Prospective evaluation of abnormal glucose metabolism and insulin resistance in patients with atypical endometrial hyperplasia and endometrial cancer

Weight-Loss and Metformin-Use Improve the Reversal Rate in Patients with Endometrial Hyperplasia

Objective

To evaluate the therapeutic outcomes of weight loss and metformin use in patients with endometrial hyperplasia (EH), and to identify the factors influencing treatment efficacy.

Methods

This study included data from patients diagnosed with either EH or endometrial atypical hyperplasia (EAH). Patients selected a progestin treatment regimen based on their diagnosis. Those with concurrent obesity or insulin resistance received additional weight management support and metformin therapy. Follow-up assessments were conducted every 3-6 months.

Results

A total of 202 patients were included. The metformin group exhibited significantly greater improvement in abnormal uterine bleeding (91.5% vs 57.1%, p < 0.001) and in ultrasound findings (91.5% vs 66.7%, p < 0.001) than the non-metformin group. Patients who achieved >3% weight loss and those using metformin showed a significantly higher rate of disease reversal than those with ≤3% weight loss (91.2% vs 77.6%, p = 0.034) and the non-metformin group (93.2% vs 52.4%, p < 0.001). At follow-up durations exceeding 12 months, metformin use was associated with a significantly higher disease reversal rate (82.1% vs 42.9%, p = 0.048) and a lower recurrence rate (12.8% vs 28.6%, p = 0.048). Weight loss of >3% (odds ratio: 0.041, 95% confidence interval: 0.004-0.437, p = 0.008) and metformin use (odds ratio: 0.059, 95% confidence interval: 0.011-0.311, p = 0.001) were both independently associated with improved reversal rates in patients with EH/EAH.

Conclusion

Combining progestin therapy with weight loss and metformin is more effective in reversing EH than progestin alone. Regular metformin use, alongside weight loss, serves as a protective factor in EH management, with the protective effect of metformin increasing with longer use.

Is hemoglobin A1c valuable for predicting concurrent endometrial cancer in diabetic women with endometrial intraepithelial neoplasia?

AIM

The purpose of this study was to determine the predictive value of preoperative hemoglobin A1c (HgA1c) level for endometrial cancer in diabetic women with endometrial intraepithelial neoplasia (EIN).

MATERIALS AND METHODS

Six hundred patients with EIN were retrospectively studied in a tertiary referral center in Turkey between January 2014 and December 2021. One hundred and thirteen diabetic patients with EIN who met the inclusion criteria were enrolled in the study and divided into three groups according to the final pathological results: Group 1 with benign findings (n = 29), Group 2 with EIN (n = 34) and Group 3 with endometrial cancer (n = 50). Demographic, clinical and biochemical characteristics were compared among the three groups. Receiver operating characteristic analysis (ROC) was used to evaluate the predictive value of HgA1c for concurrent endometrial cancer in EIN.

RESULTS

Mean preoperative HgA1c levels were different among three groups (5.41 ± 0.64, 6.01 ± 0.72, 6.65 ± 1.15, p < 0.001, respectively). The highest value of HgA1c level was found in cancer group and difference within pairs was statistically significant (p < 0.001). Age and duration of menopause were also different among groups (p < 0.005). After adjustment of HgA1c level for age and duration of menopause differences were maintained (p < 0.001), the cutoff value was detected as ≥6.05% for HgA1c and sensitivity, specificity was 60%, 70%, respectively (p < 0.001).

CONCLUSIONS

HgA1c could be used in prediction of endometrial cancer. The optimal cutoff value determined in our study could be considered in predicting endometrial cancer in diabetic women with EIN.

Effects of Weight Status and Related Metabolic Disorders on Fertility-Sparing Treatment Outcomes in Endometrial Atypical Hyperplasia and Endometrial Cancer: A Retrospective Study

Simple Summary

Fertility-sparing treatment for young women with endometrial atypical hyperplasia or endometrioid endometrial cancer has become an important priority. The aim of our retrospective study was to evaluate the effects of different weight statuses and related metabolic disorders on the oncological and reproductive outcomes of fertility-sparing treatment. We found that there was a parabola-shaped relationship between the cumulative complete response rate of treatment and BMI. The apex of the curve was observed at a BMI of 21–22 kg/m². Furthermore, we demonstrated that hyperuricemia was an independent risk factor for the failure of conservative treatment, correlating with a lower cumulative 32-week CR rate and longer treatment duration. Our results indicate that a target BMI interval for weight management should be appropriately established for patients with EAH/EEC. Early active interventions for related metabolic disorders, preferably before 32 weeks of treatment, should be provided to improve treatment efficacy.

