Trends in Uterine Cancer Mortality in the United States: A 50-Year Population-Based Analysis

OBJECTIVE

To analyze mortality trends in uterine cancer in the United States over 50 years with an emphasis on age and race and ethnicity.

METHODS

Data on uterine cancer deaths from 1969 to 2018 were obtained from the National Center for Health Statistics. Trends were examined by age and race and ethnicity after adjustment for the hysterectomy rate and pregnancy.

RESULTS

Uterine cancer mortality decreased between 1969 and 1997 (from 6.03 to 4.00/100,000) but increased between 1997 and 2018 (from 4.00 to 5.02/100,000). From 2001 to 2018, mortality rates increased by 1.25-fold across all age groups. In 2018, the mortality rate from uterine cancer for patients aged 70 years or older and 60-69 years was sixfold and threefold higher, respectively, than in younger patients (aged 50-59 years) (54.87/100,000 vs 27.80/100,000 vs 8.70/100,000). The mortality rate for non-Hispanic Black women was 2.2-fold higher than for non-Hispanic White, Hispanic, and non-Hispanic Asian or Pacific Islander women (17.6/100,000 vs 7.82/100,000, 6.54/100,000, and 4.24/100,000, respectively). On an intersection analysis of age and race, non-Hispanic Black women aged older than 60 years had a threefold higher mortality rate than non-Hispanic White women (72/100,000 vs 24/100,000). A notable finding was that young non-Hispanic Black and Hispanic women (30-39 years) had the highest annual increases in mortality at 3.3% and 3.8% per year compared with 2.2% in non-Hispanic White women.

CONCLUSION

Since 2001, the uterine cancer mortality rate has increased across all four racial and ethnic groups examined, with the highest increase seen among non-Hispanic Black women. The largest increase in mortality was observed among younger non-Hispanic Black and Hispanic women.

Lymph node dissection in uterine leiomyosarcomas: A matched-pair study

OBJECTIVE

To assess the impact of the lymph node dissection (LND) in the disease-free (DFS) and overall survival (OS) of the women treated surgically of uterine leiomyosarcoma (ULMS).

MATERIAL AND METHODS

A multicentric retrospective study was conducted among European countries collecting patients diagnosed of uterine sarcoma (SARcoma of the UTerus - SARCUT study). A total of 390 ULMS were selected for the present study to compare patients who underwent LND and those who did not. A further matched-pair subanalysis identified 116 women, 58 pairs (58 with LND and 58 without it) comparable in age, tumor size, surgical procedures, extrauterine disease and adjuvant treatment. Demographic data, pathology results and follow-up were abstracted from medical records and analyzed. Disease-free (DFS) and overall survival (OS) were studied using Kaplan-Meier curves and Cox regression analysis.

RESULTS

Among the 390 patients, the 5-year DFS was significantly higher in no-LDN group comparing to the LDN group (57.7% vs. 33.0%; HR 1.75, 95% CI 1.19-2.56; p = 0.007), but not the 5-year OS (64.6% vs. 64.3%; HR 1,10 95% CI 0,77-1,79; p = 0.704). In the matched-pair subanalysis, there were no statistical differences between the study groups. The 5- year DFS was 50.5% in the no-LND and 33.0% in the LND group (HR 1.38; 95% CI 0,83-2.31; p = 0,218) and the 5-year OS was 59.7% and 64.3% respectively (HR 0.81; 95% CI 0,45-1,49; p = 0,509).

CONCLUSIONS

LND performed in women diagnosed of ULMS have no impact neither in the disease-free nor in the overall survival compared to patients without LDN in a complete homogeneous group.

The prevalence and prognostic impact of tumor-infiltrating lymphocytes in uterine carcinosarcoma

OBJECTIVE

To examine the prevalence and prognostic role of tumor microenvironment (TME) markers in uterine carcinosarcoma (UCS) through immunohistochemical characterization.

METHODS

The internal database of our institution was queried out for women with UCS who underwent surgery and thereafter postoperative chemotherapy with carboplatin and paclitaxel between January 2012 and December 2017. Tissue microarrays containing surgical samples of UCS from 57 women were assessed by immunohistochemistry for CD3, CD4, CD8, FOXP3, PD-1, PD-L1, and PD-L2.

RESULTS

The mean age was 65.3 years (range, 49 to 79 years). For the epithelial component (E), CD3_E and CD4_E were highly expressed in 38 (66.7%) and in 40 (70.1%) patients, respectively, and were significantly associated with more advanced stages (p = 0.038 and p = 0.025, respectively). CD8_E was highly expressed in 42 (73.7%) patients, FOXP3_E 16 (28.1%), PD-1_E 35 (61.4%), PD-L1_E 27 (47.4%) and PD-L2_E 39 (68.4%). For the sarcomatous component (S), the prevalence of high expression was: CD3_S 6 (10.5%), CD4_S 20 (35.1%), CD8_S 44 (77.2%), FOXP3_S 8 (14%), PD-1_S 14 (24.6%), PD-L1_S 14 (24.6%) and PD-L2_S 8 (14%). By multivariate analysis, the CD8/FOXP3_S ratio (p = 0.026), CD4_E (p = 0.010), PD-L1_E (p = 0.013) and PD-L1_S (p = 0.008) markers significantly influenced progression-free survival. CD4/FOXP3_S ratio (p = 0.043), PD-1_E (p = 0.011), PD-L1_E (p = 0.036) and PD-L1_S (p = 0.028) had a significant association with overall survival.

CONCLUSION

Some differences in UCS clinical outcomes may be due to the subtype of TILs and PD-1/PD-L1 axis immune checkpoint signaling.

Primary diffuse large B-cell lymphoma of the uterus: A SEER database analysis

Uterine diffuse large B-cell lymphoma (DLBCL) is a rare clinical condition. Most studies for uterine DLBCL are derived from case reports and series. Our main objective was to present a new case while also investigating the demographic, clinical characteristics, and survival of women with primary uterine DLBCL as compared to non-uterine DLBCL using the Surveillance, Epidemiology, and End Results incidence database. We queried the Surveillance, Epidemiology, and End Results database for women aged 18 years or older with a diagnosis of primary DLBCL from 1975 to 2017. The most common site of primary uterine DLBCL is the cervix uteri not otherwise specified, followed by endometrium, uterus not otherwise specified, corpus uteri, myometrium and isthmus uteri. Non-uterine DLBCL cases tend to be older than uterine DLBCL cases. Uterine DLBCL is most common among women aged 40 to 64 years. Patients with uterine DLBCL showed greater survival than non-uterine DLBCL patients, and patients treated in the rituximab era also exhibited a survival benefit. Both the elderly and African American cohorts experienced worse overall survival.

Trends and age-period-cohort effects on mortality of the three major gynecologic cancers in China from 1990 to 2019: Cervical, ovarian and uterine cancer

BACKGROUND

Gynecologic cancers seriously threaten women's life and health. This study aims to assess the long-term trends of mortality from the three major gynecologic cancers in China and to examine the age-, period-, and cohort-specific effects behind them during the period 1990 to 2019.

METHODS

The mortality data of cervical, ovarian, and uterine cancer in China were obtained from the Global Burden of Disease Study 2019 and were analyzed with the age-period-cohort framework.

RESULTS

It was found that the net drift for cervical cancer mortality was -0.19% (95% CI, -0.46% to 0.08%) per year, for ovarian cancer was 0.76% (95% CI, 0.57% to 0.95%) per year, and for uterine cancer was -3.09% (95% CI, -3.44% to -2.76%) per year from 1990 to 2019. During this period, while cervical cancer remained the most common cause of death among gynecologic cancers among Chinese women, ovarian cancer replaced uterine cancer as the second leading cause of death in gynecologic cancers after about 2005. Significant age, cohort, and period effects were found for the mortality trends of all three major gynecologic cancers.

CONCLUSIONS

The secular trends of mortality from the three major gynecologic cancers in China and their underlying age, period, and cohort effects are likely to reflect the progress of diagnosis and treatment, rapid socio-economic transitions, and the accompanying lifestyle and behavior changes. More priorities of further epidemiology studies and efforts on the prevention and control should be given to three major gynecologic cancers.

Matched-pair Analysis for Survival Endpoints Between Women With Early-stage Uterine Carcinosarcoma and Uterine Serous Carcinoma

OBJECTIVE

The objective of this study was to compare survival endpoints between women with uterine carcinosarcoma and those with uterine serous carcinoma utilizing matching analysis.

METHODS

Patients with stages I to II who underwent hysterectomy at our institution were included in this analysis. Patients with carcinosarcoma were then matched to patients with serous carcinoma based on stage, and adjuvant management received (observation, radiation treatment alone, chemotherapy alone, or combined modality with radiotherapy and chemotherapy. Recurrence-free survival, disease-specific survival, and overall survival were calculated for the 2 groups.

