Prevalence of adenomyosis in endometrial cancer patients: a systematic review and meta-analysis

Multiparametric magnetic resonance imaging-based assessment of the effect of adenomyosis on determining the depth of myometrial invasion in endometrial cancer

Background

Accurate preoperative diagnosis of endometrial cancer (EC) with deep myometrial invasion (DMI) is critical to deciding whether to perform lymphadenectomy. However, the presence of adenomyosis makes distinguishing DMI from superficial myometrial invasion (SMI) on magnetic resonance imaging (MRI) challenging. We aimed to evaluate the accuracy of multiparametric MRI (mpMRI) in diagnosing DMI in EC coexisting with adenomyosis (EC-A) compared with EC without coexisting adenomyosis and to evaluate the effect of different adenomyosis subtypes on myometrial invasion (MI) depth in EC.

Methods

Patients with histologically confirmed International Federation of Gynecology and Obstetrics (FIGO) stage I EC who underwent preoperative MRI were consecutively included in this 2-center retrospective study. Institution 1 was searched from January 2017 to November 2022 and institution 2 was searched from June 2017 to March 2021. Patients were divided into 2 groups: group A, patients with EC-A; group B, EC patients without coexisting adenomyosis, matched 1:2 according to age ±5 years and tumor grade. A senior radiologist assessed the MRI adenomyosis classification in group A. Then, 2 radiologists (R1/R2) independently interpreted T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), T1-weighted contrast-enhanced (T1CE), and a combination of all images (mpMRI) respectively, and then assessed MI depth. Accuracy, sensitivity, specificity, and the areas under the receiver operating curve (AUC) were calculated. The chi-square test was used to compare the accuracy of diagnosing DMI. Interobserver agreement was evaluated using the Kappa test.

Results

A total of 70 cases in group A and 140 cases in group B were included. The accuracy, sensitivity, and specificity of consensus were 94.3% [95% confidence interval (CI): 88.9-99.7%] vs. 92.1% (95% CI: 87.7-96.6%), 60.0% (95% CI: 17-92.7%) vs. 86.7% (95% CI: 68.4-95.6%), and 96.9% (95% CI: 88.4-95.5%) vs. 93.6% (95% CI: 86.8-97.2%) (group A vs. group B, respectively). There was no significant difference in the diagnostic accuracy of DMI on each sequence between the groups (Reviewer 1/Reviewer 2): PT2WI=0.14/0.17, PDWI=0.50/0.33, PT1CE=0.90/0.18, PmpMRI=0.50/0.37. The AUC for T2WI, DWI, T1CE, and mpMRI (Reviewer 1/Reviewer 2), respectively, were 0.54 (95% CI: 0.42-0.66)/0.78 (95% CI: 0.67-0.87), 0.63 (95% CI: 0.50-0.74)/0.77 (95% CI: 0.65-0.86), 0.69 (95% CI: 0.57-0.80)/0.79 (95% CI: 0.68-0.88), and 0.91 (95% CI: 0.82-0.97)/0.89 (95% CI: 0.79-0.95) (group A) and 0.83 (95% CI: 0.76-0.89)/0.85 (95% CI: 0.78-0.90), 0.83 (95% CI: 0.76-0.89)/0.86 (95% CI: 0.79-0.91), 0.88 (95% CI: 0.82-0.93)/0.86 (95% CI: 0.80-0.92), and 0.91 (95% CI: 0.85-0.95)/0.87 (95% CI: 0.80-0.92) (group B). Interobserver agreement was highest with mpMRI [κ=0.387/0.695 (case/control)]. The consensus results of MRI categorization of adenomyosis revealed no significant difference in the accuracy of diagnosing DMI by adenomyosis subtype (Pspatial relationship>0.99, Paffected area=0.52, Paffected pattern=0.58, Paffected size>0.99).

Conclusions

The presence of adenomyosis or adenomyosis subtype had no significant effect on the interpretation of the depth of MI. T1CE can increase the contrast between adenomyosis and cancer foci; therefore, the information provided by T1CE should be valued.

Whether surgical procedure can improve the prognosis of endometrial cancer arising in adenomyosis (EC-AIA)? A systematic review and meta-analysis

PURPOSE

Endometrial cancer arising in adenomyosis (EC-AIA) is frequently detected accidentally following a general hysterectomy for adenomyosis. Whether supplemental lymphadenectomy in patients with EC-AIA can improve the survival outcome remains inconclusive. Herein, the authors summarized the data of patients with EC-AIA and further explored the impact of lymphadenectomy on the prognosis of these patients.