Abstract

Background: Although obesity was an independent risk factor for fertility-sparing treatment in endometrial atypical hyperplasia (EAH) and endometrioid endometrial cancer (EEC), the roles of other weight statuses and related metabolism were unclear. This study aimed to investigate the body mass index (BMI) interval that produced optimal treatment efficacy and the effects of related metabolic disorders in EAH/EEC patients. Methods: A total of 286 patients (including 209 EAH and 77 well-differentiated EEC) under progestin therapy were retrospectively analyzed. The cumulative complete response (CR) rate, relapse rate, and fertility outcomes were compared among different weight or metabolic statuses. Results: Underweight and overweight/obese status significantly decreased the cumulative 16-week and 32-week CR rate (p = 0.004, p = 0.022, respectively). The highest 16-week CR rate was observed at a BMI of 21–22 kg/m² in the overall population (p = 0.033). Obesity (HR 0.37, 95%CI 0.15–0.90, p = 0.029) and PCOS (HR 0.55, 95%CI 0.31–0.99, p = 0.047) were associated with lower 16-week CR rate. Hyperuricemia (HR 0.66, 95%CI 0.45–0.99, p = 0.043) was associated with lower 32-week CR rate. The 16-week and 32-week CR rate (p = 0.036, p = 0.008, respectively) were significantly lower in patients exhibiting both obesity and hyperuricemia. Conclusions: The optimal fertility-sparing treatment efficacy was observed at a BMI of 21–22 kg/m² in EAH/EEC. Hyperuricemia was an independent risk factor for long-term treatment outcomes.

Glycosylation and its research progress in endometrial cancer

Endometrial cancer (EC) is one of the most common tumors in the female reproductive system, which seriously threatens women's health, particularly in developed countries. 13% of the patients with EC have a poor prognosis due to recurrence and metastasis. Therefore, identifying good predictive biomarkers and therapeutic targets is critical to enable the early detection of metastasis and improve the prognosis. For decades, extensive studies had focused on glycans and glycoproteins in the progression of cancer. The types of glycans that are covalently attached to the polypeptide backbone, usually via nitrogen or oxygen linkages, are known as N‑glycans or O‑glycans, respectively. The degree of protein glycosylation and the aberrant changes in the carbohydrate structures have been implicated in the extent of tumorigenesis and reported to play a critical role in regulating tumor invasion, metabolism, and immunity. This review summarizes the essential biological role of glycosylation in EC, with a focus on the recent advances in glycomics and glycosylation markers, highlighting their implications in the diagnosis and treatment of EC.

Comparative aspects of treatment of endometrial hyperplasia in women of reproductive age with overweight

The aim. Minimization of the frequency of recurrence of endometrial hyperplasia (EH) in women of reproductive age with overweight (OW) depending on the tactics of treatment. Materials and methods. 90 women of reproductive age with endometrial hyperplasia and OW were selected. They, in turn, were divided into three groups: group 1 – 30 women who took a gonadotropin-releasing hormone agonist (GnRH agonist), namely at a dose of 3.75 mg intramuscularly once every 28 days; group 2 – 30 women who used progestin (norethisterone) at a dose of 10 mg per day from day 16 to 25 of the cycle, group 3 – 30 women who took combined oral contraception (COC) (30 mcg ethinyl estradiol and 150 mcg desogestrel) in a cyclic mode 21/7. Evaluation of the effectiveness of therapy included a clinical picture of the disease 6 months after the start of treatment, assessment of the variability of the average values of endometrial thickness and uterine size on ultrasound (US) of the pelvis 6 months after treatment. Also analyzed the effectiveness of therapy based on the results of morphological examination of the endometrium in a biopsy of the uterine mucosa, performed 6 months after the start of treatment. In addition, a general analysis of the frequency of EH recurrence was performed 6–24 months after treatment. Results. The results showed that in the group in which women were prescribed GnRH agonist, there was a significantly higher effectiveness of treatment, in particular the absence of uterine bleeding and menstrual disorders (MD). At the same time, in the other norethisterone group, 53.3 % (16) of women had intermenstrual uterine bleeding. In patients in the group in which women received COC, uterine bleeding was observed in 30.0 % (i.e. 9) of patients (p <0.05). Immediately after treatment, the average values of endometrial thickness in patients of group 1, according to ultrasound, was 3.59±0.47 mm, which was significantly less than in women of groups 2 and 3 – 6.81±0.59 mm (p<0.001) and 7.58±0.69 mm (p<0.001). In addition, patients in group 1 at 3, 6, 12, 24 months after the end of hormone therapy were registered significantly lower average values of endometrial thickness, compared with patients receiving norethisterone and estrogen-progestogen drugs. Conclusions. In a comparative evaluation of the effectiveness of treatment of endometrial hyperplastic processes in overweight women, it was found that the recurrence rate after 6–24 months occurs in 6.7 % (i.e. 2) of patients after GnRH agonist therapy, in 33.3 % (i.e. in 10) patients receiving norethisterone (p<0.001), and in 50 % (i.e. 15) of women treated with COC (p<0.001).