RESULTS

A total of 134 women were included (67 women with carcinosarcoma and 67 with serous carcinoma, matched 1:1). There was no statistically significant difference between the 2 groups regarding 5-year recurrence-free survival (59% vs. 62%), disease-specific survival (66% vs. 67%), or overall survival (53% vs. 57%), respectively. The only independent predictor of shorter recurrence-free survival for the entire cohort was the lack of adjuvant combined modality therapy, while lower uterine segment involvement was the only independent predictor for shorter disease-specific survival. Lack of lymph node dissection and lack of adjuvant combined modality therapy were independent predictors of shorter overall survival.

DISCUSSION

When matched based on stage and adjuvant treatment, our study suggests that there is no statistically significant difference in survival endpoints between women with early-stage carcinosarcoma and serous carcinoma. Adjuvant combined modality treatment is an independent predictor of longer recurrence-free survival and overall survival.

Efficacy thresholds for clinical trials with advanced or metastatic leiomyosarcoma patients: A European Organisation for Research and Treatment of Cancer Soft Tissue and Bone Sarcoma Group meta-analysis based on a literature review for soft-tissue sarcomas

BACKGROUND

In 2002, the European Organisation for Research and Treatment of Cancer Soft Tissue and Bone Sarcoma Group reported well-established values for conducting phase II trials for soft-tissue sarcomas. An update is provided for leiomyosarcoma (LMS).

MATERIALS AND METHODS

Clinical trials with advanced or metastatic LMS were identified via literature review in PubMed (published 2003-2018, ≥10 adult LMS patients). End-points were 3- and 6-month progression-free survival rates (PFSR-3m and PFSR-6m). When estimates could not be derived from publications, data requests were sent out. Treatments were classified as recommended (R-T) or non-recommended (NR-T) according to the ESMO 2018 guidelines. A random effects meta-analysis was used to pool trial-specific estimates for first-line (1L) or pre-treated (2L+) patients separately. The ESMO Magnitude of Clinical Benefit Scale was used to guide the treatment effect to target in future trials.

RESULTS

From 47 studies identified, we obtained information on 7 1L and 16 2L+ trials for 1500 LMS patients. Overall, in 1L, PFSR-3m and PFSR-6m were 74% (95% confidence interval [CI] 64-82%) and 58% (95% CI 50-66%), respectively. For 2L+, PFSR-3m was 48% (95% CI 41-54%), and PFSR-6m was 28% (95% CI 22-34%). No difference was observed between R-T and NR-T for first or later lines. Under the alternative that the true benefit amounts to a hazard ratio of 0.65, a PFSR-6m ≥70% can be considered to suggest drug activity in 1L. For 2L+, a PFSR-3m ≥62% or PFSR-6m ≥44% would suggest drug activity. Specific results are also provided for uterine LMS.

CONCLUSIONS

This work provides a new benchmark for designing phase II studies for advanced or metastatic LMS.

Comparison of Chemotherapy vs Chemotherapy Plus Total Hysterectomy for Women With Uterine Cancer With Distant Organ Metastasis

This cohort study evaluates the overall survival for patients with uterine cancer with distant organ metastasis treated with chemotherapy alone vs chemotherapy plus total abdominal hysterectomy.

Genomic Amplification and Functional Dependency of the Gamma Actin Gene ACTG1 in Uterine Cancer

Sarcomere and cytoskeleton genes, or actomyosin genes, regulate cell biology including mechanical stress, cell motility, and cell division. While actomyosin genes are recurrently dysregulated in cancers, their oncogenic roles have not been examined in a lineage-specific fashion. In this report, we investigated dysregulation of nine sarcomeric and cytoskeletal genes across 20 cancer lineages. We found that uterine cancers harbored the highest frequencies of amplification and overexpression of the gamma actin gene, ACTG1. Each of the four subtypes of uterine cancers, mixed endometrial carcinomas, serous carcinomas, endometroid carcinomas, and carcinosarcomas harbored between 5~20% of ACTG1 gene amplification or overexpression. Clinically, patients with ACTG1 gains had a poor prognosis. ACTG1 gains showed transcriptional patterns that reflect activation of oncogenic signals, repressed response to innate immunity, or immunotherapy. Functionally, the CRISPR-CAS9 gene deletion of ACTG1 had the most robust and consistent effects in uterine cancer cells relative to 20 other lineages. Overall, we propose that ACTG1 regulates the fitness of uterine cancer cells by modulating cell-intrinsic properties and the tumor microenvironment. In summary, the ACTG1 functions relative to other actomyosin genes support the notion that it is a potential biomarker and a target gene in uterine cancer precision therapies.

Human epidermal growth factor 2 (HER2) in early stage uterine serous carcinoma: A multi-institutional cohort study

BACKGROUND

Human epidermal growth factor receptor 2 (HER2) has emerged as an important prognostic and therapeutic target in advanced stage and recurrent uterine serous carcinoma (USC). The significance of tumoral HER2 expression in early-stage disease has not been established.

METHODS

This multi-center cohort study included women with stage I USC treated from 2000 to 2019. Demographic, treatment, recurrence, and survival data were collected. Immunohistochemistry (IHC) was performed for HER2 and scored 0-3+. Equivocal IHC results (2+) were further tested with fluorescence in-situ hybridization (FISH). HER2 positivity was defined as 3+ IHC or FISH positive.

RESULTS

One hundred sixty-nine patients with stage I USC were tested for HER2; 26% were HER2-positive. There were no significant differences in age, race, stage, adjuvant therapy, or follow-up duration between the HER2-positive and negative cohorts. Presence of lymph-vascular space invasion was correlated with HER2-positive tumors (p = .003). After a median follow-up of 50 months, there were 43 (25.4%) recurrences. There were significantly more recurrences in the HER2-positive cohort (50.0% vs 16.8%, p < .001). HER2 positive tumors were associated with worse progression-free (PFS) and overall survival (OS) (p < .001 and p = .024). On multivariate analysis, HER2 positive tumors were associated with inferior PFS (aHR 3.50, 95%CI 1.84-6.67; p < .001) and OS (aHR 2.00, 95%CI 1.04-3.88; p = .039) compared to HER2-negative tumors.

CONCLUSIONS

Given its significant association with worse recurrence and survival outcomes, HER2 positivity appears to be a prognostic biomarker in women with stage I uterine serous carcinoma. These data provide support for clinical trials with anti-HER2-directed therapy in early-stage disease.

Evaluation of treatment results and prognostic factors of uterine sarcoma: A single-center experience

BACKGROUND

Uterine sarcomas (US) constitute a rare heterogeneous group of gynecological malignancies with aggressive characteristics and poor prognosis. Identifying the histopathological factors that determine the prognosis of the tumor and efficacy of various treatment modalities provides a reliable source for efficient treatment of affected patients. This study presents our 11-year experience with US in the south of Iran.

METHODS

Medical records of 42 patients (2001-2012) with endometrial stromal sarcoma (ESS), leiomyosarcoma (LMS), and malignant mixed Müllerian tumor (MMMT) were investigated. Hazard ratio (HR) and 2- and 5-year survival of patients were analyzed based on the patients' age, histopathological characteristics (tumor type, stage, necrosis, and mitotic index), and treatment modalities.

RESULTS

Twenty-four patients survived with median follow-up of 42.5 months; 18 died within 17 months, and 52.4% had recurrence, of whom 12 died. Two- and five-year survival rate was 78.6% and 61.9%, respectively, longest for ESS and shortest for MMMT. Higher age, tumor stage, necrosis, and mitotic index increased the HR of mortality. Radiotherapy resulted in a better survival, compared with chemotherapy alone or combined with radiotherapy.

CONCLUSION

Although ESS had the best prognosis, MMMT was the most aggressive tumor with the shortest survival time. Histological type of the tumor, staging, tumor necrosis, and mitotic index had prognostic roles. Adjuvant radiotherapy resulted in a better survival, compared with surgery alone in early stage.

Patterns of ovarian cancer and uterine cancer mortality and incidence in the contiguous USA

The main objective is to investigate the geographical variation in ovarian cancer and uterine cancer mortality, and to test associations between some risk factors and these cancer types in the contiguous US for mortality and for incidence. The modern disease surveillance software SaTScan™ was used for a spatial cluster analysis to assess any observable geographical variation in ovarian and uterine cancer mortality rates and to identify and test for spatial clusters with elevated relative risk. The analyses were first completed using age adjusted cancer rates for ovarian cancer and for uterine cancer. The cancer data was then adjusted for the risk factors (or covariates) obesity rate, smoking rate, urban, poverty rate, college education rate, race, opioids mortality rate, and for arsenic intake from well water rate. All used data for cancer mortality were for 2000-2014 while incidence data were for 2011-2015. There exist seven significant mortality clusters of ovarian cancer, with large clusters in NW, NE and SE of the US, and there exist two large mortality clusters of uterine cancer in NE and Central US. Most risk factors studied for mortality and for incidence were significant at significance levels much lower than 0.05 for either of the two cancer types, except race for ovarian cancer mortality and arsenic for ovarian incidence. This study has identified several important factors, and these findings could be used for a more effective search for cancer prevention for uterine and ovarian cancer. LIMITATIONS OF THE STUDY: The accuracy of the data could not be controlled as data were downloaded from websites. While the mortality data was complete, the incidence data had counties with missing data. The data were obtained at the county resolution. No data were available on women who had one type of cancer and then had the second type of cancer later in life. Only purely spatial clusters were studied and no temporal analysis was done.

