[Significance of prognostic evaluation of International Federation of Gynecology and Obstetrics 2009 staging system on stage I endometrioid adenocarcinoma]

OBJECTIVE

To explore the impact of 2009 International Federation of Gynecology and Obstetrics (FIGO) staging system alteration for stage I endometrioid adenocarcinoma on its' prognosis assessing.

METHODS

A retrospective study was carried out on 244 cases with endometrial carcinoma admitted in Peking University People's Hospital from Jan.1995 to Feb.2008.

RESULTS

(1) All 244 patients were divided into FIGO 2009 Ia group (n = 200) and FIGO 2009 Ib group (n = 44) according to FIGO 2009 staging system, while they were divided into FIGO 1988 Ia group (n = 34), FIGO 1988 Ib group (n = 156) and FIGO 1988 Ic group (n = 29). The others 25 cases were stage IIa (n = 16) and stage IIIa with merely positive abdominal cytology (n = 9) according to FIGO 1988 staging system.(2) The higher percentage of low-grade in FIGO 1988 Ia group than that in FIGO 2009 Ia group (P = 0.003). Compared with FIGO 2009 Ia group, the age of the patients, surgery extent, the percentage of lymph node excision and received chemotherapy and radiotherapy, there were no difference in FIGO 1988 Ia and Ib group, respectively (P > 0.05). There were 5.9% (2/34) and 6.7% (10/150) found relapse among FIGO 1988 Ia group and FIGO 1988 Ib group, and there were 2.9% (1/34) and 2.7% (4/150) for the two groups died of carcinoma. Compared with FIGO 2009 Ia group, there were not significant difference [7.5% (13/200) vs. 3.0% (6/200); P > 0.05]. The 5 years and 10 years progression-free survival (PFS) of FIGO 1988 Ia group and Ib group were (97.0 ± 3.0)%, (90.9 ± 6.5)% and (95.3 ± 2.1)%, (90.2 ± 3.6)%, respectively, in which there were not significant difference compared with that in FIGO 2009 Ia group [(96.1 ± 1.6)%, (89.6 ± 3.2)%; P > 0.05]. The 5 years and 10 years overall survival (OS) in FIGO 1988 Ia group and Ib group were 100%, (93.8 ± 6.0)% and (96.9 ± 1.8)%, (95.2 ± 2.5)%, respectively, in which there were did not significant difference with that in FIGO 2009 Ia group [(97.9 ± 1.2)%, (93.4 ± 2.8)%; P > 0.05].(3) There were not significant difference between FIGO 1988 Ic group and FIGO 2009 Ib group (P > 0.05) for the age of the patients, grade, surgery extent, lymph node excision, the percentage of received chemotherapy and radiotherapy. Between FIGO 1988 Ic group and FIGO 2009 Ib group, there were 3.4% (1/29) and 6.8% (3/44) cases found relapse, respectively. And there were 0 and 2.3% (1/44) cases died of carcinoma in the two groups, in which there were not differ much either (P > 0.05). The 5 years and 10 years PFS in FIGO 1988 Ic group were all 100%, while they were 100% and (90.9 ± 6.2)% in FIGO 2009 Ib group. The 5 years and 10 years OS in FIGO 1988 Ic group were all 100%, but were 100% and (95.0 ± 4.9)% in FIGO 2009 Ib group, in which they all did not significantly differ much (P > 0.05). (4) The patients in FIGO 2009 Ia group were younger than those in FIGO 2009 Ib group (P < 0.01). The percentage of low grade in FIGO 2009 Ia group were higher than that in FIGO 2009 Ib group (P = 0.029). The percentages of received chemotherapy and radiotherapy in FIGO 2009 Ia group were lower than that in FIGO 2009 Ib group remarkably (P < 0.01). But there were not significant difference in the uterine excision extent and the percentage of lymph node excision between the two groups (P > 0.05). There were not significantly differ in the relapse rates and the death rates between the FIGO 2009 Ia group and FIGO 2009 Ib group (P > 0.05). There were also not significant difference in PFS and OS between the two groups (P > 0.05).

CONCLUSIONS

There were not significant difference in the prognosis between FIGO 2009 stage Ia and FIGO 1988 stage Ia and Ib. There were also not significant difference in the prognosis between FIGO 2009 stage Ia and FIGO 2009 stage Ib, which may be due to received more chemotherapy and radiotherapy in FIGO 2009 stage Ib patients.

Synchronous squamous cell carcinoma of the endometrium and endometrioid adenocarcinoma of the ovary

BACKGROUND

Synchronous primary endometrial and ovarian cancers are relatively uncommon in general population. The etiology and pathogenesis of this phenomenon remains unclear. The authors' aim was to present a case of synchronous squamous cell carcinoma of the endometrium and endometrioid adenocarcinoma of the ovary and review current literature.