METHODS

Five electronic databases, namely MEDLINE, Web of Science, PubMed, Embase, and the Cochrane Library were employed for searching articles from inception to May 2023.

RESULTS

In total, 38 eligible studies enrolling 56 patients were included. Of these, 44 patients had a traceable prognosis. Kaplan-Meier curves demonstrated that patients who had undergone lymphadenectomy had a better progression-free survival (PFS) compared with those who had not undergone lymphadenectomy ( P =0.016), but there was no difference in overall survival. Univariable ( P =0.025, HR=0.25, 95% CI=0.08-0.84) and multivariable ( P =0.042, HR=0.13, 95% CI=0.020-0.930) Cox regression analyses revealed that lymphadenectomy was an independent protective factor for PFS.

CONCLUSION

For patients diagnosed with EC-AIA following hysterectomy for benign disease, further supplementary lymphadenectomy is recommended to improve PFS.

Endometrial cancer arising from adenomyosis with unusual manifestation: A case report

Endometrial Carcinoma Arising from Adenomyosis (EC-AIA) is an unusual condition, primarily occurring in postmenopausal women. We present a rare case of a 34-year-old woman with EC-AIA, highlighting the diagnostic challenges in distinguishing this malignancy from adenomyosis preoperatively. Conventional imaging methods exhibited limitations, necessitating post-surgery confirmation through comprehensive examinations. The case emphasizes the need for a multidisciplinary approach for accurate diagnosis and timely management in such uncommon gynecological conditions.

Pulmonary embolism after diagnostic curettage in patient with adenomyosis and hysteromyoma: A case report and brief review of literature

RATIONALE

Pulmonary embolism (PE) is a common cause of cardiovascular death whose major acquired risk factors include postoperative states, pregnancy, malignancy, and age. We report a case of PE that occurred after diagnostic curettage for abnormal uterine bleeding, with a medical history of adenomyosis and hysteromyoma.

PATIENT CONCERNS AND DIAGNOSES

A 31-year-old Han Chinese female was referred to our hospital with menstrual disorders, increased menstrual flow, and severe anemia. After admission, the patient was treated with a blood transfusion, iron supplementation, and erythropoietin, and diagnostic curettage was performed the following day. On the first postoperative day, the patient developed pulmonary embolism with dyspnea and fever diagnosed by CT pulmonary angiography and significantly elevated D-dimer.

INTERVENTIONS AND OUTCOMES

Molecular weight heparin was administered for PE for 2 weeks, dyspnea was relieved significantly after 2 days of treatment and the uterine bleeding did not increase; and gonadotropin-releasing hormone agonists were administered for adenomyosis after 1 week of anticoagulant therapy to reduce bleeding. We followed up for 6 months, and the patient had no recurrence of thrombosis and uterine bleeding had improved.

CONCLUSION

We speculate that the occurrence of pulmonary embolism was closely related to adenomyosis, hysteromyoma, and curettage in this patient. Treating the presence of both menstrual bleeding and thromboembolism is challenging, and careful management is necessary to avoid therapeutic contradictions.

Molecular Signature of Endometrial Cancer with Coexistent Adenomyosis: A Multicentric Exploratory Analysis

Adenomyosis has been associated with better survival outcomes in women with endometrial cancer. However, although the endometrial cancer patients' risk stratification has been revolutionized by molecular findings, the impact of the molecular signature on the favorable prognosis of endometrial cancer patients with coexistent adenomyosis is unknown. The aim of our study was to compare the prevalence of molecular groups at poor and intermediate prognosis between endometrial cancer patients with and without coexistent adenomyosis. A multicentric, observational, retrospective, cohort study was performed to assess the differences in the prevalence of p53-abnormal expression (p53-abn) and mismatch repair protein-deficient expression (MMR-d) signatures between endometrial cancer patients with and without coexistent adenomyosis. A total of 147 endometrial cancer patients were included in the study: 38 in the adenomyosis group and 109 in the no adenomyosis group. A total of 37 patients showed the MMR-d signature (12 in the adenomyosis group and 25 in the no adenomyosis group), while 12 showed the p53-abn signature (3 in the adenomyosis group and 9 in the no adenomyosis group). No significant difference was found in the prevalence of p53-abn (p = 1.000) and MMR-d (p = 0.2880) signatures between endometrial cancer patients with and without coexistent adenomyosis. In conclusion, the molecular signature does not appear to explain the better prognosis associated with coexistent adenomyosis in endometrial cancer patients. Further investigation of these findings is necessary through future larger studies.