Let-7 miRNA's Expression Profile and Its Potential Prognostic Role in Uterine Leiomyosarcoma

The lethal-7 (let-7) family is an important microRNA (miRNA) group that usually exerts functions as a tumor suppressor. We aimed to evaluate the expression profile of let-7a, let-7b, let-7c, let-7d, let-7e, let-7f, let-7g, and let-7i and to assess their value as prognostic markers in uterine leiomyosarcoma (LMS) patients. The miRNAs expression profile was assessed in 34 LMS and 13 normal myometrium (MM) paraffin-embedded samples. All let-7 family members showed downregulation in LMS. Our findings showed that patients with let-7e downregulation had worse overall survival (OS) and is an independent prognostic factor (hazard ratio [HR] = 2.24). In addition, almost half the patients had distant metastasis. LMS patients with downregulated let-7b and let-7d had worse disease-free survival (DFS); they are not independent prognostic factors (HR = 2.65). Patients’ ages were associated with let-7d, let-7e and let-7f (p = 0.0160) downregulation. In conclusion, all the let-7 family members were downregulated in LMS patients, and the greater the loss of expression of these molecules, the greater their relationship with worse prognosis of patients. Let-7e expression might influence the OS, while let-7b and le-7d might influence the DFS. The lowest expression levels of let-7d, let-7e, and let-7f were associated with the oldest patients. Our findings indicate strong evidence of let-7’s role as a potential prognostic biomarker in LMS.

Clinical comparison between neuroendocrine and endometrioid type carcinoma of the uterine corpus

OBJECTIVE

To compare the clinicopathologic features and survival outcomes of neuroendocrine tumor of the uterine corpus (NET-U) to endometrioid type endometrial carcinoma (EC).

METHODS

From 1993 to 2012, the Surveillance, Epidemiology and End Results cancer registry was queried for women diagnosed with EC or NET-U. Data regarding stage, grade, presence of extra-uterine disease, lymph node metastasis, receipt of adjuvant radiation, surgical intervention and overall survival (OS) was extracted. Chi-square tests, t-tests and Kaplan Meir curves were used for statistical analysis.

RESULTS

A total of 98,363 patients were identified: 98,245 with EC and 118 with NET-U. The mean age at diagnosis for EC was 61.7 years and 64.8 years for NET-U (p=0.01). NET-U cases were more likely to be poorly differentiated (97.0% vs. 15.6%; p≤0.01) and have nodal metastasis (56.4% vs. 11.1%; p≤0.01) when compared to EC. Presence of extrapelvic disease at the time of diagnosis was observed more frequently in NET-U compared to EC, 49.1% vs. 4.8%, respectively (odds ratio=18; 95% confidence interval=13.1-27.2; p≤0.01). Significant improvement in OS was observed in NET-U patient who received radiation (OS: 7.7 vs. 3.3 years; p≤0.01) or underwent surgical management (5.6 vs. 0.9 years; p≤0.01). The OS for EC was 14.4 vs. 4.6 years for NET-U (p≤0.01).

CONCLUSION

NET-U represents an aggressive form of uterine malignancy. When compared to EC, patients with NET-U present at more advanced stage, have more frequent extra-uterine disease and lower OS.

Clinicopathologic features and treatment in patients with early stage uterine clear cell carcinoma: A 16-year experience

OBJECTIVE

To evaluate clinicopathologic factors and adjuvant treatment effects on recurrence free (RFS) and overall survival (OS) in early stage uterine clear cell carcinoma (UCCC).

METHODS

Our retrospective review included central pathology confirmed stage I or II UCCC treated and/or followed between 2000 and 2016. Cases with pure or mixed histology with >50% UCCC were included. Data were analyzed using Kaplan-Meier method and Cox proportional hazards regressions.

RESULTS

112 women were identified. Median age was 65.5 years (range 34-94). Most patients had mixed UCCC (61%), while 39% had pure UCCC. The majority of patients had stage IA UCCC (66%) versus stage IB (15%) or stage II (18%) disease. Adjuvant treatment included chemotherapy + radiation (26%), brachytherapy (27%), whole pelvic radiation (15%), chemotherapy alone (8%), and observation (24%). Thirty-eight (34%) women had recurrent disease. Median RFS was 4.32 years (95% CI 2.77-5.78). On multivariate analysis, age ≥70 (HR 2.48, 95% 1.28-4.81) and positive LVSI (HR 2.19, 95% CI 1.15-4.18) were associated with shorter RFS. Median OS was 9.8 years (95% CI 7.46-15.93). On multivariate analyses, age ≥70 (HR 3.57, 95% CI 1.64-7.74) and positive LVSI (HR 2.46, 95% CI 1.12-5.37) were associated with shorter OS. In this retrospective descriptive uncontrolled patient series, adjuvant treatment type did not impact RFS or OS.

CONCLUSIONS

OS approaches 10 years for early stage UCCC patients. Women ≥70 years have worse PFS and OS regardless of treatment modality, encouraging consideration of quality of life implications when electing for adjuvant therapy.

Uterine Leiomyosarcoma

Uterine leiomyosarcoma (uLMS) is a rare entity among malignant gynecologic tumors with a very unfavorable prognosis and the highest prevalence in the pre- and peri-menopause. Only early-stage tumors have an acceptable prognosis, provided the patient has been treated without injuring the uterus. uLMS is often diagnosed accidentally and the correct diagnosis ishampered by equivocal features similar to the far more frequent benign uterine fibroids. Surgery is the basis of therapy, and it should be done in order to remove the uterus intact. As vaginal, abdominal, and endoscopic surgery - possibly including morcellation - are the methods of choice for the treatment of uterine fibroids, pre-operatively undiagnosed leiomyosarcoma detected by pathologic examination will have a worsened prognosis. Systemic treatment and radiotherapy are of no proven value in the adjuvant setting. Thus, there is strong need for a reliable pre-operative risk score for leiomyosarcoma in order to justify diagnostic means beyond clinical routine and to choose the correct surgical pathway. The clinical problems in the diagnosis of leiomyosarcoma and treatment are exemplified by a case report of a 30-year-old childless patient. Diagnostic tools as well as treatment options in adjuvant and palliative situations are reviewed.

Systemic Treatment of Metastatic/Recurrent Uterine Leiomyosarcoma: A Changing Paradigm

The treatment of metastatic and recurrent uterine leoimyosarcoma (uLMS) has evolved rapidly in the past several years. Leoimyosarcoma is extremely aggressive and responds poorly to traditional chemotherapeutics. Recent regulatory approval of novel treatment options has significantly expanded the therapeutic armamentarium, and the addition of these therapies has challenged clinicians to select and optimally sequence these new compounds. Additionally, the potential role of immunotherapy is being assessed in current uLMS clinical trials. Given the increasing number of agents available both in the U.S. and globally, a treatment template that addresses optimal sequencing based upon expert consensus would be useful. Current guidelines, although listing various options, lack granularity by line of therapy. Most patients with leiomyosarcoma, even in early stage, are treated with surgery followed by adjuvant chemotherapy despite uLMS being relatively chemoresistant. Adjuvant chemotherapy often includes the combination of gemcitabine and docetaxel with or without doxorubicin in first-line systemic therapy, but these cytotoxic agents only provide patients with advanced disease a 5-year survival <30%. This review will focus on examination of current guidelines and consensus building for optimal sequencing of systemic therapies for advanced or recurrent uLMS. Critical ongoing studies investigating novel approaches including immunotherapeutics and genetic alterations also will be discussed. IMPLICATIONS FOR PRACTICE: Recent regulatory approval of novel treatment options has significantly expanded the therapeutic armamentarium, and the addition of these therapies has challenged clinicians to select and optimally sequence these compounds. This review will focus on examination of current guidelines and consensus building for optimal sequencing of systemic therapies for advanced or recurrent uterine leoimyosarcoma.

Results of Postoperative Radiotherapy in the Treatment of 29 Uterine Sarcoma Patients

Aims and background

The objective of this study was to evaluate the results of surgery combined with postoperative radiotherapy (RT) in patients with uterine sarcoma in order to describe the patterns of relapse and to define prognostic factors.