CASE

The patient, a 64-year-old, nulliparous postmenopausal Greek woman presented with a complaint of abdominal pain and abnormal uterine bleeding. Preoperative computer tomography (CT) of the abdomen and pelvis, and abdominal ultrasound (U/S) revealed an intra-abdominal three cm mass with solid components between the left ovary and small bowel. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH+BS), total omentectomy, pelvic and para-aortic lymph node dissection, and removal of the implant at the serosa of small bowel. Histopathology revealed Stage IA endometrial cancer squamous type and Stage IIIC ovarian cancer of endometrioid-type. Postoperatively the patient underwent adjuvant chemotherapy and radiotherapy. Follow-up of 22 months after initial surgery revealed no evidence of recurrence.

CONCLUSION

The reason for better median overall survival of patients with synchronous primary endometrial and ovarian cancers is not intuitively obvious. Perhaps favourable clinical outcome may be related with the detection of patients at early stage and low-grade disease with an indolent growth rate.

Do uterine risk factors or lymph node metastasis more significantly affect recurrence in patients with endometrioid adenocarcinoma?

OBJECTIVES

Controversy continues over the importance of lymph node (LN) status in treating and predicting recurrence in endometrial cancer. Several predictive models are available which use uterine factors to stratify risk groups. Our objective was to determine how LN status affects recurrence and survival compared to uterine factors alone.

METHODS

A retrospective review was performed of patients undergoing complete surgical staging for clinical stage 1 endometrioid adenocarcinoma of the uterus. Patients were assessed based on PORTEC 1 high intermediate risk (H-IR) criteria (2 factors : age>60, grade 3, >50% DOI), GOG-99 H-IR criteria (age >70+1 factor, age 50-70+2 factors, any age +3 factors: grade 2 or 3, LVSI, >50% DOI), and PORTEC 2 criteria. Rates of nodal involvement, recurrence rates, PFS, and OS were compared.

RESULTS

We identified 352 clinical stage I patients with positive LN in 24% (87). 175 patients met PORTEC 1 eligibility and 66 met H-IR criteria. Rates of LN positivity were similar among groups (18.4% vs 19.7%, p=0.83) but recurrence rates were dissimilar (7.4% vs 27.3%, p=0.0004). Only 93 met PORTEC 2 criteria for treatment with no association between LN status, recurrence, and eligibility. 188 patients met H-IR eligibility criteria for GOG-99 with LN positive and recurrence rates higher in the H-IR group compared to GOG-99 eligible (34.6% vs 16.3%, p=0.0004, 28.3% vs. 10.6%, p=0.0002).

CONCLUSIONS

Patients with H-IR disease based on uterine characteristics alone have substantial risk of nodal involvement. Knowledge of LN status may better define risk, prognosis, and postoperative treatment.

[Clinical implications of positive peritoneal cytology in endometrial cancer]

OBJECTIVE

To evaluate the clinical significance of positive peritoneal cytology in patients with endometrial cancer.

METHODS

The records of 315 patients with endometrial cancer who were operated at Cancer Hospital, Fudan University between January 1996 and December 2008 were reviewed. Peritoneal cytology were performed and diagnosed in all patients. Factors related with peritoneal cytology were analyzed by correlation analysis. Log-rank test and Cox regression test was used for the analysis of prognosis, respectively.

RESULTS

(1) Peritoneal cytology were positive in 30 (9.5%) patients. Positive peritoneal cytology was associated with pathological subtype (P = 0.013), stage (P = 0.000), myometrial invasion (P = 0.012), lymph-vascular space invasion (P = 0.012), serosal involvement (P = 0.004), cervical involvement (P = 0.016), adnexal involvement (P = 0.000), and omental involvement (P = 0.000), with no association with grade (P = 0.152) and lymph node metastasis (P = 0.066). (2) Three-year overall survival (OS) and progression-free survival (PFS) were 93.0% and 85.5%, respectively. Positive peritoneal cytology, surgical stage, pathological subtype, myometrial invasion, grade, and lymph-vascular space invasion were significantly associated with worse prognosis by univariate analysis (P < 0.05), while only surgical-pathology stage and myometrial invasion were independent prognostic factors by multivariate analysis (P < 0.05). For 30 cases with positive peritoneal cytology, the patients with no high risk factors shown significantly prognoses better than those with any risk factors. The results shown that for patients with late stage (stage III-IV) endometrial cancer with positive peritoneal cytology was significantly associated with the worse OS and PFS by multivariate analysis (P = 0.006).

CONCLUSIONS

Positive peritoneal cytology was associated with serosal involvement, cervical involvement, adnexal involvement, omental involvement, and late stage. Therefore, peritoneal cytology should be performed and reported separately as a part of full surgical staging procedure.

Vaginal and pelvic recurrences in stage I and II endometrial carcinoma--survival and prognostic factors

AIM OF THE STUDY

The analysis of prognostic factors and treatment outcomes in 106 patients with Stage I and II endometrial carcinoma (EC) treated between 1980 and 2005 in the Center of Oncology, Maria Skłodowska-Curie Memorial Institute, Kracow, Poland, who developed vaginal or pelvic recurrences.

