Current strategies in the diagnosis of endometrial cancer

Tumor polo-like kinase 4 protein expression reflects lymphovascular invasion, higher Federation of Gynecology and Obstetrics stage, and shortened survival in endometrial cancer patients who undergo surgical resection

BACKGROUND

Polo-like kinase 4 (PLK4) serves as a marker for tumor features and poor outcomes in cancers. This study aimed to explore the associations of tumor PLK4 protein expression with tumor characteristics and survival in endometrial cancer (EC) patients who underwent surgical resection.

METHODS

This study included 142 EC patients who underwent surgical resection. Tumor tissue samples were obtained for tumor PLK4 protein expression detection via immunohistochemistry (IHC).

RESULTS

Among EC patients, 26.1% had a PLK4 IHC score of 0, 24.6% had a score of 1-3, 27.5% had a score of 4-6, and 21.8% had a score of 7-12. Tumor PLK4 protein expression positively associated with lymphovascular invasion (P = 0.008) and Federation of Gynecology and Obstetrics (FIGO) stage (P = 0.005). Disease-free survival (DFS) was not different between patients with tumor PLK4 IHC scores > 0 and ≤ 0 (P = 0.154) but was reduced in patients with scores > 3 vs. ≤ 3 (P = 0.009) and > 6 vs. ≤ 6 (P < 0.001). Similarly, overall survival (OS) was not different between patients with scores > 0 and ≤ 0 (P = 0.322) but was shorter in patients with scores > 3 vs. ≤ 3 (P = 0.011) and > 6 vs. ≤ 6 (P = 0.006). After adjustment, a tumor PLK4 IHC score > 6 (vs. ≤ 6) (hazard ratio (HR): 3.156, P = 0.008) or > 3 (vs. ≤ 3) (HR: 3.918, P = 0.026) was independently associated with shortened DFS and OS.

CONCLUSION

A tumor PLK4 IHC score > 6 or > 3 associates with shortened DFS and OS in EC patients who undergo surgical resection.

Circulating microRNAs as Potential Biomarkers for the Diagnosis of Endometrial Cancer: a Meta-Analysis

Endometrial cancer (EC) is the most common female genital tract malignancy worldwide. Many investigators have confirmed the possibility of using circulating miRNAs to diagnose EC; however, the results were inconsistent. Therefore, we performed the current meta-analysis to systematically evaluate the diagnostic value of circulating miRNAs in EC. We carefully searched relevant articles published prior to February 15, 2022 in the databases of PubMed, Embase, Web of Science, Cochrane Library, Wanfang database, and China National Knowledge Infrastructure (CNKI) based on PRISMA statement. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the curve (AUC) were calculated to test the diagnostic accuracy. Furthermore, subgroup analyses were performed to identify the potential sources of heterogeneity, and the Deeks' funnel plot asymmetry test was used to evaluate the potential publication bias. Twenty-one studies from 12 articles including a total of 2305 participants (1341 EC patients and 964 controls) were included in the current diagnostic meta-analysis. The overall pooled results of miRNA for EC diagnosis were: sensitivity, 0.84 (95% CI: 0.79-0.88); specificity, 0.87 (95% CI: 0.79-0.91); PLR, 6.3 (95% CI: 3.9-10.0); NLR, 0.18 (95% CI: 0.13-0.25); DOR, 35 (95% CI: 17-71); and AUC was 0.91 (95% CI: 0.89-0.94). Subgroup analysis suggested that miRNA cluster, serum type, and large sample sizes showed a better diagnostic accuracy. Moreover, there was no significant publication bias. Circulating miRNAs have great potential as novel non-invasive biomarkers for EC diagnosis.