Methods

We report on 29 patients with uterine sarcoma (US) treated from 1980 to 1995; 18 patients with primary tumors were treated with surgery and adjuvant irradiation, while 11 patients with local recurrences (LR) after previous surgical resection received only radiotherapy. We evaluated the influence of stage, histology, grade, menopausal status, total radiation dose and brachytherapy on survival. Histological diagnosis was leiomyosarcoma in 13 patients (44.8%), endometrial stromal sarcoma in 10 patients (34.5%), and mixed mesodermal tumors in six patients (20.7%). Fifteen patients presented with stage I-II disease, three with stage III, and 11 with local recurrences. External pelvic RT was administered to all patients, in five patients combined with brachytherapy. The mean total dose was 54 Gy (SE 1.78). Univariate and multivariate analyses were carried out.

Results

Overall survival (OS) for the stage I-III group was 61.1% at two years and 33.3% at five years (median 29 months, SE 13.79). Disease-free survival (DFS) was 55.6% at two years and 33.3% at five years. Median DFS was 26 months (SE 14.85). In LR cases, median OS was only 10 months (SE 4.5). Multivariate analysis demonstrated that stage was the only prognostic factor after RT for US.

Conclusions

These data suggest that postoperative and/or salvage RT has a questionable impact on disease-free and overall survival because of the lack of homogeneity of stages in the series reported in the literature; it has, however, acceptable late side effects. Prospective multicenter trials including a statistically evaluable number of patients are necessary to further clarify the role of RT treatment programs for US.

The Role of Surgery in Gestational Trophoblastic Disease

Fifty-eight consecutive patients with malignant trophoblastic tumors of gestational origin were treated at the 1st Department of Obstetrics and Gynecology of the University of Milan between 1975 and 1981. Thirty-five (60.3%) of the patients were treated with combined surgery and chemotherapy. Of these, 44.8% had genital surgery, 12% extragenital surgery, and 5.1% had emergency laparotomies. Minor surgery was done to 17.1% of the patients. Five patients (20.8 %) with tumors limited to the uterus and treated with chemotherapy only became drug-resistant, whereas 3 patients (9%) later developed lung metastases. All the patients are alive without any clinical signs of the disease. When there were metastatic tumors, the survival of the group first submitted to a « debulking » operation of the primary focus was 80%, and the survival of the group treated only with chemotherapy was 78.5%. Seven cases required extragenital surgery for the indications discussed in detail and because they had measurable HCG. Six of these had thoracotomies and one had a craniotomy. Five of the 6 patients who underwent thoracotomy (83.4%) had a complete remission. Chemotherapy remains the treatment of choice for trophoblastic tumors. Nevertheless, our data confirm that for some cases, mostly in the high risk group, complete eradication cannot be obtained with antitumor agents. Adjuvant surgery of carefully selected patients helps to save some of those who no longer respond to chemotherapy.

Analysis of Trends in Cancer Mortality in Italy 1951-1978; The Effects of Age, Period of Birth, and Period of Death

We describe trends in cancer mortality in Italy between 1951 and 1978 for 6 different sites (esophagus, lung, breast, cervix uteri, testis, and bladder) as well as all cancers. This is done using a statistical model which separates the contributions associated with age, period of birth and period of death. The results are related to equivalent analyses in England and Wales and also to trends in lifestyle in Italy (alcohol consumption, cigarette consumption, birth rates).

A Clinical and Pathologic Study of 34 Sarcomas of the Uterus

The clinical and pathologic features of 34 uterine sarcomas were studied to determine the natural history of the disease. Sixteen patients had leiomyosarcoma, five mixed mesodermal sarcoma, ten endometrial stromal sarcoma, two carcinosarcoma and one endolymphatic stromal myosis. The patients were treated without an unique protocol. At 3 years the actuarial relapse-free survival was 53.6 %: 68.4 % in stage I-II patients and 22.2 % in stage III-IV patients. As regards the histologic subtype mixed mesodermal sarcomas had the best prognosis; endometrial stromal sarcomas the worst. The necessity of a uniform clinical and histologic classification as well as the importance of controlled clinical trials are pointed out.

A Retrospective Analysis of 53 Patients with Pathologic Stage II and III Endometrial Carcinoma

From 1969 to 1977, 53 patients with surgical-pathologic stages II and III endometrial carcinoma were seen at the Istituto Nazionale Tumori of Milan. The treatment was individualized. The 5-year survival was 68.8% in stage II and 75.3% in stage III. The relapse-free survival was 68.9% and 69.4%, respectively. Adjuvant type of radiotherapy, degree of differentiation, depth of myometrial invasion, and especially sites of disease were the factors influencing survival.

The role of hormonal therapy in patients with uterine carcinoma

OBJECTIVE

The aim of the study was to describe the role of hormonal therapy in the treatment of malignant uterine tumors, indications, the effect of the treatment and to verify its safety in our study cohort. We also present an overview of recent studies on that topic.

DESIGN

Unicentric retrospective observational study and review of recent literature.

SETTING

Department of Obstetrics and Gynecology, Masaryk University, University Hospital Brno.

METHODS

The results of recent relevant studies and reviews published in English until December 2017 were used for the review. The publications were searched using the PubMed server. All patients diagnosed in our oncogynecological center between 2010 and 2016 and who were treated hormonally - either in primary therapy or in relapse settings, were included in our study. We were interested in age, BMI, stage of disease, histological type and grade of tumor, occurrence of adverse effects, duration of survival, reasons for choosing hormonal therapy. Medroxyprogesterone-acetate or megestrol-acetate was used in the treatment.

RESULTS

Between 2010 and 2016, 415 malignant tumors of the uterus were diagnosed in our oncology center. Recurrence of the disease occurred in 31 patients (8%), on average 16 months after primary treatment. Primary hormonal therapy was used in only 19 patients (5%), mostly because of contraindications of another treatment due to high age, comorbidities or obesity. Median age of patients was 83 years, mean BMI 41, median survival of patients who died was 8 months. Five patients (16%) were treated hormonally for the recurrence. Median survival from diagnosis of recurrence was 20 months. One patient (4%) experienced partial pulmonary embolism.

CONCLUSION

Hormonal therapy plays an irreplaceable role in uterine cancer patients, especially in primary non-operable patients, in treatment of a relapse, or in a fertility-sparing procedure. This treatment option is safe, with minimal adverse effects.

Adjuvant gemcitabine-docetaxel chemotherapy for stage I uterine leiomyosarcoma: Trends and survival outcomes

OBJECTIVE

To assess recent trends of administering adjuvant gemcitabine-docetaxel (GD) chemotherapy for Stage I uterine leiomyosarcoma, and to compare disease-free and overall survival between women who received and did not receive adjuvant GD chemotherapy.

METHODS

All patients diagnosed with Stage I uterine leiomyosarcoma in a California-Colorado population-based health plan inclusive of 2006-2013 were included in a retrospective cohort. Adjuvant GD chemotherapy rates, clinico-pathologic characteristics and survival estimates were assessed.

RESULTS

Of 111 women with Stage I uterine leiomyosarcoma, 33 received adjuvant GD (median 4cycles), 77 received no chemotherapy, and 1 patient excluded for non-GD chemotherapy. GD-chemotherapy and no-chemotherapy groups were similar with respect to age, stage (IA/IB), uterine weight, mitotic index, body mass index, and Charlson comorbidity score. Non-Hispanic white women were twice as likely to receive adjuvant chemotherapy as non-white or Hispanic women (37.7 vs. 17.1%, P=0.02). The proportion of women receiving adjuvant GD chemotherapy increased from 6.5% in 2006-2008 to 46.9% in 2009-2013 (P<0.001). There was no significance difference in unadjusted Kaplan-Meyer estimated disease-free (P=0.95) or overall survival (P=0.43) between GD-chemotherapy and no-chemotherapy cohorts. Corresponding adjusted Cox proportional hazard ratios for adjuvant GD chemotherapy compared to no chemotherapy were 1.01 (95% confidence interval [CI] 0.57-1.80, P=0.97) for recurrence and 1.28 (95% CI 0.69-2.36, P-0.48) for mortality.

CONCLUSIONS

Use of adjuvant GD chemotherapy for Stage I uterine leiomyosarcoma has increased significantly in the last decade, despite unclear benefit. Compared to no chemotherapy, 4-6cycles of adjuvant GD chemotherapy does not appear to alter survival outcomes.

Uterine Sarcomas: The Latest Approaches for These Rare but Potentially Deadly Tumors

Uterine sarcomas are rare malignant uterine neoplasms that are responsible for a large majority of uterine cancer-associated deaths. The subtypes include leiomyosarcomas, endometrial stromal tumors, and adenosarcomas. Standard treatment includes complete surgical resection. Adjuvant treatment with chemotherapy, hormonal therapy, or radiation may be considered in patients with high-risk disease. However, because the ability of adjuvant treatment to improve overall survival in patients with uterine sarcomas is unclear, there is no standard recommendation regarding adjuvant therapy. The risk in forgoing chemotherapy is that uterine sarcomas have a tendency to develop distant recurrences. Many cytotoxic agents have been investigated in clinical trials in an attempt to identify an effective treatment that can improve the course of this disease. Adjuvant radiation appears to improve local control but has no significant impact on survival. In this review we discuss preoperative diagnosis and the role of pathology, and we summarize the current literature regarding the management of uterine sarcomas.

