Endometrial Cancer: Who Lives, Who Dies, Can We Improve Their Story?

ZOOMit diffusion kurtosis imaging combined with diffusion weighted imaging for the assessment of microsatellite instability in endometrial cancer

PURPOSE

Detecting microsatellite instability (MSI) plays a key role in the management of endometrial cancer (EC), as it is a critical predictive biomarker for Lynch syndrome or immunotherapy response. A pressing need exists for cost-efficient, broadly accessible tools to aid patient for universal testing. Herein, we investigate the value of ZOOMit diffusion kurtosis imaging (DKI) and diffusion weighted imaging (DWI) based on preoperative pelvic magnetic resonance imaging (MRI) images in assessing MSI in EC.

METHODS

Preoperative MRI examination including ZOOMit DKI and DWI of 81 EC patients were retrospectively analyzed. The apparent diffusion coefficient (ADC), mean kurtosis (MK), mean diffusivity (MD) and the largest tumor size based on MRI images, as well as patients' clinicopathological features were compared and analyzed according to different microsatellite statuses.

RESULTS

Of the 81 patients, 59 (72.8%) who were microsatellite stability (MSS) and 22 (27.2%) who were MSI. Interobserver agreement for the quantitative parameter measurements was excellent (ICC 0.78-0.98). The ADC and MD values were significantly lower, while Ki-67 proliferation level and MK values were significantly higher in the MSI group compared to those of the MSS group. The parameters of MD and MK were independent predictors for determining MSI, and their combination showed better diagnostic efficacy with an area under the receiver operating characteristic curve (AUROC) of 0.860 (95% confidence interval, 0.765, 0.927), although there was no significant difference compared to each individual parameter.

CONCLUSION

The microstructural heterogeneity assessment of ZOOMit DKI allowed for characterizing MSI status in EC. Within the current universal MSI testing paradigm, DKI may provide added value as a potential noninvasive imaging biomarker for preoperative assessment of MSI tumors, thereby facilitating clinical decision-making.

Exploring endometrial cancer risk stratification by copy number assessment

BACKGROUND

Contemporary management of endometrial cancer includes molecular classification. The primary objective of this study was to assess the prognostic significance of copy number changes evidenced by loss of heterozygosity (LOH) or allelic imbalance (AI).

METHODS

Sequencing including TP53, POLE and MSI testing was performed. AI/LOH at 5 polymorphic markers (D2S123, D5S2346, D17S250, D17S516 and D17S1818) was assessed. Micro-satellite stable (MSS) endometrial tumors were classified as having evidence of AI/LOH or no evidence of AI/LOH.

RESULTS

482 MSS cases were evaluated for AI/LOH status. There were 226 (46.5 %) tumors with evidence of AI/LOH at ≥1 of the 5 markers and these were significantly associated with patients of older age and lower body mass index as well as tumors that were non-endometrioid histology, higher grade, demonstrated LVSI, and presented at more advanced stage. Most patients who developed recurrent disease had a tumor with AI/LOH (82.1 %). 3-year progression-free survivals (PFS) were 79.5 % in the AI/LOH group vs 95.6 % in the no AI/LOH group (p < 0.0001). TP53 mutation status was associated with PFS. 3-year PFS was significantly worse for the TP53 mutated group at 55 % vs 96 % in TP53 wild-type (p < 0.0001). Of the 373 cases classified as having no specific molecular profile there was a 6.2 % recurrence rate with AI/LOH and 3.3 % recurrence with no AI/LOH.

CONCLUSIONS

AI/LOH assessment at a limited number of markers identifies endometrial cancers with higher risk features that are more likely to recur. Copy-number assessment utilizing clinically accessible testing strategies can provide an opportunity for improved risk stratification.

Characterization of mismatch-repair/microsatellite instability-discordant endometrial cancers

BACKGROUND

Mismatch-repair (MMR)/microsatellite instability (MSI) status has therapeutic implications in endometrial cancer (EC). The authors evaluated the concordance of testing and factors contributing to MMR expression heterogeneity.