MATERIAL AND METHODS

The median age of patients was 61. Stage IB and IC of EC was diagnosed in 48 (45.3%) patients and Stage IIA and IIB in 58 (54.7%) patients. All patients were treated previously with surgery (TAH-BSO) and postoperative radiotherapy. There were 17 (16%) patients with vaginal vault recurrences, 30 (28.3%) with lower one-third vaginal recurrences, and 59 (55.7%) with pelvic recurrences. Palliative treatment (chemo- or hormonotherapy) or best supportive care only was undertaken in 53 (50.0%) patients. Radical treatment was conducted in 70.6% (12/17) of vault recurrences, 86.7% (26/30) of lower one-third vagina recurrences, and 25.4% (15/59) of pelvic recurrences, with surgery (4 patients), brachytherapy +/- chemotherapy (34 patients), and teleradiotherapy +/- chemotherapy (15 patients).

RESULTS

The 5-year overall survival rate in the observed group was 17%. Five-year survival was 23.3% (14/60) for patients with KPS 60-70 vs 8.7% (4/46) with KPS 40-50, 25% (12/48) patients with Stage I EC vs 10.3% (6/58) with Stage II EC, and 34% (16/47) patients with vaginal recurrence vs 3.4% (2/59) with pelvic recurrences.

CONCLUSIONS

In the analyzed group of 106 patients with Stage I and II EC, treated previously with surgery and postoperative radiotherapy, 5-year overall survival rate was low; in radically treated patients it was 42.1%, and 13.3% for vaginal and pelvis recurrences, respectively. Univariate analysis showed a statistically significant, unfavorable impact of KPS < 60, Stage II and recurrence pelvic. Cox multivariate analysis demonstrated that the only independent prognostic factor for 5-year overall survival was the site of recurrence.

Nodal metastasis in endometrial cancer

PURPOSE

Besides hysterectomy and bilateral salpingo-oophorectomy, the goal of surgery in early endometrial cancer is to identify extrauterine disease. The purpose of this study was to evaluate disease characteristics and survival of patients found to have nodal metastasis at staging for endometrial cancer.

METHODS

All patients presenting to our practice from January 1993 to July 2009 with a new diagnosis of early endometrial cancer underwent pelvic and paraaortic lymph node sampling at the time of surgery as permitted by the body mass index. Patient and disease characteristics of patients with nodal metastasis were abstracted by retrospective chart review. Factors contributing to disease-free and overall corrected survival were evaluated.

RESULTS

Forty-three patients with an early endometrial cancer were found to have pelvic and/or paraaortic nodal metastasis. Thirty-three percent of patients with nodal metastasis had papillary serous or clear cell cancers. Such tumors were often superficially invasive, yet were more likely to demonstrate lymphovascular space involvement as compared to endometrioid cancers. Furthermore, in a global model of disease-free and overall corrected survival, only tumor histology (endometrioid vs non-endometrioid) was a significant prognostic factor. Excluding clear cell and papillary serous tumors, only tumor grade was a significant prognostic factor in disease-free survival and overall corrected survival in patients with endometrioid adenocarcinomas and nodal involvement. Following adjuvant treatment after surgery, the recurrences were nearly evenly divided between pelvic, paraaortic nodal and distant sites. Only four of 33 (12%) patients treated with adjuvant pelvic radiation experienced a failure in the irradiated field. Furthermore, none of the patients experiencing a paraaortic nodal recurrence received adjuvant radiation to this site.

CONCLUSIONS

The data suggest a benefit to the use of adjuvant radiation for local control of disease. Furthermore, the use of paclitaxel and carboplatinum chemotherapy also appears a promising adjunct in patients with endometrioid histologies and nodal spread. Papillary serous and clear cell cancers contributed disproportionately to the incidence of nodal metastasis and an adverse prognosis following further adjuvant therapy of patients with nodal disease. Despite taxol/carboplatinum chemotherapy, over half of the patients with non-endometrioid cancers recurred, as opposed to one of 19 endometrioid cancers so treated. The ideal form of adjuvant treatment for such patients remains problematic.

Prognostic analysis of ovarian cancer associated with endometriosis

OBJECTIVE

The objective of the study was to evaluate the prognosis of ovarian cancer arising in endometriosis.

STUDY DESIGN

We retrospectively compared 42 cases of endometriosis-associated ovarian cancer (EAOC) with 184 cases of ovarian carcinoma without endometriosis (OC).

RESULTS

The median age in the EAOC group was 52 vs 59 years in OC (P < .05). In comparison with OC, the EAOC patients were more likely to have low-grade (21% vs 8%; P = .04) and early-stage tumors (International Federation of Gynecology and Obstetrics I and II combined) (49% vs 24%; P = .002). Clear cell (21% vs 2%) and endometrioid (14% vs 3%) tumors were more frequent in EAOC, whereas mucinous tumors were more prevalent in OC (P = .001). The median survival (199 vs 62 months) and the 5 year survival (62% vs 51%) were better for EAOC when compared with OC (P = .038). After controlling for age, stage, grade, and treatment, association with endometriosis was not an independent predictor of better survival in ovarian cancer.

CONCLUSION

As such, EAOC has a much better survival rate than OC. This could be explained by the higher prevalence of early-stage and low-grade tumors in EAOC when compared with OC.

