molecular subgroups. This review summarizes the factors incorporated in surgical staging (i.e., peritoneal washing, lymph node dissection, omentectomy and peritoneal biopsies), and its impact on prognosis and adjuvant treatment decisions in an era of molecular classification of EC. Moreover, the relation between FIGO stage and molecular classification is evaluated including the current gaps in knowledge and future perspectives.
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Affiliation(s)
- Jenneke C. Kasius
- Department of Obstetrics & Gynaecology, Amsterdam University Medical Centres, 1105 AZ Amsterdam, The Netherlands; (J.C.K.); (J.v.Z.)
| | | | - Kristina Lindemann
- Department of Gynaecologic Oncology, Oslo University Hospital, 0188 Oslo, Norway;
- Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
| | - David Forsse
- Department of Gynaecology and Obstetrics, Haukeland University Hospital, 5021 Bergen, Norway; (D.F.); (C.K.)
| | - Judith van Zwol
- Department of Obstetrics & Gynaecology, Amsterdam University Medical Centres, 1105 AZ Amsterdam, The Netherlands; (J.C.K.); (J.v.Z.)
| | - Gunnar B. Kristensen
- Institute for Cancer Genetics and Informatics, Department of Oncology, Division of Cancer Medicine, Oslo University Hospital, 0424 Oslo, Norway;
| | - Camilla Krakstad
- Department of Gynaecology and Obstetrics, Haukeland University Hospital, 5021 Bergen, Norway; (D.F.); (C.K.)
| | - Henrica M. J. Werner
- Department of Obstetrics and Gynaecology, GROW, Maastricht University School for Oncology & Developmental Biology, 6202 AZ Maastricht, The Netherlands;
| | - Frédéric Amant
- Department of Obstetrics & Gynaecology, Amsterdam University Medical Centres, 1105 AZ Amsterdam, The Netherlands; (J.C.K.); (J.v.Z.)
- Department of Oncology, KU Leuven, 3000 Leuven, Belgium
- Department of Gynaecology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands
- Correspondence:
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9
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Silva MG, Banazol N, Coelho P, Fragata JIG. Metastatic endometrial stromal sarcoma: A rare cause of right-sided intracardiac mass. J Card Surg 2021; 36:2143-2145. [PMID: 33651415 DOI: 10.1111/jocs.15463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 02/09/2021] [Accepted: 02/18/2021] [Indexed: 01/20/2023]
Abstract
The endometrial stromal sarcoma (EES) is a rare uterine malignancy and its intracardiac metastasis are exceedingly rare. We report a case of a 53-year-old female patient diagnosed with a metastatic tumor of a ESS in the right side of the heart, who underwent successful surgical resection and initiated chemotherapy with docetaxel and gemcitabine. At a 9-month follow-up, the patient was in New York Heart Association-Class I, without any further complications.
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Affiliation(s)
- Manuela G Silva
- Department of Cardiothoracic Surgery, Hospital Santa Marta-Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Nuno Banazol
- Department of Cardiothoracic Surgery, Hospital Santa Marta-Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Pedro Coelho
- Department of Cardiothoracic Surgery, Hospital Santa Marta-Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - José I G Fragata
- Department of Cardiothoracic Surgery, Hospital Santa Marta-Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
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Sh Hassan AA, Alsultan AA, Al Ghamdi RK, Albluwi NM, Aljamea JH, AlHammadi HM, Alzakari MJ, Almisbah MH, Alsubaie FA, Alajmi MS. Uterine Tumor Resembling Sex-Cord Tumor: A Case Report. Cureus 2020; 12:e12010. [PMID: 33324531 PMCID: PMC7732140 DOI: 10.7759/cureus.12010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Uterine tumors resembling sex-cord tumors are a rare group of tumors with uncertain etiology and histogenesis. The sex-cord tumors are classified into two groups. The first group includes endometrial stromal tumors with foci of sex cord differentiation less than 50% while the second group is composed predominantly or exclusively by sex cord-like elements. We report the case of a middle-aged woman who presented with heavy vaginal bleeding with initial ultrasound findings suggestive of uterine leiomyoma. There was no improvement noticed after a trial of medical treatment; hence, the surgical treatment in the form of total abdominal hysterectomy was undertaken. A few weeks after the surgery, the patient presented with unexplained abdominal pain. Imaging studies demonstrated a hypermetabolic lesion in the upper part of the vagina that was suspicious for malignancy. Complete resection of the mass was performed along with para-aortic lymphadenopathy. Histopathological examination revealed a uterine tumor resembling a sex-cord tumor. Uterine tumors resembling sex-cord tumors are a unique group of uterine neoplasms that exhibits diverge clinical and biological characteristic. Surgical pathologists must recognize this rare entity and differentiate it from other lesions.