«VULNERABLE» ENDOMETRIUM: A MODERN VIEW ON THE PATHOGENESIS AND PATHOGENETIC THERAPY OF ENDOMETRIAL HYPERPLASTIC PROCESSES

Relevance: Endometrium is a unique human tissue with a strong regenerative potential which is implemented after desquamation during each menstrual cycle. At that, regeneration in the endometrium is not accompanied by scarring. Endometrial hyperplasia as a variant of defect transformation is a widespread disease which remains an urgent problem of modern medicine. In recent years, endometrial hyperplasia is becoming more common among patients of reproductive age. This problem is even more significant due to the spread of endometrial cancer in developed countries, and endometrial hyperplasia being its precursor. Purpose: The article describes modern views on the pathogenesis and pathogenetic therapy of endometrial hyperplastic processes. Materials and Methods: Sources available in the Pubmed, Embase, Cochrane databases were analyzed and international reviews of randomized controlled studies in that area were selected for the last few years using the keywords «endometrial hyperplasia,» «atypical hyperplasia,» «endometrial cancer,» «progestins,» and «hysterectomy.» Results: The article discusses the modern ideas about etiopathogenesis and the tactics of management of patients, according to the data of foreign literature. Conclusion: Early diagnostics and timely treatment of endometrial hyperplasiaare an important preventive factor due to the high risk of malignancy. The patient management algorithm depends on many factors: the type of hyperplastic conditions, the patient’s age, unrealized reproductive function, and etc. Progestin therapy is more preferable for young patients wishing to preserve reproductive function. If cellular atypia is present, panhysterectomy is the first line of treatment for women who have realized their reproductive function and have endometrial hyperplasia with atypia.

High prevalence of pulmonary embolism prior to cancer therapies in patients with ovarian and endometrial cancers detected by contrast-enhanced CT using D-dimer as an index

OBJECTIVE

We aimed to evaluate the prevalence of pulmonary embolism (PE) before cancer therapies in patients with ovarian and endometrial cancers with enhanced computed tomography (CT) using D-dimer (DD), and determine the optimal cut-off level of DD.

METHODS

Since 2009, we have performed preoperative venous thromboembolism (VTE) screening of patients with ovarian and endometrial cancer. For patients with DD levels of more than 1.0 μg/ml, enhanced CT images were obtained from the pulmonary apex to the foot to detect PE and deep venous thrombosis (DVT) simultaneously.

RESULTS

Among patients with ovarian cancer, 84 of 413 (20.3%) had VTEs (DVT alone, n = 31 [7.5%]; PE with or without DVT, n = 53 [12.8%]; PE alone, n = 12 [2.9%]). Among patients with endometrial cancer, 50 of 455 (11.0%) had VTEs (DVT alone, n = 19 [4.2%]; PE with or without DVT, n = 31 [6.8%], PE alone, n = 14 [3.1%]). The optimal cut-off level of DD was estimated to be ≥1.5 and ≥1.2 μg/ml in ovarian and endometrial cancers, respectively.

CONCLUSION

Our study revealed a high prevalence of PE before cancer therapies in patients with ovarian and endometrial cancers by enhanced CT using DD.