METHODS

Six hundred sixty-six ECs were characterized using immunohistochemistry (IHC), MSI testing, and mut-L homolog 1 (MLH1) methylation. Select samples underwent whole-transcriptome analysis and next-generation sequencing. MMR expression of metastatic/recurrent sites was evaluated.

RESULTS

MSI testing identified 27.3% of cases as MSI-high (n = 182), MMR IHC identified 25.1% cases as MMR-deficient (n = 167), and 3.8% of cases (n = 25) demonstrated discordant results. A review of IHC staining explained discordant results in 18 cases, revealing subclonal loss of MLH1/Pms 1 homolog 2 (PMS2) (n = 10) and heterogeneous MMR IHC (mut-S homolog 6 [MSH6], n = 7; MLH1/PMS2, n = 1). MSH6-associated Lynch syndrome was diagnosed in three of six cases with heterogeneous expression. Subclonal or heterogeneous cases had a 38.9% recurrence rate (compared with 16.7% in complete MMR-deficient cases and 9% in MMR-proficient cases) and had abnormal MMR IHC results in all metastatic recurrent sites (n = 7). Tumors with subclonal MLH1/PMS2 demonstrated 74 differentially expressed genes (determined using digital spatial transcriptomics) when stratified by MLH1 expression, including many associated with epithelial-mesenchymal transition.

CONCLUSIONS

Subclonal/heterogeneous MMR IHC cases showed epigenetic loss in 66.7%, germline mutations in 16.7%, and somatic mutations in 16.7%. MMR IHC reported as intact/deficient missed 21% of cases of Lynch syndrome. EC with subclonal/heterogeneous MMR expression demonstrated a high recurrence rate, and metastatic/recurrent sites were MMR-deficient. Transcriptional analysis indicated an increased risk for migration/metastasis, suggesting that clonal MMR deficiency may be a driver for tumor aggressiveness. Reporting MMR IHC only as intact/deficient, without reporting subclonal and heterogeneous staining, misses opportunities for biomarker-directed therapy.

PLAIN LANGUAGE SUMMARY

Endometrial cancer is the most common gynecologic cancer, and 20%-40% of tumors have a defect in DNA proofreading known as mismatch-repair (MMR) deficiency. These results can be used to guide therapy. Tests for this defect can yield differing results, revealing heterogeneous (mixed) proofreading capabilities. Tumors with discordant testing results and mixed MMR findings can have germline or somatic defects in MMR genes. Cells with deficient DNA proofreading in tumors with mixed MMR findings have DNA expression profiles linked to more aggressive characteristics and cancer spread. These MMR-deficient cells may drive tumor behavior and the risk of spreading cancer.

Real-world perioperative treatment patterns and burden of recurrent disease in patients with high-risk endometrial cancer: a SEER-Medicare study

OBJECTIVES

To elucidate unmet needs in high-risk endometrial cancer (EC), this study described perioperative treatment patterns in Medicare beneficiaries with high-risk EC and quantified the impact of disease recurrence on clinical and economic outcomes among patients receiving adjuvant therapy.

METHODS

Patients aged ≥66 years with high-risk EC (stage I/II EC of non-endometrioid histology or stage III/IVA EC of any histology) receiving hysterectomy with bilateral salpingo-oophorectomy from SEER-Medicare data (2007-2019) were identified; perioperative treatment patterns were described. Post-operative treatment patterns were described among patients receiving adjuvant therapy; overall survival (OS), all-cause and EC-related healthcare resource utilization and costs were evaluated from recurrence date (using a claims-based algorithm developed with clinical input) for recurrent patients and from a frequency-matched date for non-recurrent patients.

RESULTS

Of 2,279 patients receiving EC surgery, 3.1% received neoadjuvant therapy and 55.3% received adjuvant therapy. Among 1,199 patients receiving adjuvant therapy, systemic adjuvant therapy with radiation (38.9%) was most common. Median OS was 1.4 years among 378 (31.5%) recurrent patients identified over a median follow-up of 3.7 years. Recurrent patients had significantly higher per-patient-year rates of all-cause outpatient visits (37.7 vs. 22.6), EC-related outpatient visits (14.5 vs. 3.0), and all-cause hospitalizations (1.3 vs. 0.4) than non-recurrent patients, and an excess of $84,562 and $62,128 in all-cause and EC-related annual costs, predominantly driven by hospitalizations.