The Risk of Endometrial Cancer and Uterine Sarcoma Following Endometriosis or Pelvic Inflammatory Disease

The relationship between uterine corpus cancer and endometriosis was conflicting. We aimed to determine the risk of uterine cancer in patients with endometriosis or pelvic inflammatory disease (PID). In this population-based cohort study, a total of 135,236 females with endometriosis (n = 20,510) or PID (n = 114,726), as well as 135,236 age-matched controls, were included. Cox regression models estimated the risk of uterine cancer in each group. Sub-outcomes of risk for uterine corpus cancer included endometrial cancer and uterine sarcoma were analyzed. An age subgroup analysis was performed to determine the moderator effect of age. A landmark analysis depicted the time varying effect of endometriosis and PID. A propensity score matching analysis was conducted to validate the findings. Patients with endometriosis had significantly higher risk of endometrial cancer (adjusted hazard ratio, aHR = 2.92; 95% CI = 2.12-4.03) and uterine sarcoma (aHR = 5.83; 95% CI = 2.02-16.89), while PID was not associated with the risk of uterine cancer. The increased risk of uterine cancer in patients with endometriosis persisted after propensity score matching (aHR = 2.83, 95%CI = 1.70-4.71). The greatest risk of endometrial cancer occurred in patients who had endometriosis for 37 to 60 months (adjusted relative risk, aRR = 9.15, 95% CI = 4.40-19.02). Females aged 12 to 35 years were at the greatest risk of endometriosis-associated uterine cancer (RR = 6.97, 95% CI = 3.41-14.26). In conclusion, patients with endometriosis were at great risk of uterine cancer, including endometrial cancer and uterine sarcoma, compared with propensity score-matched populations and compared with patients of PID. Younger females with endometriosis and patients who had endometriosis for three to five years were at the greatest risk of endometriosis-associated uterine cancer.

Predictive value of hemogram parameters in malignant transformation of the endometrium in patients with different risk factors

OBJECTIVES

To investigate whether the pretreatment hemogram parameters and their ratios can be used in predicting the endometrial transformation in patients with abnormal uterine bleeding.

MATERIAL AND METHODS

Records of all patients who underwent an endometrial histopathological evaluation between 2011 and 2021 were investigated. Hemogram, neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) were analyzed. Chi square and Mann Whitney U tests were used for analysis. P<0.05 was considered statistically significant.

RESULTS

427 patients were included, of whom 117 were presented with endometrial hyperplasia without atypia (27.4%; mean age, 42±9.7; Group II), 70 with atypia (16.3%; mean age, 53.4±9; Group III), 102 with early endometrial cancer (EC) (23.8%; mean age, 63±7.8; Group IV) and 38 with advanced disease (8.8%; mean age, 63.3±10.5; Group V). Patients without pathology constituted the control group (23.4%; mean age, 42.2±9.5; Group I). Risk factors for atypia and carcinoma were determined as age, postmenopausal state, obesity, diabetes, and increased estrogen exposure (each, p<0.05). There was no significant difference in NLR and PLR (p>0.05). However, hemoglobin and hematocrit levels were higher in Groups IV and V (13.9 vs 13.1 mg/dL, and 39.1 vs 38.8%, respectively; p<0.01). Platelet value was significantly higher in Groups III to V (282x109/L, 283x109/L and 295x109/L; p<0.05, p<0.05 and p<0.01, respectively).

CONCLUSIONS

Our findings support the impact of inflammation on malign transformation from normal endometrial mucosa to atypia and carcinoma. NLR and PLR values showed no statistical difference. Instead, thrombocytosis may have a predictive role in EC.

Protein biomarkers in cervicovaginal lavages for detection of endometrial cancer

BACKGROUND

Rates of endometrial cancer (EC) are increasing. For a definitive diagnosis, women undergo various time-consuming and painful medical procedures, such as endometrial biopsy with or without hysteroscopy, and dilation and curettage, which may create a barrier to early detection and treatment, particularly for women with inadequate healthcare access. Thus, there is a need to develop robust EC diagnostics based on non- or minimally-invasive sampling. The objective of this study was to quantify a broad range of immuno-oncology proteins in cervicovaginal lavage (CVL) samples and investigate these proteins as predictive diagnostic biomarkers for EC.