The Role of Hyperglycemia in Endometrial Cancer Pathogenesis

Endometrial cancer is one of the most common cancers in women worldwide and its incidence is increasing. Epidemiological evidence shows a strong association between endometrial cancer and obesity, and multiple mechanisms linking obesity and cancer progression have been described. However, it remains unclear which factors are the main drivers of endometrial cancer development. Hyperglycemia and type 2 diabetes mellitus are common co-morbidities of obesity, and there is evidence that hyperglycemia is a risk factor for endometrial cancer independent of obesity. This review aims to explore the association between hyperglycemia and endometrial cancer, and discuss the evidence supporting a role for increased glucose metabolism in endometrial cancer and how this phenotype may contribute to endometrial cancer growth and progression. Finally, the potential role of blood glucose lowering strategies, including drugs and bariatric surgery, for the treatment of this malignancy will be discussed.

Medroxyprogesterone acetate plus metformin for fertility-sparing treatment of atypical endometrial hyperplasia and endometrial carcinoma: trial protocol for a prospective, randomised, open, blinded-endpoint design, dose-response trial (FELICIA trial)

INTRODUCTION

Progestin therapy is the only fertility-sparing treatment option for patients with atypical endometrial hyperplasia (AEH) and endometrial cancer (EC). However, the results of three meta-analyses revealed a high remission rate, as well as an association with a high rate of relapse. We previously conducted a phase II of medroxyprogesterone acetate (MPA) plus metformin as a fertility-sparing treatment for AEH and EC patients, and reported that metformin inhibited disease relapse after remission.

METHODS AND ANALYSIS

A randomised, open, blinded-endpoint design phase IIb dose response trial was planned to commence in July 2019. The trial aims to identify the appropriate dose of metformin to be combined with MPA therapy for fertility-sparing treatment of patients with AEH and EC. The primary endpoint of the trial is the 3-year relapse-free survival (RFS) rate. The secondary endpoints are RFS rate, the overall rate of response to MPA therapy, the conception rate after treatment, the outcome of pregnancy, toxicity evaluation and changes in insulin resistance and body mass index. A total of 120 patients will be enrolled from 15 Japanese institutions within a 2.5-year period and followed up for at least 3 years.

ETHICS AND DISSEMINATION

The protocol was approved by the institutional review board at Chiba University Hospital and boards at 14 other institutions. The trial will be conducted according to the principles of the World Medical Association's Declaration of Helsinki and in accordance with Good Clinical Practice (GCP) standards. The trial findings will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

Japan Registry of Clinical Trials (jRCT2031190065).

New therapeutic approaches for the fertility-sparing treatment of endometrial cancer

This review seeks to describe new fertility-sparing endometrial cancer (EC) treatment strategies that take into consideration the medical and general health background of patients. We particularly focus on the application of metformin, which is a biguanide widely prescribed for treatment of type 2 diabetes mellitus. Fertility-sparing treatment using progestin is considered a standard treatment option for patients with atypical endometrial hyperplasia (AEH) and EC who desire to conceive. A previous meta-analysis of fertility-sparing treatments revealed a high remission rate; however, high rates of relapse persisted. Most young patients with AEH and EC who are subjected to fertility-sparing treatment have a background of obesity, insulin resistance and abnormal glucose tolerance complicated with polycystic ovary syndrome. Recently, metformin has been attracting more attention in the field of cancer research. Several in vitro and in vivo reports regarding the efficacy of metformin in EC management have accumulated. Thus far, the efficacy of combining metformin with progestin has been revealed in a single phase II study of medroxyprogesterone acetate in combination with metformin as a fertility-sparing treatment for patients with AEH or EC. In addition to improving the metabolic profile of patients with EC having metabolic disorders, metformin supplementation may improve the long-term oncological outcome of these patients. To date, many clinical trials employing progestin and metformin as a fertility-sparing treatment of AEH and EC are ongoing. In the near future, it is expected that the clinical advantage of metformin progestin combination therapy will be clarified.

Diabetes mellitus and responsiveness of endometrial hyperplasia and early endometrial cancer to conservative treatment

