Endometrial cancer in women 45 years of age or younger: a clinicopathological analysis

Endometrial Cancer in Reproductive-Aged Females: Etiology and Pathogenesis

Endometrial cancer is the most common gynecologic malignancy in developed countries, and the incidence is rising in premenopausal females. Type I EC is more common than Type II EC (80% vs. 20%) and is associated with a hyperestrogenic state. Estrogen unopposed by progesterone is considered to be the main driving factor in the pathogenesis of EC. Studies show that BMI > 30 kg/m2, prolonged duration of menses, nulliparity, presence of polycystic ovarian syndrome, and Lynch syndrome are the most common causes of EC in premenopausal women. Currently, there are no guidelines established to indicate premenopausal patients who should be screened. This review aims to synthesize current data on the etiology, risk factors, presentation, evaluation, and prognosis of endometrial cancer in this population.

Oncologic, fertility, and obstetric outcomes with MPA therapy in women with endometrial cancer and atypical endometrial hyperplasia

AIM

Medroxyprogesterone acetate (MPA) is one of the treatments of atypical endometrial hyperplasia (AEH) and endometrial cancer (EC) to preserve the fertility. Efficacy of MPA therapy and fertility and obstetric outcomes after remission were evaluated in EC or AEH patients.

METHODS

Among patients diagnosed with EC or AEH at Tokushima University Hospital between January 2002 and October 2020, we retrospectively analyzed patients, ages range from 26 to 40, who underwent conservative management using MPA (400-600 mg/day).

RESULTS

In total, 19 patients underwent MPA therapy. The 18 (94%) patients achieved complete response (CR), and 1 (5%) patient achieved partial response (PR). Relapse occurred in 6 (32%) patients who had achieved CR. Of the patients who relapsed, 4 patients resumed MPA therapy and were in remission. Among 19 patients, 13 patients attempted pregnancy after CR. All of them underwent ovulation induction or assisted reproductive technology. As a result, 20 pregnancies in 10 (77%) patients and 12 live births in 9 (69%) patients were achieved. Rate of spontaneous abortion was 35% (7/20).

CONCLUSIONS

MPA therapy can produce a high remission rate, and be considered an effective treatment for patients who wish fertility preservation. Around 70% patients who attempt to pregnancy can have at least one baby by infertility treatments. Because recurrence rate after MPA therapy is high, it may be desirable to aim for early pregnancy by active intervention.

Temporal Trends in Treatment and Outcomes of Endometrial Carcinoma in the United States, 2005-2020

Endometrial cancer has continued to see a rising incidence in the US over the years. The main aim of this study was to assess current trends in patients' characteristics and outcomes of treatment for endometrial carcinoma over 16 years. A dataset from the National Cancer Database (NCDB) for patients diagnosed with endometrial carcinoma from 2005 to 2020 was used in this retrospective, case series study. The main outcomes and measures of interest included tumor characteristics, hospitalization, treatments, mortality, and overall survival. Then, 569,817 patients who were diagnosed with endometrial carcinoma were included in this study. The mean (SD) age at diagnosis was 62.7 (11.6) years, but 66,184 patients (11.6%) were younger than 50 years, indicating that more patients are getting diagnosed at younger ages. Of the patients studied, 37,079 (6.3%) were Hispanic, 52,801 (9.3%) were non-Hispanic Black, 432,058 (75.8%) were non-Hispanic White, and 48,879 (8.6%) were other non-Hispanic. Patients in the 4th period from 2017 to 2020 were diagnosed more with stage IV (7.1% vs. 5.2% vs. 5.4% vs. 5.9%; p < 0.001) disease compared with those in the other three periods. More patients with severe comorbidities (Charlson Comorbidity Index score of three) were seen in period 4 compared to the first three periods (3.9% vs. ≤1.9%). Systemic chemotherapy use (14.1% vs. 17.7% vs. 20.4% vs. 21.1%; p < 0.001) and immunotherapy (0.01% vs. 0.01% vs. 0.2% vs. 1.1%; p < 0.001) significantly increased from period 1 to 4. The use of laparotomy decreased significantly from 42.1% in period 2 to 16.7% in period 4, while robotic surgery usage significantly increased from 41.5% in period 2 to 64.3% in period 4. The 30-day and 90-day mortality decreased from 0.6% in period 1 to 0.2% in period 4 and 1.4% in period 1 to 0.6% in period 4, respectively. Over the period studied, we found increased use of immunotherapy, chemotherapy, and minimally invasive surgery for the management of endometrial cancer. Overall, the time interval from cancer diagnosis to final surgery increased by about 6 days. The improvements observed in the outcomes examined can probably be associated with the treatment trends observed.