High Incidence of Carcinosarcoma among Patients Previously Treated with Tamoxifen

BACKGROUND

Tamoxifen acts as an estrogen antagonist within the breast tissue. In the uterus, tamoxifen is an agonist for some estrogen receptors and therefore can cause hyperplasia or neoplasia in the endometrium.

OBJECTIVES

To compare characteristics of patients with uterine sarcoma who were and were not previously treated with tamoxifen.

METHODS

The medical records of all women with uterine sarcoma who had been treated at the Carmel Medical Center in Haifa, Israel, during 2000-2013 were retrospectively reviewed. Disease characteristics, histological type of sarcoma, patient demographics, treatments and final outcomes were compared between patients who had and those who had not been exposed to tamoxifen.

RESULTS

Of the 66 patients identified, 14 (21%) had been exposed to tamoxifen, one of them for 3 years and 13 for at least 5 years. Mean ages were 69 ± 8 and 66 ± 12 years for those exposed and those not exposed to the drug, respectively. Rates of uterine carcinosarcoma were 86% (12/14) and 44% (23/52), respectively (P < 0.006). Patients with carcinosarcoma were older than other sarcoma patients (73 ± 7 vs. 59 ± 11 P < 0.005).There were no statistically significant differences between the two groups in rates of diabetes mellitus, hypertension, dyslipidemia or heart disease. The mean time from diagnosis to death was 7.37 ± 0.42 years. The overall survival rates of carcinosarcoma patients were not statistically different from that of other sarcoma patients. Tamoxifen exposure was not associated with overall survival among all sarcoma patients, nor among the subgroup of carcinosarcoma patients.

CONCLUSIONS

Tamoxifen treatment was associated with elevated incidence of carcinosarcoma among women with uterine sarcoma, but was not found to be associated with prognosis or with co-morbidities.

Postoperative chemotherapy on placental site trophoblastic tumor in early stage: analysis of 60 cases

PURPOSE OF INVESTIGATION

To review the literature of placental site trophoblastic tumor (PSTT) and explore the effect of postoperative chemotherapy in patients with Stage I.

MATERIALS AND METHODS

The authors searched literature on Medline, Excerpta Medica Database (EMBASE), and other resources using the keywords "placental site trophoblastic tumor" and "PSTT" from 1981 ito 2014.

RESULTS

A total number of 60 patients with Stage I disease were identified, and the presentation, treatment, tumor response, disease status, and follow-up were retrieved and reviewed. According to the authors' knowledge, 725 cases associated with PSTT have been reported in 29 nations/areas since 1981. In this series, the probability of overall survival at ten years in the group of surgery alone and postoperative chemotherapy were 96.7% and 79.1% (p = 0.199), and recurrence-free survival rates were 91.8% and 63.3%, respectively.

CONCLUSION

The benefit from postoperative chemotherapy is still equivocal. There is a need for scrupulousness before adding postoperative chemotherapy.

Uterine Sarcoma Treated by Cytoreductive Surgery and Intraperitoneal Hyperthermic Perfusion: a Feasiblity Study

The purpose of this study was to evaluate the feasibility and the outcome impact of cytoreductive surgery (CRS) followed by intraperitoneal hyperthermic perfusion (IPHP) in patients affected by uterine sarcoma (US). Ten US patients were treated with CRS+IPHP (closed technique, cisplatin+mitomycin C or cisplatin+doxorubicin). Median follow-up was 25 months (range: 2-61). Five patients received preoperative chemotherapy. Nine cases underwent optimal CRS. Five-year overall and progression-free survivals were 65% and 30%, respectively. There was no operative morbidity, nor mortality and nor toxicity. Six patients presented disease progression. CRS+IPHP proved feasible and safe, with encouraging outcome results, warranting confirmation by further prospective controlled trials.

Referral patterns between high- and low-volume centers and associations with uterine cancer treatment and survival: a population-based study of Medicare, Medicaid, and privately insured women

BACKGROUND

High-volume center surgery and gynecologic oncology care are associated with improved outcomes for women with uterine cancer. Referral patterns, from biopsy through to chemotherapy, may have patients interacting with high-volume centers for all, a portion, or none of their care. The relative frequency, the underlying factors that contribute to referral, and the potential impact of these referral patterns on treatment outcomes are unknown.

OBJECTIVE

We sought to analyze the referral patterns and subsequent impact of care sites on treatment for women with high- and low-risk uterine cancer.

STUDY DESIGN

This is a population-based retrospective cohort study of uterine cancer cases from 2004 through 2009 in North Carolina. Using state cancer registry files linked to Medicare, Medicaid, and private payer insurance claims, we analyzed referral and treatment patterns by annual surgical volume (high ≥12/y). We examined clinical and demographic factors associated with referral and used modified Poisson regression to evaluate risk of referral, lymphadenectomy, and chemotherapy. Stratified Kaplan-Meier plots and Cox proportional hazard models were used to examine survival.

RESULTS

A total of 2053 women were analyzed, including 34% (n = 677) with grade 3 histology. Of 1630 (80%) women with preoperative biopsies, referral patterns (biopsy to surgery) were: low volume to high volume (n = 652, 40%), followed by high volume to high volume (n = 605, 37%), then low volume to low volume (n = 318, 20%), and the rare high volume to low volume (n = 50, 3%). Women retained in low-volume centers after biopsy were older, were less likely to have private insurance, and had more comorbidities. High-risk histology (aRR, 1.14; 95% confidence interval, 1.04-1.25) was positively associated with referral, while Medicaid insurance was negatively associated with referral (aRR, 0.64; 95% confidence interval, 0.42-0.96). Most women (74%, n = 1557) had surgery at high-volume centers. Lymphadenectomy was less likely at low-volume centers (aRR, 0.71; 95% confidence interval, 0.64-0.77). Similarly, for high-risk patients, the relationship between low-volume center surgery and subsequent chemotherapy was aRR, 0.71 (95% confidence interval, 0.48-1.02). Of 290 women who received chemotherapy, the referral patterns (surgery to chemotherapy) were: high volume-all (high volume to high volume), high volume-hybrid (high volume to low volume, or low volume to high volume), and high volume-none (low volume to low volume). In all, 36% (n = 104/290) received chemotherapy at a low-volume center, the majority (68%, n = 71/104) of whom were referred from high-volume centers after surgery. Crude, unadjusted mortality risk of chemotherapy recipients differed by referral pattern (surgery to chemotherapy): high volume-all patients (hazard ratio, 1.0; referent), followed by high volume-hybrid (hazard ratio, 1.33; 95% confidence interval, 0.93-1.91) then high volume-none patients (RR, 1.95; 95% confidence interval, 1.24-3.08).

CONCLUSION

Most women with uterine cancer treated at high-volume centers arrive through referral, which is affected by age and type of insurance, in addition to histology. For high-risk women who require chemotherapy, survival may be related to the extent of treatment received at high-volume centers.

[Uterine Carcinosarcoma: Clinicopathological Features and Prognostic Factors]

INTRODUCTION

Uterine carcinosarcoma is a rare and aggressive biphasic malignancy and is currently included in the high risk endometrial carcinoma group. The aims of this study were to determine the clinicopathological profile, treatment, recurrence/progression patterns, survival and prognostic factors.

MATERIAL AND METHODS

Retrospective study of 42 patients, surgically staged and followed-up at a cancer centre, between 2005 and 2013. Clinical data was retrieved from records and pathological characteristics were reviewed for this study.

RESULTS

Median age was 72 years (61 - 78) and the majority presented comorbid diseases. Stage distribution as follows: 13 (31.0%) stage I; eight (19.0%) stage II; nine (21.4%) stage III; and 12 (28.6%) stage IV. Chemotherapy was instituted in 12 patients and 21 received radiotherapy. Disease progressed in 16 patients and recurred in nine after a short interval. Median overall survival was 18 months (6.8 - 40) and median disease-free survival was 6 months (0 - 22.8). The only independent prognostic factor related with poor survival was serosal invasion (p = 0.02; HR adjusted 4.22; IC 95% 1.29 - 13.79).

DISCUSSION

In accordance to other studies, diagnosis of uterine carcinosarcoma is frequently done with advanced disease and presents a high rate of progression/recurrence. The variable which has been consistently identified as main prognostic factor is stage, but in this study the only independent factor was serosal invasion.

CONCLUSION

The present study represents the larger series of uterine carcinosarcoma studied in Portugal and reflects the clinical presentation, histopathological characteristics and stage at diagnosis and confirms the aggressiveness of this rare tumor.