Effect of coexisting adenomyosis on tumour characteristics and prognosis of endometrial cancer: A systematic review and meta-analysis

To compare clinicopathological features and survival outcomes in patients with endometrial cancer, with and without associated adenomyosis. PubMed, Embase and Scopus databases were systematically searched for relevant observational studies. The pooled effect sizes were reported as either hazards ratio (HR) for survival-related outcomes or as odds ratio (OR) for other categorical outcomes. Weighted mean difference (WMD) was reported for continuous outcomes. All the analyses used the random effects model. A total of 21 studies (N = 46,420) were included. Compared to endometrial cancer patients without adenomyosis, patients with associated adenomyosis had improved overall 5-year survival (OS) (HR 0.62, 95% CI: 0.50, 0.79) and disease-free survival (DFS) (HR 0.60, 95% CI: 0.44, 0.82). Disease-specific survival was statistically similar in patients with and without adenomyosis (HR 0.60, 95% CI: 0.35, 1.05). Among patients with adenomyosis, the risk of having an advanced tumour grade (Grade 2 or 3) was lower (OR 0.51, 95% CI: 0.42, 0.62) and a risk of having International Federation of Gynaecology and Obstetrics (FIGO) stage I or II was higher (OR 2.23, 95% CI: 1.65, 3.01). Patients with adenomyosis had lower risk of tumour invasion of adnexa, cervical stromal invasion, deep myometrial involvement (DMI), lympho-vascular space invasion (LVSI) and peritoneal invasion. Presence of adenomyosis in patients with endometrial cancer is associated with favourable tumour characteristics and may improve the survival.

Clinical efficacy of a novel method of fertility-preserving adenomyomectomy in infertile women with diffuse adenomyosis

Beneficial and detrimental effect of surgical adenomyomectomy is still controversial in infertile women with severely diffuse adenomyosis. The primary objective of this study was to assess whether a novel method of fertility-preserving adenomyomectomy could improve pregnancy rates. The secondary objective was to evaluate whether it could improve dysmenorrhea and menorrhagia symptoms in infertile patients with severe adenomyosis. A prospective clinical trial was conducted between December 2007 and September 2016. Fifty women with infertility due to adenomyosis were enrolled in this study after clinical assessments by infertility experts. A novel method of fertility-preserving adenomyomectomy was performed on 45 of 50 patients. The procedure included T- or transverse H-incision of the uterine serosa followed by preparation of the serosal flap, excision of the adenomyotic tissue using argon laser under ultrasonographic monitoring, and a novel technique of suturing between the residual myometrium and serosal flap. After the adenomyomectomy, the changes in the amount of menstrual blood, relief of dysmenorrhea, pregnancy outcomes, clinical characteristics, and surgical features were recorded and analyzed. All patients obtained dysmenorrhea relief 6 months postoperatively (numeric rating scale [NRS]; 7.28 ± 2.30 vs 1.56 ± 1.30, P < .001). The amount of menstrual blood decreased significantly (140.44 ± 91.68 vs 66.33 ± 65.85 mL, P < .05). Of the 33 patients who attempted pregnancy postoperatively, 18 (54.5%) conceived either by natural means, in vitro fertilization and embryo transfer (IVF-ET), or thawing embryo transfer. Miscarriage occurred in 8 patients, while 10 (30.3%) had viable pregnancies. This novel method of adenomyomectomy resulted in improved pregnancy rates, as well as relief of dysmenorrhea and menorrhagia. This operation is effective in preserving fertility potential in infertile women with diffuse adenomyosis.