METHODS

One hundred ninety-two women undergoing hysterectomy for benign or malignant indications were enrolled in this cross-sectional study. Classification of women to four disease groups: benign conditions (n = 108), endometrial hyperplasia (n = 18), low-grade endometrioid carcinoma (n = 53) and other EC subtypes (n = 13) was based on histopathology of biopsy samples collected after the surgery. CVL samples were collected in the operating room during the standard-of-care hysterectomy procedure. Concentrations of 72 proteins in CVL samples were evaluated using multiplex immunoassays. Global protein profiles were assessed using principal component and hierarchical clustering analyses. The relationships between protein levels and disease groups and disease severity were determined using Spearman correlation, univariate and multivariate receiver operating characteristics, and logistic regression analyses.

RESULTS

Women with EC and benign conditions exhibited distinctive cervicovaginal protein profiles. Several proteins in CVL samples (e.g., an immune checkpoint protein, TIM-3, growth factors, VEGF, TGF-α, and an anti-inflammatory cytokine, IL-10) discriminated EC from benign conditions, particularly, when tested in combinations with CA19-9, CA125, eotaxin, G-CSF, IL-6, MCP-1, MDC, MCP-3 and TRAIL (sensitivity of 86.1% and specificity of 87.9%). Furthermore, specific biomarkers (e.g., TIM-3, VEGF, TGF-α, TRAIL, MCP-3, IL-15, PD-L2, SCF) associated with histopathological tumor characteristics, including histological type and grade, tumor size, presence and depth of myometrial invasion or mismatch repair protein status, implying their potential utility for disease prognosis or monitoring therapies.

CONCLUSIONS

This proof-of-principle study demonstrated that cervicovaginal sampling coupled with multiplex immunoassay technology can offer a minimally to non-invasive method for EC detection.

MRI-based radiomics model for distinguishing endometrial carcinoma from benign mimics: A multicenter study

PURPOSE

To develop and validate an MRI-based radiomics model for preoperatively distinguishing endometrial carcinoma (EC) with benign mimics in a multicenter setting.

METHODS

Preoperative MRI scans of EC patients were retrospectively reviewed and divided into training set (158 patients from device 1 in center A), test set #1 (78 patients from device 2 in center A) and test set #2 (109 patients from device 3 in center B). Two radiologists performed manual delineation of tumor segmentation on the map of apparent diffusion coefficient (ADC), diffusion-weighted imaging (DWI) and T2-weighted imaging (T2WI). The features were extracted and firstly selected using Chi-square test, followed by refining using binary least absolute shrinkage and selection operator (LASSO) regression. The support vector machine (SVM) was employed to build the radiomics model, which is tuned in the training set using 10-fold cross-validation, and then assessed on the test set. Performance of the model was determined by area under the receiver-operating characteristic curve (AUC), accuracy, sensitivity, specificity and F1-score.

RESULTS

Five most informative features are selected from the extracted 3142 features. The SVM with linear kernel was employed to build the radiomics model. The AUCs of the model were 0.989 (95% confidence interval [CI]: 0.968-0.997) for the training set, 0.999 (95% CI: 0.991-1.000) for test set #1, 0.961 (95% CI: 0.902-0.983) for test set #2. Accuracies of the model were 0.937 for the training set (precision: 0.919, recall: 0.963, F1-score: 0.940), 0.974 for test set #1 (precision: 0.949, recall: 1.000, F1-score: 0.974) and 0.908 for test set #2 (precision: 0.899, recall: 0.954, F1-score: 0.925). These results confirmed the efficacy of this model in predicting EC in different centers.

CONCLUSION

The MRI-based radiomics model showed promising potential for distinguishing EC with benign mimics and might be useful for surgical management of EC.

Suppression of PI3K/Akt/mTOR/c-Myc/mtp53 Positive Feedback Loop Induces Cell Cycle Arrest by Dual PI3K/mTOR Inhibitor PQR309 in Endometrial Cancer Cell Lines