Incidence and mortality of gynaecological cancers: Secular trends in urban Shanghai, China over 40 years

AIM

Appraisal of cancer trends is essential for future cancer control, but relevant studies in China are scarce due to a lack of long-term data. With 40-years of cancer registry data, we sought to evaluate secular time trends in incidence and mortality of gynaecological cancers in an urban Chinese population.

MATERIALS AND METHODS

Data on incidence and mortality of invasive cervical, uterine and ovarian cancer were collected by the Shanghai Cancer Registry. Age-standardised incidence and mortality rates were calculated for women aged 20-84 in urban Shanghai between 1973 and 2012. Age-period-cohort Poisson regression models were used to evaluate age, period and cohort effects. Overall linear trends, interpreted as the estimated annual percentage change (EAPC), were derived from the net drift in age-drift models.

RESULTS

Overall, cervical cancer incidence and mortality substantially decreased (EAPC = -4.5% and -5.5%, respectively); however, an upward trend was apparent among younger women (age <60). Uterine cancer incidence increased slightly (EAPC = 1.8%), while mortality decreased over time (EAPC = -2.4%). Ovarian cancer incidence and mortality both increased, although the increase in incidence (EAPC = 1.8%) was larger than mortality (EAPC = 0.6%). While cohort effects were most evident for cervical cancer incidence and mortality, significant age, period, and cohort effects were found for all three gynaecological cancers evaluated.

CONCLUSIONS

These secular trends in incidence and mortality of gynaecological cancers in Shanghai likely reflect changing risk factor profiles and improved cancer prognosis over time, and suggest new priorities and call for additional efforts for gynaecological cancer prevention and control for women in China.

Prognosis of Patients with Gestational Trophoblastic Neoplasia and Obstetric Outcomes of Those Conceiving After Chemotherapy

AIM

To assess prognosis of gestational trophoblastic neoplasia (GTN) and obstetric outcome after chemotherapy.

PATIENTS AND METHODS

Sixty-six patients had diagnosis of hydatiform mole on curettage and 18 developed GTN. Two patients were referred with pathological diagnosis of GTN. Chemotherapy was tailored according to International Federation of Gynecology and Obstetrics risk scoring system.

RESULTS

All patients with GTN but one, were recovered by chemotherapy and had no evidence of disease after a median follow-up of 80 months. Only the patient with epithelioid trophoblastic tumor died of disease. Seven out of the eight women who tried to conceive after chemotherapy became pregnant. Ten conceptions occurred, resulting in no molar pregnancy, three miscarriages and seven term-live healthy births (70.0%). All seven babies showed normal development and growth after a median follow-up of 38 months.

CONCLUSION

The prognosis of women with GTN is very good, and obstetric outcomes of those who conceive after chemotherapy are similar to those of the general population.

Cancer treatment and survivorship statistics, 2016

The number of cancer survivors continues to increase because of both advances in early detection and treatment and the aging and growth of the population. For the public health community to better serve these survivors, the American Cancer Society and the National Cancer Institute collaborate to estimate the number of current and future cancer survivors using data from the Surveillance, Epidemiology, and End Results cancer registries. In addition, current treatment patterns for the most prevalent cancer types are presented based on information in the National Cancer Data Base and treatment-related side effects are briefly described. More than 15.5 million Americans with a history of cancer were alive on January 1, 2016, and this number is projected to reach more than 20 million by January 1, 2026. The 3 most prevalent cancers are prostate (3,306,760), colon and rectum (724,690), and melanoma (614,460) among males and breast (3,560,570), uterine corpus (757,190), and colon and rectum (727,350) among females. More than one-half (56%) of survivors were diagnosed within the past 10 years, and almost one-half (47%) are aged 70 years or older. People with a history of cancer have unique medical and psychosocial needs that require proactive assessment and management by primary care providers. Although there are a growing number of tools that can assist patients, caregivers, and clinicians in navigating the various phases of cancer survivorship, further evidence-based resources are needed to optimize care. CA Cancer J Clin 2016;66:271-289. © 2016 American Cancer Society.

Gynaecologic mortality in Enugu, Nigeria

A retrospective review of 79 deaths in 2033 gynaecologic admissions at a referral centre showed that the leading causes of mortality were cervical cancer, choriocarcinoma, septic abortion and ovarian cancer, in that order. The results suggest a need for an organized cancer programme to limit morbidity and mortality from malignant disease of the female genital tract.

Maternal Near Miss According to World Health Organization Classification Among Women with a Hydatidiform Mole: Experience at the New England Trophoblastic Disease Center, 1994-2013

OBJECTIVE

To investigate the frequency of potentially life-threatening conditions (PLTCs) and maternal near misses (MNMs) at the New England Trophoblastic Disease Center (NETDC) in recent years, when there has been earlier diagnosis of molar pregnancy.

STUDY DESIGN

This study included patients with molar pregnancy at the NETDC between 1994 and 2013. Clinical and pathologic reports were reviewed. PLTC and MNM criteria and maternal deaths were searched in medical records using the World Health Organization criteria and classification.

RESULTS

We identified 375 patients with molar pregnancy and no patient developed a MNM or maternal death. Only 6 (1.6%) had PLTCs (hemorrhage with hemodynamic instability, severe preeclampsia, respiratory distress, blood transfusion, and ICU admission).

CONCLUSION

We observed a low rate of PLTC and no cases of MNMs or maternal deaths related to molar pregnancy, likely due to earlier diagnosis at the NETDC in recent years.

The Role of Steroid Sulfatase as a Prognostic Factor in Patients with Endometrial Cancer

PURPOSE

The aim of the study was to determine steroid sulfatase (STS) expression in endometrial cancer patients and its correlation with disease prognosis.

MATERIALS AND METHODS

We conducted a retrospective study in 59 patients who underwent surgery with histologically confirmed endometrial cancer from January 2000 to December 2011 at Hanyang University Hospital. Immuno-histochemical staining of STS was performed using rabbit polyclonal anti-STS antibody.

RESULTS

Sixteen of the 59 patients (27.1%) were positive for STS expression. Disease free survival (DFS) was 129.83±8.67 [95% confidence interval (CI): 112.84-146.82] months in the STS positive group (group A) and 111.06±7.17 (95% CI: 97.01-125.10) months in the STS negative group (group B) (p=0.92). Overall survival (OS) was 129.01±9.38 (95% CI: 110.63-147.38) months and 111.16±7.10 (95% CI: 97.24-125.07) months for the groups A and B, respectively (p=0.45). Univariate analysis revealed that FIGO stage and adjuvant therapy are significantly associated with DFS and OS. However, in multivariate analysis, FIGO stage and adjuvant therapy did not show any statistical significance with DFS and OS. STS was also not significantly associated with DFS and OS in univariate and multivariate analysis.

CONCLUSION

STS expression was not significantly associated with DFS and OS, despite positive STS expression in 27% of endometrial cancer patients. Therefore, the role of STS as a prognostic factor in patients with endometrial cancer remains unclear and requires further research.

Progesterone Receptor Expression Is an Independent Prognosticator in FIGO Stage I Uterine Leiomyosarcoma

OBJECTIVES

To analyze the clinical role of hormone receptors in a large uterine sarcomas series with long-term follow-up.

METHODS

Protein expression of estrogen receptor (ER) and progesterone receptor (PR) by immunohistochemistry was studied in tissue microarrays from 294 patients diagnosed with uterine sarcoma in Norway from 1970 to 2000 and analyzed for an association with clinicopathologic parameters and outcome.

RESULTS

ER and PR were detected in 136 of 291 and 184 of 291 tumors (three noninformative cases each), respectively. Expression was unrelated to histology, patient age, tumor diameter, the degree of atypia, the presence of necrosis or vascular invasion, or mitotic counts. ER and PR expression was unrelated to survival in the analysis of the entire cohort. When survival analysis was confined to stage I leiomyosarcoma (n = 147), higher PR score was significantly related to longer overall survival (OS) (P = .042). Clinicopathologic prognosticators in this group were age (P = .041), tumor diameter (P = .001), and mitotic count (P = .007), with a trend for atypia (P = .087). In Cox multivariate analysis, PR score (P = .019), tumor diameter (P = .013), and mitotic count (P = .002) were independent prognosticators of OS.

CONCLUSIONS

Hormone receptor expression is not informative of outcome in the analysis of uterine sarcomas of all stages and histologic types. PR expression identifies patients with longer survival in stage I leiomyosarcoma.

Causes of Cancer Death Among First-Degree Relatives in Japanese Families with Lynch Syndrome

AIM

To elucidate the causes of cancer death in Japanese families with Lynch syndrome (LS).

METHODS

The distributions of cancer deaths in 485 individuals from 67 families with LS (35, 30, and two families with MutL homologue 1 (MLH1), MSH2, and MSH6 gene mutations, respectively), obtained from the Registry of the Japanese Society for Cancer of the Colon and Rectum were analyzed.