Objective: The conservative treatment of endometrial hyperplasia without atypia (HWA), atypical endometrial hyperplasia (AH/EIN) and early endometrioid carcinoma (EEC) is based on progestins. We aimed to assess whether diabetes mellitus affects the responsiveness of HWA, AH/EIN and EEC to conservative treatment, through a systematic review and meta-analysis. Study design: Electronic databases were searched for studies assessing the outcome of conservative treatment in HWA, AH/EIN and EEC, stratified based on the diagnosis of diabetes mellitus. The association of diabetes mellitus with treatment failure was assessed by using odds ratio (OR). A p-value  < .05 was considered significant. The risk of publication bias was assessed by using a funnel plot. A subgroups analyses was performed based on histologic diagnosis of benignity (HWA) or premalignancy/malignancy (AH/EIN or EEC). Results: Six studies with 876 patients (383 HWA, 365 AH/EIN and 128 EEC) were included. Overall, diabetes mellitus was not associated with outcome of treatment (OR = 1.20; p = .62). The association was not significant in both the HWA subgroup (OR = 0.95; p = .93) and in AH/EIN and EEC subgroup (OR = 1.43; p = .46). There was no significant risk of publication bias. Conclusions: Diabetes mellitus does not affect the outcome of conservative treatment in HWA, AH/EIN and EEC.

Insulin resistance and overweight prolonged fertility-sparing treatment duration in endometrial atypical hyperplasia patients

Objective

Our previous study showed that insulin resistance (IR) was related to endometrial hyperplasia as well as endometrial cancer. But the exact impact of IR on fertility-sparing treatment in endometrial hyperplasic disease is unclear. This study investigated how IR affects fertility-sparing treatment in endometrial atypical hyperplasia (EAH) patients.

Methods

The 151 EAH patients received fertility-sparing treatment were retrospectively investigated. All patients received high-dose progestin combined with hysteroscopy. Therapeutic effects were evaluated by hysteroscopy every 3 months during the treatment.

Results

The median age was 33.0 years old (range, 21–54 years old). Sixty-one patients (40.4%) were insulin resistant. Three patients were excluded from the analysis because they chose hysterectomy within 3 months after initiation of progestin treatment. The 141 out of 148 (95.3%) patients achieved complete response (CR). No difference was found in cumulative CR rate between those with or without IR (90.2% vs. 95.6%, p=0.320). IR significantly affected therapeutic duration to achieve CR (8.1±0.5 months with IR vs. 6.1±0.4 months without IR, p=0.004). Overweight (body mass index [BMI]≥25 kg/m²) was associated with higher risk of treatment failure (odds ratio=5.61; 95% confidence interval=1.11–28.35; p=0.040) and longer therapeutic duration to achieve CR (7.6±0.5 months vs. 6.3±0.4 months, p=0.019). EAH patients with both IR and overweight (IR+BMI+) had the longest therapeutic time compared with other patients (8.8±0.6 months vs. 5.6±0.7, 6.3±0.4, and 6.4±0.8 months for IR−BMI+, IR−BMI−, and IR+BMI−, respectively, p=0.006).

Conclusion

IR and overweight were associated with longer therapeutic duration in EAH patients receiving progestin-based fertility-sparing treatment.

The unrecognized burden of cardiovascular risk factors in women newly diagnosed with endometrial cancer: A prospective case control study

BACKGROUND

Cardiovascular disease is a major cause of death in endometrial cancer survivors. The aim of this study was to determine whether women newly diagnosed with endometrial cancer have a higher prevalence of cardiovascular risk factors than the general population.

METHODS

The prevalence of adequately treated and unrecognized/inadequately treated cardiovascular risk factors and the corresponding 10-year cardiovascular risk by QRISK2 score was measured in 150 consecutive women undergoing primary treatment for endometrioid endometrial cancer in the North West of England, and 746 age and ethnicity-matched control women from the Health Survey for England 2014.

RESULTS

Women with endometrial cancer had higher proportions of obesity (BMI≥30 60.7% vs. 32.4%, p<0.0001) and a preponderance of unrecognized and inadequately treated cardiovascular risk factors. Compared with controls, endometrial cancer cases had a higher prevalence of incident hyperglycemia (57.2%vs.11.5%, p<0.0001), total: HDL cholesterol ratio>4.5 (26.7%vs.13.7%, p<0.0001), and were more likely to have three or more cardiovascular risk factors (22%vs.6%, p<0.0001). This equates to a higher 10-year cardiovascular risk (median QRISK2 score 12.6% vs. 8.8%, p<0.0001). Optimization of risk factors would have a greater impact on absolute cardiovascular disease risk for cases than controls (QRISK2 score reduction 1.8% vs. 0.7%).

CONCLUSIONS

Women undergoing primary treatment for endometrial cancer have a higher prevalence of cardiovascular risk factors than women without the disease. Early identification and treatment of these risk factors could improve outcomes for endometrial cancer survivors.