Endometrial Cancer Arising in Adenomyosis (EC-AIA): A Systematic Review

Endometrial cancer arising in adenomyosis (EC-AIA) is a rare uterine disease characterized by the malignant transformation of the ectopic endometrium within the adenomyotic foci. Clinicopathological and survival data are mostly limited to case reports and a few cohort studies. We aimed to assess the clinicopathological features and survival outcomes of women with EC-AIA through a systematic review of the literature. Six electronic databases were searched, from 2002 to 2022, for all peer-reviewed studies that reported EC-AIA cases. Thirty-seven EC-AIA patients from 27 case reports and four case series were included in our study. In our analysis, EC-AIA appeared as a rare disease that mainly occurs in menopausal women, shares symptoms with endometrial cancer, and is challenging to diagnose preoperatively. Differently from EC, it shows a higher prevalence of the non-endometrioid histotype, advanced FIGO stages, and p53-signature, which might be responsible for its worse prognosis. Future studies are necessary, to confirm our findings and further investigate this rare condition.

Combined Carcinoid Carcinoma and Squamous Cell Carcinoma of the Endometrium: A Case Report and Survey of Related Literature

Introduction

Histologically, endometrial neuroendocrine carcinoma is an extremely rare pathological type of endometrial cancer. In addition, this type is characterized by high invasiveness and poor clinical outcome, which was classified into carcinoid (low grade), and small-cell and large-cell neuroendocrine carcinoma (high grade). Globally, reports on endometrial carcinoid carcinoma are limited. Clinically, it is also rare to see primary squamous cell carcinoma of endometrium.

Case Presentation

Here, we report an interesting case of mixed carcinoma of endometrium with both carcinoid and squamous cell carcinoma, which presented with persistent vaginal bleeding and hyponatremia.

Conclusion

Careful pathologic review is necessary to diagnose this rare disease. More studies in the future are warranted to demonstrate the primary surgical treatments and the efficacy of adjuvant therapy of this disease.

Quality of Life after Risk-Reducing Hysterectomy for Endometrial Cancer Prevention: A Systematic Review

BACKGROUND

Risk-reducing hysterectomy (RRH) is the gold-standard prevention for endometrial cancer (EC). Knowledge of the impact on quality-of-life (QoL) is crucial for decision-making. This systematic review aims to summarise the evidence.

METHODS

We searched major databases until July 2022 (CRD42022347631). Given the paucity of data on RRH, we also included hysterectomy as treatment for benign disease. We used validated quality-assessment tools, and performed qualitative synthesis of QoL outcomes.

RESULTS

Four studies (64 patients) reported on RRH, 25 studies (1268 patients) on hysterectomy as treatment for uterine bleeding. There was moderate risk-of-bias in many studies. Following RRH, three qualitative studies found substantially lowered cancer-worry, with no decision-regret. Oophorectomy (for ovarian cancer prevention) severely impaired menopause-specific QoL and sexual-function, particularly without hormone-replacement. Quantitative studies supported these results, finding low distress and generally high satisfaction. Hysterectomy as treatment of bleeding improved QoL, resulted in high satisfaction, and no change or improvements in sexual and urinary function, although small numbers reported worsening.

CONCLUSIONS

There is very limited evidence on QoL after RRH. Whilst there are benefits, most adverse consequences arise from oophorectomy. Benign hysterectomy allows for some limited comparison; however, more research is needed for outcomes in the population of women at increased EC-risk.

Sonographic Assessment of Uterine Biometry for the Diagnosis of Diffuse Adenomyosis in a Tertiary Outpatient Clinic

Background: to compare several uterine biometric parameters at transvaginal ultrasound (TVUS) between adenomyosis and non-adenomyosis uteri and evaluate their role for the diagnosis of diffuse adenomyosis. Methods: prospective observational study conducted between the 1 February 2022 and the 30 April 2022. In this case, 56 patients with TVUS diagnosis of adenomyosis were included. A 1:1 ratio age and parity-matched group of non-adenomyosis patients was selected. We compared sonographic uterine biometric parameters (longitudinal (LD), anteroposterior (APD) and transverse (TD) diameters, volume, simple and complex diameter ratios) and investigated their diagnostic performance. Results: all sonographic parameters were significantly different between the study groups, except for TD/(LD+APD). Optimal cut-off values of APD and LD/APD showed the best sensitivity and specificity. APD diameter equal or superior to 39.5 mm (95% CI, 36.2–42.8) had sensitivity of 0.70 (95% CI, 0.57–0.80), specificity of 0.71 (95% CI, 0.59–0.82) and accuracy of 0.75 (95% CI, 0.66–0.84). LD/APD equal or inferior to 2.05 (95% CI, 1.96–2.13) showed sensitivity and specificity of 0.70 (95% CI, 0.57–0.80) each and accuracy of 0.72 (95% CI, 0.62–0.81). Conclusions: several biometric uterine parameters at TVUS in fertile-aged women were statistically different between adenomyosis and non-adenomyosis uteri, though their optimal cut-off values showed low accuracy in diagnosing adenomyosis.