Clinical characteristics and radiation therapy modality of younger patients with early-stage endometrial cancer, a multicenter study in China's real world

BACKGROUND

Endometrial cancer is a prevalent gynecologic malignancy found in postmenopausal women. However, in the last two decades, the incidence of early-stage has doubled in women under 40 years old. This study aimed to investigate the clinical and pathological characteristics and adjuvant therapeutic modalities of both young and not -young patients with early-stage endometrial cancer in China's real world.

METHODS

This retrospective study analyzed patients with early-stage endometrial cancer at 13 medical institutions in China from 1999 to 2015. The patients were divided into two groups: young (≤ 45 years old) and non-young (> 45 years old). Statistical comparisons were conducted between the two groups for clinical characteristics, pathological features, and survival. The study also identified factors that affect local recurrence-free survival (LRFS) using Cox proportional risk regression analysis. Propensity score matching (1:1) was used to compare the effects of local control between vaginal brachytherapy (VBT) alone and pelvic external beam radiotherapy (EBRT) ± VBT.

RESULTS

The study involved 1,280 patients, 150 of whom were 45 years old or younger. The young group exhibited a significantly higher proportion of stage II, low-risk, lower uterine segment infiltration (LUSI), and cervical invasion compared to the non-young group. Additionally, the young patients had significantly larger maximum tumor diameters. The young group also had a significantly higher five-year overall survival (OS) and a five-year LRFS. Age is an independent risk factor for LRFS. There was no significant difference in LRFS between young patients with intermediate- to high-risk early-stage endometrial cancer who received EBRT ± VBT and those who received VBT alone.

CONCLUSIONS

In the present study, young patients had better characteristics than the non-young group, while they exhibited higher levels of aggressiveness in certain aspects. The LRFS and OS outcomes were better in young patients. Age is an independent risk factor for LRFS. Additionally, VBT alone may be a suitable option for patients under 45 years of age with intermediate- to high-risk early-stage endometrial cancer, as it reduces the risk of toxic reactions and future second cancers while maintaining similar local control as EBRT.

LGR5, a prognostic stem cell target, promotes endometrial cancer proliferation through autophagy activation

Endometrial cancer (EC) is a common malignant tumor in women worldwide. Although early EC has a good prognosis, advanced endometrial cancer is still associated with the risk of drug resistance and recurrence. Cancer stem cells (CSCs), a category closely related to drug resistance and recurrence, are rarely studied at present. Here, we constructed a risk model containing ten stemness-related prognostic genes. Compared with patients in the low-risk group, patients in the high-risk group had a shorter overall survival time. The accuracy of this model was verified by ROC in the TCGA (AUC = 0.779) and Peking University People's Hospital (PKUPH, AUC = 0.864) cohorts. The risk score and stage were independent risk factors in the multivariate regression analysis, which was subsequently used to construct the nomogram and verified in the TCGA cohort. LGR5 was significantly correlated with overall survival and involvement in the Wnt signaling pathway. In addition, LGR5 was highly expressed in EC tissues and was related to age, stage, histological type, and menopause status in the TCGA database. Overexpression of LGR5 accelerated the proliferation rate of EC cells, which may be related to autophagy activation. Taken together, our study established a prognostic model based on transcription sequencing data from the TCGA database and verified it in the PKUPH cohort, which has prospective clinical implications for the prognostic evaluation of EC. We systematically studied the code gene LGR5 in EC, which may help clinicians make personalized prognostic assessments and effective clinical decisions for EC.