Role of lymphadenectomy in endometrioid endometrial cancer

OBJECTIVE

To assess the risk factors associated with node involvement.

STUDY DESIGN

In the period 1990-2008 a total of 265 endometrial cancers were treated in the Institut Universitari Dexeus. We analysed the rate of myometrial invasion, tumour grade, histological type and node involvement.

RESULTS

Overall, 86% of tumours were endometrioid, 5.3% papillary serous, 4.9% mixed and 2.6% endometrial stroma sarcoma. Among those with endometrioid histology, lymphadenectomy was not performed (NL) in 85 cases (37.2%), whereas pelvic lymphadenectomy (PL) or pelvic and aortic lymphadenectomy (PAL) was carried out in 84 (36.84%) and 59 patients (25.87%), respectively. In NL patients the overall disease-free survival (DFS) rate at five years was 92.8%. In the PL group, node involvement was observed in 2.4% of cases and the five-year DFS rate was 92.3%. Among PAL patients, 18.6% showed node involvement (72.7% positive pelvic nodes and 63.6% aortic). Aortic involvement was present in 5.9% of cases when there was no pelvic disease, whereas in the presence of positive pelvic nodes the rate of aortic involvement was 50%. The DFS rate at five years was 93.6%. Referring to the risk factors, when infiltration was > 50% of the myometrium, lymph node involvement occurred in 37% of cases and G3 tumors in 45.5%.

CONCLUSIONS

Node involvement is more commonly observed in cases with > 50% myometrial invasion and G3, accounting for 25% of cases that can be considered as at-risk patients. When node involvement is present it is equally distributed between the pelvic and aortic levels. As node involvement is a predictive factor for distant metastasis, the 25% of patients considered to be at risk should undergo pelvic and aortic lymphadenectomy

[Current indications of lymphadenectomy in endometrial cancer]

Endometrial cancer is a tumor associated with a good prognosis as it is often diagnosed at an early stage. Up to 20 % of patients with stage I disease have a nodal involvement. Knowledge of nodal status provides important prognostic information. As preoperative assessment yields a poor value, prognostic lymphadenectomy appears to be indicated. However, therapeutic benefit of pelvic and para-aortic lymphadenectomy remains controversial. Recent randomized trials did not find any impact on survival for patients with low risk of nodal involvement. Thus, lymphadenectomy should no more be systematically performed in this low risk group. Nevertheless, pelvic and para-aortic lymphadenectomy seems to have a benefit in the high risk group, as isolated involved para-aortic nodes have been described.

Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study): a retrospective cohort analysis

BACKGROUND

In response to findings that pelvic lymphadenectomy does not have any therapeutic benefit for endometrial cancer, we aimed to establish whether complete, systematic lymphadenectomy, including the para-aortic lymph nodes, should be part of surgical therapy for patients at intermediate and high risk of recurrence.

METHODS

We selected 671 patients with endometrial carcinoma who had been treated with complete, systematic pelvic lymphadenectomy (n=325 patients) or combined pelvic and para-aortic lymphadenectomy (n=346) at two tertiary centres in Japan (January, 1986-June, 2004). Patients at intermediate or high risk of recurrence were offered adjuvant radiotherapy or chemotherapy. The primary outcome measure was overall survival.

FINDINGS

Overall survival was significantly longer in the pelvic and para-aortic lymphadenectomy group than in the pelvic lymphadenectomy group (HR 0.53, 95% CI 0.38-0.76; p=0.0005). This association was also recorded in 407 patients at intermediate or high risk (p=0.0009), but overall survival was not related to lymphadenectomy type in low-risk patients. Multivariate analysis of prognostic factors showed that in patients with intermediate or high risk of recurrence, pelvic and para-aortic lymphadenectomy reduced the risk of death compared with pelvic lymphadenectomy (0.44, 0.30-0.64; p<0.0001). Analysis of 328 patients with intermediate or high risk who were treated with adjuvant radiotherapy or chemotherapy showed that patient survival improved with pelvic and para-aortic lymphadenectomy (0.48, 0.29-0.83; p=0.0049) and with adjuvant chemotherapy (0.59, 0.37-1.00; p=0.0465) independently of one another.

INTERPRETATION

Combined pelvic and para-aortic lymphadenectomy is recommended as treatment for patients with endometrial carcinoma of intermediate or high risk of recurrence. If a prospective randomised or comparative cohort study is planned to validate the therapeutic effect of lymphadenectomy, it should include both pelvic and para-aortic lymphadenectomy in patients of intermediate or high risk of recurrence.

FUNDING

Japanese Foundation for Multidisciplinary Treatment of Cancer, and the Japan Society for the Promotion of Science.