Excess Heme Promotes the Migration and Infiltration of Macrophages in Endometrial Hyperplasia Complicated with Abnormal Uterine Bleeding

In patients, endometrial hyperplasia (EH) is often accompanied by abnormal uterine bleeding (AUB), which is prone to release large amounts of heme. However, the role of excess heme in the migration and infiltration of immune cells in EH complicated by AUB remains unknown. In this study, 45 patients with AUB were divided into three groups: a proliferative phase group (n = 15), a secretory phase group (n = 15) and EH (n = 15). We observed that immune cell subpopulations were significantly different among the three groups, as demonstrated by flow cytometry analysis. Of note, there was a higher infiltration of total immune cells and macrophages in the endometrium of patients with EH. Heme up-regulated the expression of heme oxygenase-1 (HO-1) and nuclear factor erythroid-2-related factor 2 (Nrf2) in endometrial epithelial cells (EECs) in vitro, as well as chemokine (e.g., CCL2, CCL3, CCL5, CXCL8) levels. Additionally, stimulation with heme led to the increased recruitment of THP-1 cells in an indirect EEC-THP-1 co-culture unit. These data suggest that sustained and excessive heme in patients with AUB may recruit macrophages by increasing the levels of several chemokines, contributing to the accumulation and infiltration of macrophages in the endometrium of EH patients, and the key molecules of heme metabolism, HO-1 and Nrf2, are also involved in this regulatory process.

Prevalence of adenomyosis in women undergoing hysterectomy for abnormal uterine bleeding, pelvic pain or uterine prolapse – A retrospective cohort study

Background

Adenomyosis can cause symptoms like dysmenorrhea, dyspareunia, pelvic pain and bleeding disorders and is related to subfertility and obstetrical complications. The disease is probably underestimated and underdiagnosed because of difficulties in reliable clinical examination and imaging results. The age-related prevalence of adenomyosis still remains unclear. In this retrospective analysis we describe the rate of adenomyosis in two independent cohorts of patients undergoing hysterectomy for benign diseases (2011–2013 and 2015–2018) and its correlation to presurgical symptoms respectively indications for hysterectomy.

Materials and methods

All surgeries have been performed in the same department of minimally invasive gynecological surgery by a total of two experienced surgeons following a surgical internal standard for the indication bleeding disorder, dysmenorrhea. We analyzed the overall rate of patients with adenomyosis in both cohorts and related the histological presence of adenomyosis to presurgical symptoms. We also analyzed a subgroup of postmenopausal patients with uterine prolapse.

Results

In 307 patients we detected 42.0% of cases with histologically proven adenomyosis. In the group of patients with bleeding disorders and dysmenorrhea as indication for surgery we found the highest rate of adenomyosis (59.3%, cohort 1). 81,1% patients with adenomyosis (cohort 1) reported symptoms. In the subgroup of 42 postmenopausal patients, we found 23.8% of cases with adenomyosis.

Conclusion

Our data shows that a positive anamnesis regarding the symptoms bleeding disorders and dysmenorrhea is suspicious for adenomyosis. In hysterectomy specimen adenomyosis can be found in more than 40%. The role of adenomyosis-related symptoms requires further investigation, especially in adolescent and postmenopausal patients.

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In 307 patients undergoing hysterectomy we detected 42.0% of cases with adenomyosis.

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In patients with bleeding disorders and dysmenorrhea we found the highest rate of adenomyosis (59.3%).

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81,1% of patients with adenomyosis reported symptoms.

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In 58.9% of patients with adenomyosis we found additional fibroids.

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In 42 postmenopausal patients we found adenomyosis in 23.8% of cases.

Adenomyosis-associated recurrent acute cerebral infarction mimicking Trousseau's syndrome: A case study and review of literature

Background

Adenomyosis is a common and benign uterine disease. Acute cerebral infarction (CI) associated with adenomyosis is rarely reported and difficult to treat. We experienced successful treatment for this disease.