CONCLUSIONS

Our findings highlight the considerable clinical and economic burden experienced by patients with high-risk EC experiencing recurrence and emphasize the unmet need for novel therapies in early settings to mitigate this burden.

Short-Term Outcome of Robotic versus Laparoscopic Hysterectomy for Endometrial Cancer in Women with Diabetes: Analysis of the US Nationwide Inpatient Sample

This study investigated short-term outcomes of robotic versus laparoscopic hysterectomy for endometrial cancer (EC) in women with diabetes. We extracted the data of hospitalized females aged ≥18 years who were diagnosed with EC and diabetes and underwent robotic or laparoscopic hysterectomy from the US Nationwide Inpatient Sample (NIS) 2005-2018. Associations between study variables and in-hospital outcomes, including complications, unfavorable discharge, length of stay (LOS), and hospital costs, were examined using logistic regression. A total of 5745 women (representing 28,176 women in the US) were included. Multivariable analysis revealed that robotic surgery was significantly associated with a decreased risk of unfavorable discharge (adjusted odds ratio [aOR] = 0.63, 95% confidence interval [CI]: 0.46, 0.85) than pure laparoscopic surgery. Women who underwent robotic surgery had a significantly shorter LOS (0.46 fewer days, 95% CI: -0.57, -0.35) but higher total hospital costs (6129.93 greater USD; 95% CI: 4448.74, 7811.12). Compared with pure laparoscopic surgery, robotic hysterectomy was associated with less unfavorable discharge among women aged ≥60 years (aOR = 0.60, 95% CI: 0.44, 0.80). For US women with EC and diabetes, robotic hysterectomy is associated with shorter LOS, decreased risk of unfavorable discharge, especially among older patients, and higher total costs than laparoscopic surgery.

Non-coding RNAs in gynecologic cancer

The term "gynecologic cancer" pertains to neoplasms impacting the reproductive tissues and organs of women encompassing the endometrium, vagina, cervix, uterus, vulva, and ovaries. The progression of gynecologic cancer is linked to various molecular mechanisms. Historically, cancer research primarily focused on protein-coding genes. However, recent years have unveiled the involvement of non-coding RNAs (ncRNAs), including microRNAs, long non-coding RNAs (LncRNAs), and circular RNAs, in modulating cellular functions within gynecological cancer. Substantial evidence suggests that ncRNAs may wield a dual role in gynecological cancer, acting as either oncogenic or tumor-suppressive agents. Numerous clinical trials are presently investigating the roles of ncRNAs as biomarkers and therapeutic agents. These endeavors may introduce a fresh perspective on the diagnosis and treatment of gynecological cancer. In this overview, we highlight some of the ncRNAs associated with gynecological cancers.

The right time for change: A report on the heterogeneity of IVB endometrial cancer and improved risk-stratification provided by new 2023 FIGO staging criteria

OBJECTIVE

We sought to provide a contemporary report on stage IVB endometrial carcinoma (2009 FIGO criteria) and applied the 2023 FIGO staging criteria to this population.

METHODS

Retrospective review of patients who underwent cytoreduction for stage IVB endometrial carcinoma (2009 FIGO criteria) from 2014 to 2020 was performed. Demographics, clinicopathologic factors, and outcomes were recorded. Disease burden and distribution were determined by imaging, operative notes, and pathology reports. Patients were re-staged according to 2023 FIGO staging criteria. Categorical variables were compared using χ² or Fisher's exact test, and Kaplan-Meier curves compared survival outcomes using the log-rank test.

RESULTS

Eighty-eight cases were included. Most patients (63.6%) were not suspected to have stage IVB (2009 FIGO criteria) disease prior to surgery. Seventy-two percent of patients underwent primary cytoreduction, and 12 (19%) were suboptimal. Median progression-free survival (PFS) was 12 months (95% CI 10-16 months), and median overall survival (OS) was 38 months (95% CI 19-61 months). Degree of cytoreduction (p = 0.0101) and pelvic-confined metastatic disease (p = 0.0149) were significant prognostic factors, while distant metastases were not associated with worse outcomes. For those patients who underwent primary cytoreduction, number (p = 0.0453) and diameter (p = 0.0192) of tumor deposits were associated with PFS. When 2023 FIGO staging criteria were applied, 58% of patients underwent change in stage, and 8% did not meet criteria for complete staging. PFS was significantly different based on 2023 FIGO staging (p = 0.0307); a trend in OS was also noted (p = 0.0550).