Gene mutations in PIK3CA, PIK3R1, KRAS, PTEN, and PPP2R1A commonly detected in type I endometrial cancer lead to PI3K/Akt/mTOR pathway activation. Bimiralisib (PQR309), an orally bioavailable selective dual inhibitor of PI3K and mTOR, has been studied in preclinical models and clinical trials. The aim of this study is to evaluate the anticancer effect of PQR309 on endometrial cancer cells. PQR309 decreased cell viability in two-dimensional and three-dimensional cell culture models. PQR309 induced G1 cell cycle arrest and little cell death in endometrial cancer cell lines. It decreased CDK6 expression and increased p27 expression. Using the Proteome Profiler Human XL Oncology Array and Western blot assay, the dual inhibitor could inhibit the expressions of c-Myc and mtp53. KJ-Pyr-9, a c-Myc inhibitor, was used to prove the role of c-Myc in endometrial cancer survival and regulating the expression of mtp53. Knockdown of mtp53 lowered cell proliferation, Akt/mTOR pathway activity, and the expressions of c-Myc. mtp53 silence enhanced PQR309-inhibited cell viability, spheroid formation, and the expressions of p-Akt, c-Myc, and CDK6. This is the first study to reveal the novel finding of the PI3K/mTOR dual inhibitor in lowering cell viability by abolishing the PI3K/Akt/mTOR/c-Myc/mtp53 positive feedback loop in endometrial cancer cell lines.

Association between genetic polymorphisms and endometrial cancer risk: a systematic review

Introduction

Endometrial cancer is one of the most commonly diagnosed cancers in women. Although there is a hereditary component to endometrial cancer, most cases are thought to be sporadic and lifestyle related. The aim of this study was to systematically review prospective and retrospective case–control studies, meta-analyses and genome-wide association studies to identify genomic variants that may be associated with endometrial cancer risk.

Methods

We searched MEDLINE, Embase and CINAHL from 2007 to 2019 without restrictions. We followed PRISMA 2009 guidelines. The search yielded 3015 hits in total. Following duplicate exclusion, 2674 abstracts were screened and 453 full-texts evaluated based on our pre-defined screening criteria. 149 articles were eligible for inclusion.

Results

We found that single nucleotide polymorphisms (SNPs) in HNF1B, KLF, EIF2AK, CYP19A1, SOX4 and MYC were strongly associated with incident endometrial cancer. Nineteen variants were reported with genome-wide significance and a further five with suggestive significance. No convincing evidence was found for the widely studied MDM2 variant rs2279744. Publication bias and false discovery rates were noted throughout the literature.

Conclusion

Endometrial cancer risk may be influenced by SNPs in genes involved in cell survival, oestrogen metabolism and transcriptional control. Larger cohorts are needed to identify more variants with genome-wide significance.

Identification and functional analyses of differentially expressed metabolites in early stage endometrial carcinoma

Diagnosis of endometrial cancer is primarily based on symptoms and imaging, with early-stage disease being difficult to diagnose. Therefore, development of potential diagnostic biomarkers is required. Metabolomics, a quantitative measurement of the dynamic metabolism in living systems, can be applied to determine metabolite profiles in different disease states. Here, serum metabolomics was performed in 46 early stage endometrial cancer patients and 46 healthy volunteers. In addition, the effect of identified metabolites on tumor cell behavior (invasion, migration, proliferation, apoptosis and autophagy) was examined in endometrial cancer cell lines. Compared with controls, phenylalanine, indoleacrylic acid (IAA), phosphocholine and lyso-platelet-activating factor-16 (lyso-PAF) were differentially detected in patients. Functional analyses demonstrated that IAA, PAF and phenylalanine all dose-dependently inhibited tumor cell invasion and migration, and suppressed cell proliferation. PAF also induced tumor cell apoptosis and autophagy, while phenylalanine had no effect on apoptosis or autophagy. IAA triggered apoptosis and had a biphasic effect on autophagy: inhibiting autophagy with doses <1 mmol/L but inducing at 1 mmol/L. Interestingly, the alterations in proliferation, apoptosis and autophagy caused by 1 mmol/L IAA, were all reversed by the concomitant treatment of tryptophan (100 μmol/L). Phosphocholine inhibited tumor cell invasion and migration, and promoted cell proliferation and autophagy, all in a dose-dependent manner. Phosphocholine also protected cells from TNF-α-induced apoptosis. In conclusion, 4 serum metabolites were identified by serum metabolomics in endometrial cancer patients and functional analyses suggested that they may play roles in modulation of tumor cell behavior, although their exact mode of action still needs to be determined.