Identification of a gene expression signature for survival prediction in type I endometrial carcinoma

Endometrial cancer is the most common malignancy of the female reproductive tract. In many cases the prognosis is favorable, but 22% of affected women die from the disease. We aimed to study potential differences in gene expression between endometrioid adenocarcinomas from survivors (5-year survival) and nonsurvivors. Forty-five patients were included in the investigation, of which 21 were survivors and 24 were nonsurvivors. The tumors were analyzed with genome-wide expression array analysis, represented by 13,526 genes. Distinct differences in gene expression were found between the groups. A t-test established that 218 genes were significantly differentially expressed (p < 0.001) between the two survival groups, and in a cross-validation test 40 of the 45 (89%) tumors were classified correctly. The 218 differentially expressed genes were subjected to hierachical clustering analysis, which yielded two clusters both exhibiting over 80% homogeneity with respect to survival. When the additional constraint of fold change (FC > 2) was added the hierachical clustering yielded similar results. Stage I tumors are expected to have a favorable prognosis. However, in our tumor material there were six nonsurvivors with stage I tumors. Five out of six stage I nonsurvivors clustered in the nonsurvival fraction. Our findings suggest that a subgroup of early stage endometroid adenocarcinomas can be correctly classified as potentially aggressive by using molecular biology in combination with conventional markers, thereby providing a tool for a more accurate classification and risk evaluation of the individual patient.

High frequency microsatellite instability has a prognostic value in endometrial endometrioid adenocarcinoma, but only in FIGO stage 1 cases

OBJECTIVES

to analyze the prognostic value of microsatellite instability (MSI) in a population-based study of FIGO stage 1-4 endometrial endometrioid adenocarcinomas.

STUDY DESIGN

survival analysis in 273 patients of MSI status and clinico-pathologic features. Using a highly sensitive pentaplex polymerase chain reaction to establish MSI status, cases were divided into microsatellite stable (MSS), MSI-low (MSI-L, 1 marker positive) and MSI-high (MSI-H, 2-5 markers positive).

RESULTS

after 61 months median follow-up (1-209), 34 (12.5%) of the patients developed metastases but only 6.4% of the FIGO 1. MSI (especially as MSI-H vs. MSS/MSI-Lcombined) was prognostic in FIGO 1 but not in FIGO 2-4. The 5 and 10 year recurrence-free survival rates were 98% and 95% in the MSS/MSI-L vs. 85% and 73% in the MSI-H patients (p=0.005).

CONCLUSIONS

MSI-H status assessed by pentaplex polymerase chain reaction is an indicator of poor prognosis in FIGO 1, but not in FIGO 2-4 endometrial endometrioid adenocarcinomas.

Immunoexpression and clinical significance of the PTEN and MLH1 proteins in endometrial carcinomas

Carcinogenesis is a multistep process resulting from mutations in genes controlling the cellular growth, differentiation, apoptosis, and genome integrity maintenance. We investigated relationships between the PTEN and MLH1 immunoreactivity in the cancer cells and the histological subtypes of endometrial carcinoma as well as the survival times of the affected women. The PTEN and MLH1 protein immunoexpression was also examined separately in both clinicopathological groups of endometrial carcinoma. We estimated the practical use of the proteins as diagnostic and predictive markers. The histoclinical analysis was performed on 104 patients. The follow-up in all the cases was well known. To assess the expression of both proteins in the cancer cells we adopted a semiquantitative immunohistochemical analysis. We proved that the incidence of the PTEN and MLH1 nuclear positive cells was significantly higher in the serous type than in the endometrioid one. We also demonstrated a strong correlation between both cytoplasmic and nuclear PTEN immunoexpression and the survival times in the entire cohort. In conclusion, the PTEN and MLH1 immunohistochemical analysis broadens the microscopic diagnosis of the endometrial carcinomas. However, the PTEN and MLH1 antibodies tests cannot determine the recognition of the cancer, and they should not be regarded as independent prognostic factors.

[Pelvic lymphadenectomy as an alternative to adjuvant radiotherapy in early stage endometrial cancer at high risk of recurrent lymphatic metastases (stage I)]

AIM

The aim of this study was to evaluate if the surgical approach without pelvic lymphadenectomy and with adjuvant radiotherapy in the patients suffering from endometrioid adenocarcinoma type at high risk (of lymphatic metastasis) in early stage can be substituted by only surgery with pelvic lymphadenectomy (with or without para-aortic lymphadenectomy).

METHODS

A retrospective study was carried out on 56 patients who underwent surgery with eventual adjuvant radiotherapy and were attended during the follow-up in the Operative Unit of Gynecology and Obstetrics from 1997 to 2004. The patients were divided into two groups: the low risk group and the high risk group. The cancer grading (G) was defined before the surgery with an hystological exam on endometrial biopsies. The follow-up had a medium duration of 30 months (range: 9-44 months) and consisted of the evaluation of: cancer related survival (CRS); recurrence free survival (RFS). Both were evaluated according to age, risk type, and therapy adopted.