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Affiliation(s)
- Azhar A Sh Hassan
- Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Anfal A Alsultan
- Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Raghad K Al Ghamdi
- Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Naif M Albluwi
- Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Jawad H Aljamea
- Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Hassan M AlHammadi
- Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Mujtaba J Alzakari
- Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Mahdi H Almisbah
- Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Fatima A Alsubaie
- Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Modhi S Alajmi
- Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
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11
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Lawlor H, Ward A, Maclean A, Lane S, Adishesh M, Taylor S, DeCruze SB, Hapangama DK. Developing a Preoperative Algorithm for the Diagnosis of Uterine Leiomyosarcoma. Diagnostics (Basel) 2020; 10:E735. [PMID: 32977421 DOI: 10.3390/diagnostics10100735] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/19/2020] [Accepted: 09/19/2020] [Indexed: 02/07/2023] Open
Abstract
Early diagnosis of the rare and life-threatening uterine leiomyosarcoma (LMS) is essential for prompt treatment, to improve survival. Preoperative distinction of LMS from benign leiomyoma remains a challenge, and thus LMS is often diagnosed post-operatively. This retrospective observational study evaluated the predictive diagnostic utility of 32 preoperative variables in 190 women who underwent a hysterectomy, with a postoperative diagnosis of leiomyoma (n = 159) or LMS (n = 31), at the Liverpool Women’s National Health Service (NHS) Foundation Trust, between 2010 and 2019. A total of 7 preoperative variables were associated with increased odds of LMS, including postmenopausal status (p < 0.001, OR 3.08), symptoms of pressure (p = 0.002, OR 2.7), postmenopausal bleeding (p = 0.001, OR 5.01), neutrophil count ≥7.5 × 109/L (p < 0.001, OR 5.72), haemoglobin level <118 g/L (p = 0.037, OR 2.22), endometrial biopsy results of cellular atypia or neoplasia (p = 0.001, OR 9.6), and a mass size of ≥10 cm on radiological imaging (p < 0.0001, OR 8.52). This study has identified readily available and easily identifiable preoperative clinical variables that can be implemented into clinical practice to discern those with high risk of LMS, for further specialist investigations in women presenting with symptoms of leiomyoma.
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Omori M, Kawai M, Ogawa T, Sasatsu S, Fukasawa H, Nakazawa K, Kondo T, Hirata S. Lesion-targeted cytology to improve cytological sampling for atypical polypoid adenomyomas of the uterus: A case series and review of the literature. Cytopathology 2020; 31:579-585. [PMID: 32779225 DOI: 10.1111/cyt.12899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 07/14/2020] [Accepted: 08/03/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Atypical polypoid adenomyomas (APAs) are uncommon tumours consisting of atypical endometrioid glands and fibromyomatous stroma. Identifying the biphasic nature of atypical glandular components and spindle mesenchymal components without atypia is crucial for the cytological diagnosis of APA. We investigated the utility of lesion-targeted cytology (LTC) to directly collect firm spindle components. METHODS We recruited seven consecutive surgical patients who underwent cytological examinations before surgery and were diagnosed with APA on postoperative histological examinations. Cytological smears were obtained by routine sampling in five cases and by targeted sampling using transvaginal ultrasonography, that is, LTC, in two cases. We retrospectively analysed the cytological findings from our cases and compared them to those of APA cases previously reported in the English literature. RESULTS Among 5/7 cases that involved routine cytological sampling, normal cytological findings were found in 2 and atypical glandular cells were found in 3, but spindle cells from mesenchymal components were not detected. In contrast, among 2/7 cases in which sampling involved LTC, spindle cells without atypia, in addition to atypical glandular cells were found. CONCLUSIONS Lesion-targeted cytology is useful to assess mesenchymal components of APAs and may improve the cytological diagnosis of APA.