Case Description

A 50-year-old woman presented with a 2-day history of visual disturbance. Magnetic resonance imaging showed multiple tiny diffusion-weighted high-density spots on several lobes. No common risk factors for stroke were detected. Cancer antigen 125 level was 999 U/mL, along with massively expanded uterus and adnexa. Based on the diagnosis of benign adenomyosis, Xa inhibitor and GnRH agonists were administered for CI and adenomyosis, respectively. Acute CI recurred 7 days after admission. We suspected a relationship between infarction and adenomyosis and concluded hysterectomy as a proper treatment strategy based on the literature. Eighteen months after hysterectomy, no recurrence of CI without anti-thrombus medications has been detected.

Conclusion

Hysterectomy is a radical therapy that is effective in preventing acute CI due to adenomyosis associated with ischemic symptoms.

Molecular Insights into Endometrial Cancer in Mice

Pluripotent, very small embryonic-like stem cells (VSELs) and the 'progenitors' endometrial stem cells (EnSCs) along with associated molecular changes in endometrial cancer, that developed seven months after neonatal exposure to estradiol in one of the sixty mice, were studied in the present study. Endocrine disruption affected both endometrium and myometrium, there was accumulation of endometrial fluid and significant hyperplasia. Disrupted endometrial-myometrial junction resulted in mobilization of myometrial cells into endometrium and epithelial and stromal cells into myometrium suggestive of adenomyosis. Markers specific for VSELs/ EnSCs (OCT-4, NANOG, SSEA-1, SCA-1, c-KIT) showed increased expression in uterine sections and marked upregulation of corresponding transcripts (Oct-4A, Oct-4, Sox-2, Nanog, Sca-1, c-Kit) was noted in RNA extracted from both uterine tissue and stem cells enriched from endometrial fluid. Hormonal receptors (ER-α, ER-β, PR, FSHR) were upregulated in both tumor sections and in endometrial fluid. ER-β and FSHR (Fshr3) expression was prominent suggesting a major role in endometrial cancer. Cancer cells showed global hypomethylation (reduced expression of 5-methyl cytosine), reduced expression of tumor suppressor gene (PTEN) and increased expression of cancer stem cells marker (CD166) which suggested dysregulation and aberrant oncogenic events. Increased expression of PCNA, Ki67, SOX-9 suggested excessive proliferation and hyperplasia which are predominant signs of endometrial cancer. Results suggest that VSELs increase in numbers and possibly transform into cancer stem cells (co-express CD166 and OCT-4) in endometrial cancer. Expression of OCT-4, CD133, ALDHA1 and CD166 in side-population cells from human endometrial cancer samples suggests a possible role of VSELs in human endometrial cancer as well.

The impact of uterine adenomyosis on the histopathological risk factors and survival in patients with endometrial adenocarcinoma

A retrospective cohort study was performed on patients diagnosed with endometrial adenocarcinoma (EC) during a 9-year period to investigate the impact of co-existing adenomyosis on patients with EC. Group A included women with EC and adenomyosis and Group B EC cases without the presence of adenomyosis. Group A was more likely to have early-stage disease, tumours without deep myometrial invasion, low-grade tumours and tumours with negative lymphovascular space invasion when compared to Group B (p = 0.012, p = 0.004, p < 0.001, p = 0.02). There were no statistically significant difference between Group A and Group B for lymph node metastasis (p = 0.064). There was no significant relation between the adenomyosis and survival outcomes in the multivariant analysis (p = 0.437). As a conclusion, patients with adenomyosis were more likely to accompany good histopathologic prognostic factors. Multivariate analysis showed no significant effect of adenomyosis on recurrence and survival parameters.IMPACT STATEMENTWhat is already known on this subject? Adenomyosis is one of the most common accompanying benign histopathological findings of type 1 endometrial carcinomas (EC). Adenomyosis comprises some characteristics similar to malignant tumours, such as invasion, abnormal tissue growth and angiogenesis. Despite concerns have arisen due to both their high incidence and similar molecular links, the possible relation between EC and adenomyosis is still not well grounded.What the results of this study add? We presented a 9-year period retrospective cohort of a tertiary referring single centre and evaluated the prognostic effect of adenomyosis in patients with EC as well as the survival outcomes of these patients. The co-occurrence of adenomyosis was more likely to accompany early-stage (stages 1-2) disease, low-grade tumours (grades 1-2) and tumours with negative LVSI in patients with EC. However, multivariate and survival analysis showed no significant effect of adenomyosis on recurrence and survival parameters.What the implications are of these findings for clinical practice and/or further research? Based on these findings, we suggest that the presence of adenomyosis should not be considered as a prognostic factor in EC. Our results support the overriding opinion about the prognostic value of co-occurrence of adenomyosis and EC. However, further studies exploring the molecular and genomic markers in these two groups are needed to uncover the exact relation of adenomyosis on the prognosis of EC.