RESULTS

Four patients (7.1%) showed relapse during the period of study in a medium time of 24 months (range: 12-36): 2 of these patients (C and D cases; 36%) had a relapse both locally (pelvic wall) and distantly; the other two (A and B cases; 36%) had only a distant relapse. None of the patients at the stage IA had a relapse, but it occurred in the 8.7% of the cases (N.=2) IB and in the 10.5 % of the patients IC (N.=2). One patient of the low risk group (3.8%) (case A) had a distant relapse (lungs) 12 months after the surgery and died 6 months after the appearance of the relapse without any additional treatment, because of age and of concomitant pathologies which suggested another illness. Three patients of the high risk group (10%) had a local and /or distant relapse (one only distant, two both distant and local). One of them with distant relapse (36 months after the primary treatment) (case B) is still alive, even though she has got a controlled cancer, 8 months after the rescue treatment (chemotherapy), whereas two of them died in a medium time of 14 months (range 13-15 months) from the rescue treatment (C and D cases). One of the three patients of the high risk group underwent the standard surgical treatment with lympho-adenectomy (case B) whereas the other two underwent the standard surgical treatment with aiding radiotherapy (C and D cases). The CRS and the RFS were 96.2% and 96.2% in the low risk group, 93.3% and 90% in the high risk group, respectively.

CONCLUSIONS

The standard surgery offers a good prognosis to the low risk group patients. To the high risk group the CRS and the RFS were better with standard surgery with lymphadenectomy than with standard surgery with adjuvant radiotherapy. The degree of differentiation of the cancer is the most important prognostic factor in relation to the survival free from relapse (RFS).

[Clinicopathologic features of 234 cases with borderline ovarian tumors]

OBJECTIVE

To determine the clinicopathologic characteristics and prognostic factors that may be used to predict the poor outcome of patients with borderline ovarian tumors.

METHODS

All cases with borderline ovarian tumors treated in the West China Second University Hospital from January 2001 to June 2007 were analyzed retrospectively for clinicopathologic features, treatment parameters and outcome of treatment. Univariate and multivariate analyses were used to assess independent prognostic factors using the logistic regression model.

RESULTS

The median age of 234 patients was 40.1 years with a range of 14 to 80 years. There were 101 (43.2%), 94 (40.2%), 19 (8.1%), 12 (5.1%), 8 (3.4%) cases of serous, mucinous, mixed, endometrioid and clear cell tumors, respectively. Out of 234 cases, 182 (77.8%) underwent laparotomy and 45 (19.2%) underwent laparoscopy. Seven women underwent laparoconversion. Fertility sparing surgery was performed on 119 cases (50.9%) and radical surgery was performed on 115 cases (49.1%). Totally 161 (68.8%) patients had stage I, 19 (8.1%) had stage II, 54 (23.1%) had stage III, and none had stage IV disease. Sixty-four women received postoperative chemotherapy. The median follow-up was 40 months with a range of 8 to 78 months. Recurrence was found in 26 cases (11.1%) during follow-up, and no tumor-related death was reported. The logistic regression model showed that surgery procedure (OR = 2.304, P = 0.024), cyst rupture (OR = 2.213, P = 0.038), stage (OR = 4.114, P < 0.01), microinvasion (OR = 2.291, P = 0.046) and peritoneal implants (OR = 2.101, P = 0.016) were the five independent prognostic factors affecting recurrence.

CONCLUSIONS

Although patients with borderline ovarian tumors have an excellent prognosis, the risk of recurrence remains in some patients. Emphasis should be put on these patients with high risk factors and preventive strategies should be taken to prevent their progression.

Prolonged survival among women with BRCA germline mutations and advanced endometrial cancer: a case series

It is unclear if BRCA mutation carriers diagnosed with advanced endometrial cancer have a better prognosis compared to sporadic cases. From a population database of BRCA1 and 2 mutation carriers in Southwestern Ontario, Canada, we identified three women with advanced-stage endometrial cancer. They were 57, 59, and 64 years of age, and of English/Scottish, Ashkenazi Jewish, and English heritage, respectively. They had different mutations in BRCA1 (Q1240X:C3837T; 68_69delAG; 1961delA). One had a sarcomatoid carcinoma and two had uterine papillary serous carcinoma. All had stage IVB disease, with surgery followed by adjuvant chemotherapy and/or radiotherapy. Follow-up has ranged from 3.3 to 14.6 years. They are still alive and well with no evidence of recurrent disease. This observation raises the question as to whether BRCA mutations may be associated with a better prognosis in patients with advanced endometrial cancer

Folate receptor alpha as a tumor target in epithelial ovarian cancer

OBJECTIVES

Folate receptor alpha (FRalpha) is a folate-binding protein overexpressed on ovarian and several other epithelial malignancies that can be used as a target for imaging and therapeutic strategies. The goal of this study is to improve historical data that lack specific information about FRalpha expression in rare histological subtypes, primary disease versus metastatic foci, and recurrent disease.

METHODS

FRalpha expression was analyzed by immunohistochemistry on 186 primary and 27 recurrent ovarian tumors, including 24 pairs of samples obtained from the same individuals at diagnosis and at secondary debulking surgery. For 20 of the 186 primaries, simultaneous metastatic foci were also analyzed. FRalpha staining was analyzed in light of disease morphology, stage, grade, debulking status, and time from diagnosis to recurrence and death.

RESULTS

FRalpha expression was apparent in 134 of 186 (72%) primary and 22 of 27 (81.5%) recurrent ovarian tumors. In 21 of 24 (87.5%) matched specimens, recurrent tumors reflected the FRalpha status detected at diagnosis. Metastatic foci were similar to primary tumors in FRalpha staining. FRalpha status was not associated with time to recurrence or overall survival in either univariate or multivariable analyses.