RESULTS

Among 98 cancer deaths of first-degree relatives of unknown mutation status, 53%, 19%, 13% (among females), 7% (among females) and 5% were due to colorectal, gastric, uterine, ovarian, and hepatobiliary cancer, respectively. The proportion of deaths from extra-colonic cancer was significantly higher in families with MSH2 mutation than in those with MLH1 mutation (p=0.003).

CONCLUSION

In addition to colonic and uterine cancer, management and surveillance targeting gastric, ovarian and hepatobiliary cancer are considered important for Japanese families with LS. Extra-colonic cancer in families with MSH2 mutation might require for more intensive surveillance.

Novel targeted therapies in uterine serous carcinoma, an aggressive variant of endometrial cancer

Uterine serous carcinoma (USC) is a rare but aggressive subtype of endometrial cancer. Although it represents only 10% of all endometrial cancer cases, USC accounts for up to 40% of all endometrial cancer-related recurrences and subsequent deaths. With such a dismal prognosis, there is an expanding role for novel targeted approaches in the treatment of USC. Recent whole-exome sequencing studies have demonstrated gain of function of the HER2/NEU gene, as well as driver mutations in the PIK3CA/AKT/mTOR and cyclin E/FBXW7 oncogenic pathways in a large number of USCs. The results emphasize the relevance of these novel therapeutic targets for biologic therapy of USC, which will be reviewed in this article.

[The accuracy of the causes of death and the estimated trend: the case of cervix uteri]

BACKGROUND

reduction in cervical cancer mortality is the ultimate goal of the screening. Quality of death certificate reports has been improved over time, but they are still inaccurate, making it difficult to assess time trends in mortality.

OBJECTIVES

to evaluate the accuracy of the topographic coding of causes of death and to estimate the mortality time trend for cervical cancer through the method of incidence-based mortality (IBM) using cancer registry (CR) data.

DESIGN

from the mortality registry (MR), we extracted data on deaths for cervix uteri cancer, corpus uteri cancer, and uterus cancer not otherwise specified (NOS) referred to residents in Reggio Emilia (Emilia-Romagna Region, Northern Italy) from 1997 to 2013. Deaths were checked with the CR to verify the topographical site of the primary tumour. Furthermore, by using CR data, we constructed a cohort of incident cervical cancer cases diagnosed between 1997 and 2009 with a 5-year follow-up. We calculated cause-specific IBM (excluding ovary) and IBM for all cause, crude and standardized, and annual percentage change (APC).

RESULTS

out of 369 deaths for uterine cancer, 269 were reported in the RT: 32 for cervix uteri cancer, 76 for corpus uteri cancer, 161 for uterus cancer NOS. 28 of the 32 persons who died for cervical cancer were incidents for cervix uteri cancer. 63 of the 76 who died for corpus uteri cancer were incidents for corpus uteri cancer. Of the 161 who died of uterus cancer NOS, 80 were incidents for corpus uteri cancer, 45 for cervix uteri cancer, 28 for uterus cancer NOS, 5 for vagina cancer, and 3 for cancer of other non-specified organs. Applying these proportions of misclassification, we can estimate that the real number of cervical cancer deaths is 2.4 folds the number of cases reported in the MR as cervical cancer. IBM for all causes decreased significantly over the years (APC: -9.5; 95%CI -17.1;-1.1); cause-specific IBM decreases, but not significantly (APC: -5.1; 95%IC -16.1;+7.3). There is no improvement in survival (r2=0.02; p=0.6), while the incidence shows a decrease (APC: -6.6;95%CI -10.0;-3.0).

CONCLUSIONS

mortality for cervical cancer is still underestimated by deaths certificates: for each reported case, there are other 1.4 cases that are reported with other less specific causes.

Exome Sequencing of Uterine Leiomyosarcomas Identifies Frequent Mutations in TP53, ATRX, and MED12

Uterine leiomyosarcomas (ULMSs) are aggressive smooth muscle tumors associated with poor clinical outcome. Despite previous cytogenetic and molecular studies, their molecular background has remained elusive. To examine somatic variation in ULMS, we performed exome sequencing on 19 tumors. Altogether, 43 genes were mutated in at least two ULMSs. Most frequently mutated genes included tumor protein P53 (TP53; 6/19; 33%), alpha thalassemia/mental retardation syndrome X-linked (ATRX; 5/19; 26%), and mediator complex subunit 12 (MED12; 4/19; 21%). Unlike ATRX mutations, both TP53 and MED12 alterations have repeatedly been associated with ULMSs. All the observed ATRX alterations were either nonsense or frameshift mutations. ATRX protein levels were reliably analyzed by immunohistochemistry in altogether 44 ULMSs, and the majority of tumors (23/44; 52%) showed clearly reduced expression. Loss of ATRX expression has been associated with alternative lengthening of telomeres (ALT), and thus the telomere length was analyzed with telomere-specific fluorescence in situ hybridization. The ALT phenotype was confirmed in all ULMSs showing diminished ATRX expression. Exome data also revealed one nonsense mutation in death-domain associated protein (DAXX), another gene previously associated with ALT, and the tumor showed ALT positivity. In conclusion, exome sequencing revealed that TP53, ATRX, and MED12 are frequently mutated in ULMSs. ALT phenotype was commonly seen in tumors, indicating that ATR inhibitors, which were recently suggested as possible new drugs for ATRX-deficient tumors, could provide a potential novel therapeutic option for ULMS.

Uterine leiomyosarcomas are rare, malignant smooth muscle tumors with a poor 5-year survival and high recurrence rate. They account for 1–2% of all uterine malignancies with an estimated incidence of 0.4/100,000 women per year. The symptoms and signs of this tumor type widely overlap with those of common benign uterine leiomyomas, making early diagnosis of uterine leiomyosarcomas difficult. Currently, the diagnosis of these tumors is often incidental and postoperative. Despite previous cytogenetic and molecular studies, their molecular background has remained elusive. Identification of novel molecular genetic characteristics in uterine leiomyosarcomas is clinically relevant to further improve the diagnosis and prognosis of the patients. Here, we performed exome sequencing on 19 tumors, revealing frequent mutations in TP53, ATRX, and MED12. The discovery of frequent inactivating ATRX mutations provides a potential novel therapeutic target for uterine leiomyosarcomas.

A Retrospective Analysis of the Impact of Myomectomy on Survival in Uterine Sarcoma

Laparoscopic myomectomy is a minimally invasive, conservative surgical approach commonly used for the treatment of uterine fibroids. However, there is a lack of effective means to distinguish the nature of uterine tumors prior to surgery. The impact of fibroid morcellation during laparoscopic surgery on the dissemination of cancerous uterine fibroids and long-term survival of patients has gained increasing attention. A retrospective cohort study was conducted to analyze the impact of different surgical approaches on recurrence-free survival (RFS) and overall survival (OS) in patients with a postoperative pathological diagnosis of uterine sarcoma at a single medical center. Patients who underwent the first surgery for uterine fibroids (confined to the uterus) and had a postoperative pathological diagnosis of uterine sarcoma were selected in the Chinese PLA General Hospital from January 2005 to January 2014. Based on the use of fibroid morcellation, the subjects were divided into fibroid morcellation (FM) and total hysterectomy (TH, non-morcellation) groups. Follow-up outcomes, including RFS and OS times, were observed. In total, 59 patients were included, with 30 cases in the FM group and 29 cases in the TH group. There were no significant differences in RFS and OS time between the two groups (RFS: P = 0.16, OS: P = 0.09). Multivariate correlation analysis showed that the impact of a higher grade level on RFS and OS was nearly 2-fold the impact of a lower grade level (RFS: P = 0.04, odds ratio (OR) = 1.97; OS: P = 0.03, OR = 2.29). Intraoperative morcellation, postoperative adjuvant therapy, age, tumor size, FIGO stage, and surgical approach were not risk factors affecting RFS and OS. Fibroid morcellation during laparoscopic surgery (including laparoscopic, transvaginal and transabdominal approaches) had no significant impact on RFS and OS time in patients. However, the 5-year RFS and OS rates were both lower in the FM group than in the TH group. Grade level was a significant risk factor for the prognosis of patients with uterine sarcoma.

Comparative Survival Outcomes of Uterine Papillary Serous Carcinoma, Clear Cell Carcinoma, Grade 3 Endometrioid Adenocarcinoma, and Carcinosarcoma of Endometrial Cancer in Rajavithi Hospital

BACKGROUND

Uterine papillary serous carcinoma (UPSC), clear cell carcinoma (CC), grade 3 endometrioid adenocarcinoma (G3EC), and carcinosarcoma (CS) have been identified as high-grade endometrial cancers and account for the majority of uterine cancer deaths.

OBJECTIVE

To compare survival outcomes of patients with UPSC, CC, G3EC and CS in Rajavithi Hospital.

MATERIAL AND METHOD

A retrospective review was performed of all patients with FIGO stage I-IV endometrial cancer in Rajavithi Hospital between 1 January 2007 and 31 December 2012. Kaplan-Meier estimates were made of overall survival (OS) and progression-free survival (PFS), and log-rank tests were used to compare survival distributions between histological subtypes. Cox regression was used to estimate hazard ratios for histological subtypes, adjusted for other significant prognostic factors.