Adenomyosis as a Risk Factor for Myometrial or Endometrial Neoplasms—Review

Adenomyosis is a common benign gynecological condition, defined as an extension of endometrial tissue into the myometrium. Some studies suggest that adenomyosis could be a favorable prediction factor associated with survival outcomes in endometrial cancer. The aim of our systematic review was to investigate the current knowledge regarding adenomyosis and a possible molecular mechanism of carcinogenesis in adenomyotic lesions. In addition, the long-term prognosis for patients with endometrial cancer and coexisting adenomyosis (and endometriosis) was a key point of the research. The current literature was reviewed by searching PubMed, using the following phrases: “adenomyosis and endometrial cancer” and “malignant transformation of adenomyosis”. According to the literature, genetic mutations, epigenetic changes, and inactivation of specific tumor suppressor genes in adenomyosis are still poorly understood. Data regarding the influence of adenomyosis on survival outcomes in endometrial cancer seem to be contradictory and require further clinical and molecular investigation.

Clinical Characteristics of Patients with Endometrial Cancer and Adenomyosis

Simple Summary

Endometrial cancer (EC) reportedly have a better prognosis in patients with coexistent adenomyosis. It is possible to hypothesize that this difference may be attributable to different clinical profiles. On this account, we aimed to define the clinical profile of endometrial cancer (EC) patients with and without adenomyosis through a systematic review and meta-analysis. We included 8 studies with 5681 patients and found that EC women with adenomyosis were less likely to be nulliparous than EC women without adenomyosis, while no significant differences were found with regard to age, BMI, and premenopausal status.

Abstract

A better endometrial cancer (EC) prognosis in patients with coexistent adenomyosis has been reported. Unfortunately, it is still unclear if this better prognosis is related to a more favorable clinical profile of adenomyosis patients. We aimed to evaluate differences in the clinical profiles of EC patients with and without adenomyosis. A systematic review and meta-analysis was performed by searching seven electronics databases for all studies that allowed extraction of data about clinical characteristics in EC patients with and without adenomyosis. Clinical characteristics assessed were: age, Body Mass Index (BMI), premenopausal status, and nulliparity. Mean difference in mean ± standard deviation (SD) or odds ratio (OR) for clinical characteristics between EC patients with and without adenomyosis were calculated for each included study and as a pooled estimate, and graphically reported on forest plots with a 95% confidence interval (CI). The Z test was used for assessing the overall effect by considering a p value < 0.05 as significant. Overall, eight studies with 5681 patients were included in the qualitative analysis, and seven studies with 4366 patients in the quantitative analysis. Pooled mean difference in mean ± SD between EC women with and without adenomyosis was −1.19 (95% CI: −3.18 to 0.80; p = 0.24) for age, and 0.23 (95% CI: −0.62 to 1.07; p = 0.60) for BMI. When compared to EC women without adenomyosis, EC women with adenomyosis showed a pooled OR of 1.53 (95% CI: 0.92 to 2.54; p = 0.10) for premenopausal status, and of 0.60 (95% CI: 0.41 to 0.87; p = 0.007) for nulliparity. In conclusion, there are not significant differences in clinical characteristics between EC patients with and without adenomyosis, with the exception for nulliparity. Clinical features seem to not underlie the better EC prognosis of patients with adenomyosis compared to patients without adenomyosis.