CONCLUSION

Stage IVB endometrial carcinoma (2009 FIGO criteria) encompasses a diverse cohort of patients, where certain clinicopathologic features, tumor burden, and degree of cytoreduction are associated with outcomes. The 2023 FIGO staging criteria significantly improves our ability to risk-stratify patients.

The contemporary presentation and diagnosis of endometrial cancer recurrence: When, where, and how?

OBJECTIVE

To examine patients with confirmed endometrial cancer recurrence; evaluate patterns, presentation, and mode of diagnosis.

STUDY DESIGN

A retrospective review of women with endometrial cancer diagnosis between 2014 and 2020. Disease recurrences were evaluated. Medical records were reviewed focusing on presentation at time of recurrence. Relationships were assessed using χ2, Fisher's exact test, t-test, and Wilcoxon test. The Kaplan-Meier product limit was used to estimate survival. Multiple logistic regression analysis was used to assess the impact of covariates.

RESULTS

Endometrial cancer recurrence was identified in 201 (11.7%) patients. Sixty percent (120/201) of patients presented with symptoms. Pain was the most common presenting symptom (23.4%, 47/201) and bleeding was reported in <14% (28/201). Patients with symptomatic presentation were less likely to be able to receive treatment for their recurrent disease (76.7% vs 91.3%, p = 0.005). Asymptomatic pelvic exam diagnosed recurrence in 13.4% (27/201) and was more common in patients initially diagnosed with early-stage disease (66.7% vs 34.5% p = 0.001) of endometrioid histology (66.7% vs 36.8%, p = 0.003) without prior adjuvant therapy (48.2% vs 17.9%, p = 0.001). More than1/3 of diagnoses were made by providers outside of the oncologic care team.

CONCLUSION

The majority of women with recurrent endometrial cancer were symptomatic and pain is a common complaint associated with disease recurrence. Patients with symptomatic presentation of disease recurrence were less likely to receive treatment for recurrent disease but this did not result in an overall survival (OS) difference. Given the rising mortality rate of endometrial cancer further work is needed to develop multidisciplinary surveillance strategies that will enable meaningful treatment of disease recurrence.

Real-world treatment of German patients with recurrent and advanced endometrial cancer with a post-platinum treatment: a retrospective claims data analysis

PURPOSE

Endometrial cancer (EC) is the sixth most common malignancy among females worldwide. Due to limited therapeutic options, treatment of advanced or recurrent disease is associated with poor outcomes. The aim of this study was to describe the real-world treatment of patients with advanced or recurrent EC who received a systemic treatment following platinum-based chemotherapy.

METHODS

This retrospective cohort study was based on anonymized German claims data covering the period between January 1, 2010, and June 30, 2020. Patients with EC who started an anticancer treatment following platinum-based chemotherapy were observed for a minimum follow-up of 12 months. Available claims data were used to describe patient characteristics, subsequent treatment lines, healthcare resource utilization, and overall survival (OS) of patients.

RESULTS

Out of 713 patients with advanced or recurrent EC and who had received a platinum-based treatment, 201 (mean age: 68.9 years) with a post-platinum-based treatment were identified and observed. The median OS in this population was 335.0 days. Of the 201 patients, 79 patients (39.3%) received a second line of treatment (LOT), and 21 patients (10.4%) had 3 or more treatment lines. In the LOTs following platinum-based chemotherapy, more than 70 different treatment regimens were observed. The hospitalization rate was generally high, with 5.2 hospitalizations per patient-year in the follow-up period.

CONCLUSION

The wide variety of therapeutic regimens applied in patients in Germany who progressed after platinum-based therapy confirms the lack of therapeutic strategy for these patients, and the poor prognosis highlights the urgent need for new treatment strategies.