RESULTS

One hundred sixty-three patients had confirmed diagnosis of high-grade endometrial cancer: 45 had UPSC, 30 had CC; 58 had G3EC; and 30 had CS. The median age distribution of the four groups of patients was approximately 60 years. The body mass index, underlying disease, and parity were similar in each group. All patients underwent a hysterectomy and surgical staging procedure. The 2-year progression-free survival was poorest in the CS cases (79.4%), followed by CC (87.2%), G3EC (92.2%), and UPSC cases (95.5%), and these figures were statistically significantly different among the groups (p = 0.015). The 2-year overall survival was poorest in the CC cases (70.0%), followed by CS (76.7%), UPSC (86.7%), and G3EC (87.9%); however, there were no significant differences among the groups (p = 0.071). In multivariate analysis for OS, advanced stage and suboptimal surgery were significantly associated with increased risk of death. For PFS, advanced stage and positive peritoneal cytology were significantly associated with increased risk of recurrence.

CONCLUSION

CS patients had a significantly lower rate of progression-free survival than other subtypes. These findings should be taken into account when considering counseling, primary treatment and appropriate adjuvant treatment in order to improve survival outcomes in these high-risk patients.

Comparison of the Prognostic Utility of the Diverse Molecular Data among lncRNA, DNA Methylation, microRNA, and mRNA across Five Human Cancers

INTRODUCTION

Advances in high-throughput technologies have generated diverse informative molecular markers for cancer outcome prediction. Long non-coding RNA (lncRNA) and DNA methylation as new classes of promising markers are emerging as key molecules in human cancers; however, the prognostic utility of such diverse molecular data remains to be explored.

MATERIALS AND METHODS

We proposed a computational pipeline (IDFO) to predict patient survival by identifying prognosis-related biomarkers using multi-type molecular data (mRNA, microRNA, DNA methylation, and lncRNA) from 3198 samples of five cancer types. We assessed the predictive performance of both single molecular data and integrated multi-type molecular data in patient survival stratification, and compared their relative importance in each type of cancer, respectively. Survival analysis using multivariate Cox regression was performed to investigate the impact of the IDFO-identified markers and traditional variables on clinical outcome.

RESULTS

Using the IDFO approach, we obtained good predictive performance of the molecular datasets (bootstrap accuracy: 0.71-0.97) in five cancer types. Impressively, lncRNA was identified as the best prognostic predictor in the validated cohorts of four cancer types, followed by DNA methylation, mRNA, and then microRNA. We found the incorporating of multi-type molecular data showed similar predictive power to single-type molecular data, but with the exception of the lncRNA + DNA methylation combinations in two cancers. Survival analysis of proportional hazard models confirmed a high robustness for lncRNA and DNA methylation as prognosis factors independent of traditional clinical variables.

CONCLUSION

Our study provides insight into systematically understanding the prognostic performance of diverse molecular data in both single and aggregate patterns, which may have specific reference to subsequent related studies.

Lifestyle and Weight Management Counseling in Uterine Cancer Survivors: A Study of the Uterine Cancer Action Network

OBJECTIVE

The purpose of this study was to examine the experiences, attitudes, and preferences of uterine cancer survivors with regard to weight and lifestyle counseling.

MATERIALS AND METHODS

Members of the US Uterine Cancer Action Network of the Foundation for Women's Cancer were invited to complete a 45-item, Web-based survey. Standard descriptive statistical methods and χ tests were used to analyze responses.

RESULTS

One hundred eighty (28.3%) uterine cancer survivors completed the survey. Median age was 58 years, 85% were white, and median survivorship period was 4.4 years. Most had stage I-II disease (69%) and were overweight or obese (65%). Eighty-nine percent of respondents received care by a gynecologic oncologist. Increased respondent body mass index was associated with decreased exercise frequency (P = 0.016). Only 50% of respondents underwent any weight/lifestyle counseling, with those living in the West and Southwest reporting the highest rates (70.8% and 69.2%, P = 0.011). Most who received counseling felt that discussions were motivating, performed in a sensitive manner, and did not undermine the patient-physician relationship. Specific recommendations were rarely offered; there were no reported referrals to weight loss programs or bariatric specialists, and few (6%) reported referrals to nutritionists. Respondents (85%) preferred their gynecologic oncologist address weight using direct, face-to-face counseling with specific recommendations regarding interventions and referral to specialists. Finally, self-reported overweight respondents experienced greater success with weight loss compared to those reporting obesity or morbid obesity (30.8% vs 15.8% vs 12.5%, P = 0.011).

CONCLUSIONS

Uterine cancer survivors reported high obesity, low activity rates, and a desire for substantive weight loss counseling from their gynecologic oncologists. Respondents suggested that current counseling practices are inadequate and incongruent with their needs. Further research to define optimal timing, interventional strategies, and specific recommendations for successful lifestyle changes in this population is warranted.

The Prognostic Value of C-Reactive Protein Serum Levels in Patients with Uterine Leiomyosarcoma

Objective

C-reactive protein (CRP) has previously been shown to serve as a prognostic parameter in women with gynecologic malignancies. Due to the lack of valid prognostic markers for uterine leiomyosarcoma (ULMS) this study set out to investigate the value of pre-treatment CRP serum levels as prognostic parameter.

Methods

Data of women with ULMS were extracted from databases of three Austrian centres for gynaecologic oncology. Pre-treatment CRP serum levels were measured and correlated with clinico-pathological parameters. Univariate and multivariable survival analyses were performed.

Results

In total, 53 patients with ULMS were included into the analysis. Mean (SD) CRP serum level was 3.46 mg/dL (3.96). Solely, an association between pre-treatment CRP serum levels and tumor size (p = 0.04) but no other clinic-pathologic parameter such as tumor stage (p = 0.16), or histological grade (p = 0.07), was observed. Univariate and multivariable survival analyses revealed that CRP serum levels (HR 2.7 [1.1–7.2], p = 0.037) and tumor stage (HR 6.1 [1.9–19.5], p = 0.002) were the only independent prognostic factors for overall survival (OS) in patients with ULMS. Patients with high pre-treatment CRP serum levels showed impaired OS compared to women with low levels (5-year-OS rates: 22.6% and 52.3%, p = 0.007).

Conclusion

High pre-treatment CRP serum levels were independently associated with impaired prognosis in women with ULMS and might serve as a prognostic parameter in these patients.

Diagnostic value of progesterone receptor, p16, p53 and pHH3 expression in uterine atypical leiomyoma

The differential diagnosis between atypical leiomyoma and leiomyosarcoma may be hard based on morphological criterion at times. It would be helpful to find out biomarkers that can be used to distinguish them. The aim of the study was to investigate the diagnostic value of progesterone receptor (PR), p16, p53 and pHH3 expression in a series of uterine smooth muscle tumors. Immunohistochemical expression of PR, p16, p53 and pHH3 was investigated on 32 atypical leiomyomas, 15 leiomyosarcomas and 15 usual leomyomas. The difference in expression was compared between atypical leiomyoma and other groups. The expression of PR, p16, and pHH3 was found significantly different between atypical leiomyomas and leiomyosarcomas, but lack of significant difference between atypical leiomyomas and usual leiomyomas. There was no significant difference with regard to p53 distribution among these uterine smooth muscle tumors. High p16, pHH3 expression and low PR expression preferred the diagnosis of leiomyosarcoma. The panel of antibodies used in this study is a useful complementary analysis in the assessment of problematic uterine smooth muscle tumors.

A clinical analysis of brain metastasis in gynecologic cancer: a retrospective multi-institute analysis

This study analyzes the clinical characteristics of the brain metastasis (BM) of gynecologic cancer based on the type of cancer. In addition, the study examines the factors influencing the survival. Total 61 BM patients of gynecologic cancer were analyzed retrospectively from January 2000 to December 2012 in terms of clinical and radiological characteristics by using medical and radiological records from three university hospitals. There were 19 (31.1%) uterine cancers, 32 (52.5%) ovarian cancers, and 10 (16.4%) cervical cancers. The mean interval to BM was 25.4 months (21.6 months in ovarian cancer, 27.8 months in uterine cancer, and 33.1 months in cervical cancer). The mean survival from BM was 16.7 months (14.1 months in ovarian cancer, 23.3 months in uterine cancer, and 8.8 months in cervical cancer). According to a multivariate analysis of factors influencing survival, type of primary cancer, Karnofsky performance score, status of primary cancer, recursive partitioning analysis class, and treatment modality, particularly combined therapies, were significantly related to the overall survival. These results suggest that, in addition to traditional prognostic factors in BM, multiple treatment methods such as neurosurgery and combined chemoradiotherapy may play an important role in prolonging the survival for BM patients of gynecologic cancer.