CONCLUSION

FRalpha expression occurs frequently, especially in the common high-grade, high-stage serous tumors that are most likely to recur. New findings from this study show that FRalpha expression is maintained on metastatic foci and recurrent tumors, suggesting that novel folate-targeted therapies may hold promise for the majority of women with either newly diagnosed or recurrent ovarian cancer.

[Five years survival in patients with endometrioid ovarian cancer versus patients with serous ovarian cancer]

AIM

The ovarian cancer is the most malignant disease from all oncogynecological localizations. There are different scientific opinions whether the different histological types have different prognosis and survival. The aim of our research work was to evaluate if the endometrioid cancer of the ovary has a different prognosis from the serous ovarian cancer.

METHODS

84 patients were evaluated for five years period from 2003 till 2008. The patients with endometrioid ovarian cancer (42) were matched with the patients with serous ovarian cancer (42). They were matched for age, grading,stage, and level of cytoreduction.

RESULTS

84 patients (42 with endometrioid cancer and 42 with serous ovarian cancer) were evaluated for 5 years period. The five years survival of the patients with endometrioid ovarian cancer was 62% while the five years survival for patients with serous ovarian cancer was 72%. In patients with endometrioid ovarian cancer the mean survival rate was 58 months, and for patients with serous ovarian cancer 70 months (P=0.30). The estrogen receptor levels were not statistically significant between the two groups (P=0.110), while the progesteron receptor levels were statistically different (P<0.002).

CONCLUSIONS

In patients with endometrioid and serous ovarian cancer, while taking into consideration the age, grading, stage and level of cytoreduction--there is no difference for the five years survival or the length of survival.

Decreased dose density of standard chemotherapy does not compromise survival for ovarian cancer patients

For women diagnosed with ovarian cancer, the standard practice of surgery followed by adjuvant platinum-taxane combination chemotherapy, with cycles administered every 3 weeks, is based on randomized control trials. However, a substantial number of patients require delays or reductions on this schedule. The Cancer Centre of Southeastern Ontario (CCSEO) has historically administered chemotherapy every 4 weeks. We analyzed survival outcomes of our cohort. All ovarian cancer patients treated with chemotherapy at the CCSEO from 1995 to end-2002 were included in this study. Overall survival and progression-free survival were calculated from initiation of chemotherapy using the Kaplan-Meier technique and log-rank tests. Cox regression analysis was used to adjust for age and disease stage. A total of 171 patients were treated with chemotherapy (cisplatin-paclitaxel or carboplatin-paclitaxel), of which 144 received chemotherapy every 4 weeks and 27 every 3 weeks. Median progression-free survival was 19.2 months for the group treated every 4 weeks vs 13.2 months for the 3-weekly group. Median overall survival was 36.5 months compared to 27.1 months, respectively. Trends favored treatment every 4 weeks. In early-stage disease, 5-year overall survival was 74% and 5-year progression-free survival was 68%. Administration of platinum-paclitaxel chemotherapy every 4 weeks did not reduce survival of ovarian cancer patients. Importantly, median survival is favorable compared to results from landmark trials where patients were treated every 3 weeks. These results suggest that decreasing the frequency of chemotherapy cycles does not decrease survival. Prospective trials would be required to compare quality of life and cost-effectiveness.

Clinical analysis of synchronous primary neoplasms of the female reproductive tract

OBJECTIVES

In this study, a histopathologic review of synchronous primary neoplasms including gynecologic malignancies is presented, and the possible correlation among discrete tumor subsets, natural history, and survival is evaluated.

METHODS

Between the years 2000 and 2005, 20 patients suffering from synchronous primary cancers of gynecologic malignancy were identified. Clinical and pathologic information was obtained from medical records. Kaplan-Meier survival analyses were conducted.

RESULTS

Patients with synchronous primary malignancies constituted 0.63% of all genital malignancies. The most frequently observed synchronous neoplasm was ovarian cancer coexistent with endometrial cancer (40%). The mean age of patients suffering from synchronous ovarian and endometrial cancer was 45.2 years. All patients with synchronous primary genital malignancies underwent hysterectomy with bilateral salpingo-oophorectomy and/or adjuvant therapy. The mean duration of survival was 57 months (S.E.: 10.0; 95% confidence interval: 37-77).

CONCLUSION

Patients suffering from primary genital malignancies are sometimes co-afflicted with other primary cancers. Synchronous ovarian and endometrial cancer constitutes the most common of these cases, and is detected at a relatively early age, with generally favorable prognoses.

Differential methylation hybridization array of endometrial cancers reveals two novel cancer-specific methylation markers

PURPOSE

To identify novel endometrial cancer-specific methylation markers and to determine their association with clinicopathologic variables and survival outcomes.