Endometrial Cancer Incidence in Endometriosis and Adenomyosis

Women with histologically proven endometriosis/adenomyosis have an increased risk of ovarian cancer. Small studies show conflicting results on the endometrial cancer risk in women with endometriosis/adenomyosis. Therefore, we assessed the incidence of endometrial cancer in women with histologically proven endometriosis or adenomyosis. We performed a population-based retrospective cohort study of 129,862 women with histologically proven endometriosis/adenomyosis, matched with 132,700 women with a nevus selected from the Dutch pathology registry between 1990 and 2015. Histology results for endometrial cancer were retrieved. Crude and age-adjusted odds ratios for endometrial cancer were estimated. In the endometriosis/adenomyosis group, 1827 (1.4%) women had a histological report on endometrial cancer, and in the nevus group, 771 (0.6%) women. The age-adjusted OR for endometrial cancer was 2.58 (95%CI 2.37-2.81). After excluding the first year of follow-up, the age-adjusted OR was 0.76 (95%CI 0.63-0.92), indicating that endometrial cancer is most often found at time of histological diagnosis of endometriosis/adenomyosis. In around 20% of the endometrial cancer cases, the endometrial cancer was not recognized until after hysterectomy. Of these women, 35% had no prior (micro)curettage or biopsy. This study shows an increased incidence of endometrial cancer in women with histologically proven endometriosis and adenomyosis.

Mifepristone inhibited the expression of B7-H2, B7-H3, B7-H4 and PD-L2 in adenomyosis

BACKGROUND

The immune mechanism was shown to be involved in the development of adenomyosis. The aim of the current study was to evaluate the expression of the immune checkpoints B7-H2, B7-H3, B7-H4 and PD-L2 in adenomyosis and to explore the effect of mifepristone on the expression of these immune checkpoints.

METHODS

The expression of B7-H2, B7-H3, B7-H4 and PD-L2 in normal endometria and adenomyosis patient samples treated with or without mifepristone was determined by immunohistochemistry analysis.

RESULTS

In adenomyosis patient samples, the expression of B7-H2, B7-H3 and B7-H4 was increased in the eutopic and ectopic endometria compared with normal endometria, both in the proliferative and secretory phases. Moreover, the expression of B7-H2 and B7-H3 was higher in adenomyotic lesions than in the corresponding eutopic endometria, both in the proliferative and secretory phases. The expression of PD-L2 was higher in adenomyotic lesions than in normal endometria in both the proliferative and secretory phases. In the secretory phase but not the proliferative phase, the expression of B7-H4 and PD-L2 in adenomyotic lesions was significantly higher than that in the corresponding eutopic endometria. In normal endometria and eutopic endometria, the expression of B7-H4 was elevated in the proliferative phase compared with that in the secretory phase, while in the ectopic endometria, B7-H4 expression was decreased in the proliferative phase compared with the secretory phase. In addition, the expression of B7-H2, B7-H3, B7-H4 and PD-L2 was significantly decreased in adenomyosis tissues after treatment with mifepristone.

CONCLUSIONS

The expression of the immune checkpoint proteins B7-H2, B7-H3, B7-H4 and PD-L2 is upregulated in adenomyosis tissues and is downregulated with mifepristone treatment. The data suggest that B7 immunomodulatory molecules are involved in the pathophysiology of adenomyosis.

Impact of adenomyosis on the prognosis of patients with endometrial cancer

Background

Despite the high prevalence of adenomyosis in hysterectomy specimens of endometrial carcinoma (EC) patients, the relationship between adenomyosis and EC prognosis appears unclear.

Objective

To assess the prognostic value of coexistent adenomyosis in patients with EC.

Methods

A systematic review and meta‐analysis was performed by searching six electronic databases for studies reporting data on prognosis of EC patients with and without coexistent adenomyosis. Studies with patient selection based on prognostic factors were excluded. Pooled univariate hazard ratio (HR) analyses for overall survival (OS) and disease‐free survival (DRF) were performed, using EC patients without adenomyosis as a control group. For DFS, pooled multivariate HR analysis was also evaluable.

Results

Three studies of 2505 EC patients (553 with and 1952 without adenomyosis) were included. Compared with EC patients without adenomyosis, EC patients with coexistent adenomyosis showed a pooled HR of 0.533 (CI 95%, 0.329–0.864) for OS at univariate analysis; 0.536 (CI 95%, 0.334–0.859) for DFS at univariate analysis; and 0.875 (CI 95%, 0.331–2.315) for DFS at multivariate analysis.

Conclusion

In EC patients with coexistent adenomyosis, the risk of death is halved compared with EC patients without adenomyosis. However, the independence of this association needs to be verified in future studies.

The risk of death is halved in EC patients with coexistent adenomyosis compared with EC patients without adenomyosis, whereas the risk of EC recurrence does not appear to be affected.