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Affiliation(s)
- Makiko Omori
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Masataka Kawai
- Department of Pathology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Tatsuyuki Ogawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Satoko Sasatsu
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Hiroko Fukasawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Kumiko Nakazawa
- Department of Pathology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Tetsuo Kondo
- Department of Pathology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Shuji Hirata
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
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13
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Gordon HG, Mooney S, Readman E. Introduction of the MyoSureLITE in an established outpatient hysteroscopy clinic. Aust N Z J Obstet Gynaecol 2020; 60:784-789. [PMID: 32696466 DOI: 10.1111/ajo.13207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 06/06/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Endometrial polyps are a common cause of abnormal uterine bleeding. The MyoSureLITE intrauterine morcellation device is effective at resecting endometrial polyps; however, its use in the outpatient setting requires appraisal. AIM To assess the feasibility, utility, acceptability and costs associated with introduction of the MyoSureLITE into an established outpatient hysteroscopy (OPH) clinic. MATERIAL AND METHODS A prospective clinical database from a tertiary Melbourne hospital was analysed from 1 July 2015 to 30 June 2018. Three 12-month time periods were compared: pre-introduction and trial phase, early use, and established use of the MyoSureLITE. Wait times, patient acceptability, second OPH bookings and procedure costs were measured. RESULTS Eight hundred and seventy-one women underwent OPH during the study period, with 238 (27.3%) women presenting with endometrial polyp(s). At each timepoint, 78.5, 25 and 6.3% of women required rebooking for a subsequent hysteroscopy for pathology otherwise suitable for MyoSureLITE resection. Introduction of the MyoSureLITE avoided a subsequent procedure for 4, 60 and 69 women respectively for each year of use, with potentially reduced treatment costs for the institution. Median (IQR) wait time for definitive treatment of intrauterine pathology was 56 (24-84) days at time-period 1, decreasing to 0 (0-0) days during time-period 3, (P < 0.001); 87.6% would undergo OPH again. CONCLUSIONS Routine use of the MyoSureLITE is effective, feasible, and acceptable to women. Provision of this device in outpatient service allows a 'see-and-treat' model, saving theatre time and treatment costs, facilitating a more direct throughput from presentation to treatment.
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Affiliation(s)
- Hannah G Gordon
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Mercy Hospital for Women, Melbourne, Victoria, Australia
| | | | - Emma Readman
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Mercy Hospital for Women, Melbourne, Victoria, Australia
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Soni S, Pareek P, Narayan S. Disseminated peritoneal leiomyomatosis: an unusual presentation of intra-abdominal lesion mimicking disseminated malignancy. Med Pharm Rep 2020; 93:113-116. [PMID: 32133455 PMCID: PMC7051819 DOI: 10.15386/mpr-1421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/04/2019] [Accepted: 10/05/2019] [Indexed: 11/23/2022] Open
Abstract
Leiomyoma are commonly seen as benign smooth muscle tumors of the uterus. Smooth muscle tumors with unusual growth pattern are rare and include 3 primary neoplasms: intravenous leiomyomatosis (IVL), benign metastasizing leiomyoma (BML) and disseminated peritoneal leiomyomatosis (DPL). DPL is a rare benign disease, often giving the appearance of metastatic ovarian or peritoneal carcinoma. It is a disease that predominately affects women at their reproductive age. The risk of malignant transformation is 2–5%. There are no standard treatment guidelines for the management of the DPL. The unusual presentation of the disease delays the diagnosis or is often misdiagnosed and thus over treated, which may lead to increased morbidity and mortality. Therefore careful consideration and high index of suspicion is required for the proper management of such cases.
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Affiliation(s)
- Sweta Soni
- Department of Radiation Oncology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Puneet Pareek
- Department of Radiation Oncology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Satya Narayan
- Department of Radiation Oncology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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15
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Tunçel D, Doğukan R, Doğukan FM, Kabukçuoğlu F, Erenel H, Ayhan I. Primary Pure Uterine Lipoma: A Report of two Cases and Review of the Literature. Sisli Etfal Hastan Tip Bul 2018; 52:135-7. [PMID: 32595387 DOI: 10.14744/SEMB.2017.66375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 02/15/2017] [Indexed: 11/25/2022]
Abstract
Pure uterine lipomas are rare diagnoses despite lipoma being a common entity. The histogenesis of these lesions remains unknown, and its clinical symptoms are similar to those of uterine leiomyomas. In this report, two cases of uterine lipomas were presented with their histopathological and clinical aspects.