EXPERIMENTAL DESIGN

Differential methylation hybridization analysis (DMH) was done for 20 endometrioid endometrial cancers using normal endometrial DNA as a reference control. Combined bisulfite restriction analysis (COBRA) was used to verify methylation of sequences identified by DMH. Bisulfite sequencing was undertaken to further define CpG island methylation and to confirm the reliability of the COBRA. The methylation status of newly identified markers and the MLH1 promoter was evaluated by COBRA in a large series of endometrioid (n=361) and non-endometrioid uterine cancers (n=23).

RESULTS

DMH and COBRA identified two CpG islands methylated in tumors but not in normal DNAs: SESN3 (PY2B4) and TITF1 (SC77F6/154). Bisulfite sequencing showed dense methylation of the CpG islands and confirmed the COBRA assays. SESN3 and TITF1 were methylated in 20% and 70% of endometrioid tumors, respectively. MLH1 methylation was seen in 28% of the tumors. TITF1 and SESN3 methylation was highly associated with MLH1 methylation (P<0.0001). SESN3 and TITF1 were methylated in endometrioid and non-endometrioid tumors, whereas MLH1 methylation was restricted to endometrioid tumors. Methylation at these markers was not associated with survival outcomes.

CONCLUSIONS

The 5' CpG islands for SESN3 and TITF1 are novel cancer-specific methylation markers. Methylation at these loci is strongly associated with aberrant MLH1 methylation in endometrial cancers. SESN3, TITF1 and MLH1 methylation did not predict overall survival or disease-free survival in this large cohort of patients with endometrioid endometrial cancer.

Clinicopathologic Analysis of 187 High-grade Endometrial Carcinomas of Different Histologic Subtypes: Similar Outcomes Belie Distinctive Biologic Differences

The clinical and histopathologic features of 187 high-grade endometrial cancers [FIGO grade 3 endometrioid (EC-3), serous (SC), and clear cell (CC)] were studied to determine whether clinicopathologic differences between these various histologic subtypes existed. The study group consisted of 89 EC-3s, 61 SCs, and 37 CCs. Treatment regimens were individualized. SCs and CCs were significantly more likely than EC-3s to occur in patients older than 65 years (P=0.03), and SCs tended to occur more frequently in patients of African descent than EC-3s and CCs (P=0.07), although this was not statistically significant. EC-3s had the highest rate of associated endometrial hyperplasia (P=0.05). SCs were most likely to have high-stage disease at presentation (>or=stage IIB; P=0.01), with peritoneal dissemination at diagnosis being much more common compared with EC-3s and CCs (P=0.004). Median follow-up was 39 months, and median overall survival was 47 months. Five-year survivals were 45% (EC-3), 36% (SC), and 50% (CC)-differences that were not statistically significant. In contrast, the impact of stage on survival was significant (P<0.001). Among all other factors evaluated, only age greater than 65 years was a negative predictor (risk ratio, 2.23; P<0.001), whereas a family history of cancer reduced the risk of death when controlling for stage (risk ratio, 0.54; P=0.005). When controlling for stage, race, reproductive history, personal history of cancer, histologic subtype, depth of myometrial invasion, lymphovascular invasion, presence of an endometrial polyp, presence of hyperplasia, or staging adequacy did not affect prognosis. High-grade endometrial cancers of different histologic subtypes treated in an individualized manner are associated with similar clinical outcomes, but differences in age at presentation, race distribution, association with hyperplasia, stage, and sites of tumor dissemination support the idea that these represent distinct disease entities as defined by traditional histopathologic classification of endometrial cancers.

Obesity, diabetes, and other factors in relation to survival after endometrial cancer diagnosis

Endogenous and exogenous sources of estrogen and characteristics altering these hormone levels have been related to endometrial cancer risk; however, their relationship to survival following diagnosis is less clear. In a population-based study, we examined whether mortality after endometrial cancer diagnosis was affected by prediagnosis obesity, diabetes, smoking, oral contraceptive use, parity, or postmenopausal hormone (PMH) use. Eligible women, aged 40-79 years, diagnosed from 1991-1994 with incident invasive endometrial cancer and identified through the Wisconsin statewide mandatory cancer registry were invited to participate. Of 745 eligible cases, 166 women were deceased after 9.3 years of follow-up, with 43 attributable to endometrial cancer, based upon vital records linkage. Hazard rate ratios (HRR) and 95% confidence intervals were adjusted for age at diagnosis, menopausal status, stage of disease, and other exposures of interest. Obese women (body mass index [BMI] >or=30 kg/m(2)) prior to endometrial cancer diagnosis had an increased risk of both all-cause (HRR=1.6, 95% CI 1.0-2.5) and endometrial cancer (HRR=2.0, 95% CI 0.8-5.1) mortality, compared with nonoverweight women (BMI<25 kg/m(2)). Endometrial cancer cases with diabetes also had an increased risk of all-cause mortality compared with nondiabetic women (HRR=1.7, 95% CI 1.1-2.5), although there was no association with endometrial cancer mortality. There were no associations between PMH use, oral contraceptive use, parity, or smoking and mortality from any cause. The results suggest that history of obesity and diabetes may increase risk of mortality after endometrial cancer diagnosis; modification of these characteristics may improve survival after endometrial cancer diagnosis.