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Cotter JA, Szymanski L, Karimov C, Boghossian L, Margol A, Dhall G, Tamrazi B, Varaprasathan GI, Parham DM, Judkins AR, Biegel JA. Transmission of a TP53 germline mutation from unaffected male carrier associated with pediatric glioblastoma in his child and gestational choriocarcinoma in his female partner. Cold Spring Harb Mol Case Stud 2018; 4:mcs.a002576. [PMID: 29581140 PMCID: PMC5880265 DOI: 10.1101/mcs.a002576] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 02/08/2018] [Indexed: 11/24/2022] Open
Abstract
Li-Fraumeni syndrome (LFS) is an autosomal dominant cancer predisposition syndrome caused by germline alterations in the tumor suppressor gene TP53 LFS is associated with numerous malignancies including astrocytoma. Sanger sequencing and chromosomal microarray studies of blood and tumor tissue from a 4-yr-old boy with glioblastoma demonstrated a germline TP53 mutation with loss of heterozygosity for the short arm of Chromosome 17 as the second inactivating event in the tumor. There was no family history of LFS, but the child's mother had recently died from metastatic choriocarcinoma after antecedent normal term delivery of a then 6-mo-old daughter. The choriocarcinoma contained the same TP53 mutation detected in the proband and the 6-mo-old daughter was confirmed to be a carrier. Unexpectedly, the germline TP53 mutation was found to be inherited from the unaffected father. We report here the second genetically confirmed case of TP53-mutated choriocarcinoma in the partner of an LFS patient. Based on this case and recent literature, female partners of LFS patients may have increased risk of choriocarcinoma due to transmission of germline TP53 mutation from male carriers. Although the Toronto protocol has established an effective approach to detect tumors and improve survival in children and adults with LFS, there is a need to expand the current criteria to include surveillance of female partners of LFS patients for choriocarcinoma and other gestational trophoblastic disease. Recognition of this unique mode of transmission of TP53 mutations should be considered in genetic counseling for cancer risk assessment and family planning.
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Affiliation(s)
- Jennifer A Cotter
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, California 90027, USA
| | - Linda Szymanski
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, California 90027, USA
| | - Catherine Karimov
- Department of Medical Genetics, Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, California 90027, USA
| | - Lara Boghossian
- Department of Medical Genetics, Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, California 90027, USA
| | - Ashley Margol
- Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, California 90027, USA
| | - Girish Dhall
- Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, California 90027, USA
| | - Benita Tamrazi
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, California 90027, USA
| | | | - David M Parham
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, California 90027, USA
| | - Alexander R Judkins
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, California 90027, USA
| | - Jaclyn A Biegel
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, California 90027, USA
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Hou HL, Meng MB, Chen XL, Zhao LJ, Zhu L, Zhang BL, Wang P. The prognosis factor of adjuvant radiation therapy after surgery in uterine sarcomas. Onco Targets Ther 2015; 8:2339-44. [PMID: 26357482 PMCID: PMC4559239 DOI: 10.2147/ott.s88186] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objective This retrospective study evaluated the role of adjuvant radiotherapy (AR) after surgery in patients with uterine sarcoma and analyzed the prognostic factors of local-regional failure-free survival (LRFFS) and overall survival (OS). Patients and methods A study of a total of 182 patients with uterine sarcoma was conducted between June 1994 and October 2014. Adjuvant radiotherapy was defined as postoperative external beam radiation to the pelvis (30–50 Gray/10–25 fractions at five fractions/week). The primary end point was LRFFS, and the secondary end point was OS. Kaplan–Meier curves were compared using the log-rank test. Cox regression analyses were used to determine prognosticators for LRFFS and OS. Results The median follow-up time of all patients was 75 months, with a 5-year LRFFS of 62.1%. The 2-year and 5-year LRFFS rates were longer for those who received AR than for those who did not receive AR (83.4% vs 70.3%; 78% vs 55.3%; P=0.013). The 5-year OS of all patients was 56.2%, and no significant differences were observed in the 2-year and 5-year OS rates between these two groups (82.7% vs 71.4%; 64.1% vs 51.7%; P=0.067). Importantly, in patients with leiomyosarcoma, the 2-year and 5-year LRFFS and OS rates were longer for those who received AR than for those who did not receive AR (P=0.04 and P=0.02 for the 2-year and 5-year LRFFS, respectively). Conclusion Patients with uterine sarcoma who were treated with AR after surgery demonstrated an improved LRFFS compared with those who were treated with surgery alone, especially those patients with leiomyosarcoma. Therefore, the role of personalized adjuvant radiation for patients with uterine sarcoma still requires further discussion.
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Affiliation(s)
- Hai-Ling Hou
- Department of Radiation Oncology, CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, People's Republic of China
| | - Mao-Bin Meng
- Department of Radiation Oncology, CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, People's Republic of China
| | - Xiu-Li Chen
- Department of Radiation Oncology, CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, People's Republic of China
| | - Lu-Jun Zhao
- Department of Radiation Oncology, CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, People's Republic of China
| | - Li Zhu
- Department of Radiation Oncology, CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, People's Republic of China
| | - Bai-Lin Zhang
- Department of Radiation Oncology, CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, People's Republic of China
| | - Ping Wang
- Department of Radiation Oncology, CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, People's Republic of China
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