The global incidence, mortality, and burden of uterine cancer in 2019 and correlation with SDI, tobacco, dietary risks, and metabolic risk factors: An ecological study

Background and Aim

Endometrial cancer (EC) is the sixth most common cancer among women worldwide. Since global studies are based on awareness of the incidence trend, mortality, geographical diversity, and level of social development and income of countries, this study was conducted to investigate the trend of uterine cancer (UC) in the world in 2019.

Methods

Age-standardized rates (ASR) of incidence, deaths, prevalence, and disability-adjusted life years (DALYs) of UC, as well as targeted risk factors, were extracted from the Global Burden of Disease (GBD) online database 2019. Pearson correlation coefficient and SPSS 16 were used to calculate the correlation between risk factors and ASR of epidemiological indicators. Statistical significance was considered as p < 0.05.

Results

In 2019, the age-specific incidence and death rate of UC was peaking at 60-64 and 65-69 years, respectively. The highest age-standardized incidence rate per 100,000 people for UC has been reported in the Northern Mariana Islands, high sociodemographic index (SDI) countries, World Bank High-Income category, Europe continent and among World Health Organization (WHO) regions were found in the European Region. The highest age-standardized death rate per 100,000 people for UC has been reported in Grenada, high SDI countries, the World Bank High-Income category, Europe continent, and among WHO regions found in the European Region. In 2019, the age-standardized DALYs rate was 53.54 per 100,000 inhabitants, of which 48.49 cases were related to years of life lost (YLLs) and 5.05 cases were related to years lived with disability.

Conclusion

According to GBD-2019, the highest incidence, mortality, and DALY of UC are in Europe. The evidence and traces of diversity can be seen in the inequalities of UC. Race, ethnicity, economic status, level of education and awareness, co-morbidities, access, grade, and histological type of tumor are the most important causes of this inequality.

Sonographic, Demographic, and Clinical Characteristics of Pre- and Postmenopausal Women with Endometrial Cancer; Results from a Post Hoc Analysis of the IETA4 (International Endometrial Tumor Analysis) Multicenter Cohort

In this study, we conducted a comparative analysis of demographic, histopathological, and sonographic characteristics between pre- and postmenopausal women diagnosed with endometrial cancer, while also examining sonographic and anthropometric features in 'low' and 'intermediate/high-risk' cases, stratified by menopausal status. Our analysis, based on data from the International Endometrial Tumor Analysis (IETA) 4 cohort comprising 1538 women (161 premenopausal, 1377 postmenopausal) with biopsy-confirmed endometrial cancer, revealed that premenopausal women, compared to their postmenopausal counterparts, exhibited lower parity (median 1, IQR 0-2 vs. 1, IQR 1-2, p = 0.001), a higher family history of colon cancer (16% vs. 7%, p = 0.001), and smaller waist circumferences (median 92 cm, IQR 82-108 cm vs. 98 cm, IQR 87-112 cm, p = 0.002). Premenopausal women more often had a regular endometrial-myometrial border (39% vs. 23%, p < 0.001), a visible endometrial midline (23% vs. 11%, p < 0.001), and undefined tumor (73% vs. 84%, p = 0.001). Notably, despite experiencing a longer duration of abnormal uterine bleeding (median 5 months, IQR 3-12 vs. 3 months, 2-6, p < 0.001), premenopausal women more often had 'low' risk disease (78% vs. 46%, p < 0.001). Among sonographic and anthropometric features, only an irregular endometrial-myometrial border was associated with 'intermediate/high' risk in premenopausal women. Conversely, in postmenopausal women, multiple features correlated with 'intermediate/high' risk disease. Our findings emphasize the importance of considering menopausal status when evaluating sonographic features in women with endometrial cancer.

Development and validation of a nomogram for predicting overall survival in patients with early-onset endometrial cancer

BACKGROUND

This study aimed to investigate the differences in the clinicopathological characteristics of younger and older patients with endometrial cancer (EC) and develop a nomogram to assess the prognosis of early onset EC in terms of overall survival.

METHODS

Patients diagnosed with EC from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2015 were selected. Clinicopathological characteristics were compared between younger and older patients, and survival analysis was performed for both groups. Prognostic factors affecting overall survival in young patients with EC were identified using Cox regression. A nomogram was created and internal validation was performed using the consistency index, decision curve analysis, receiver operating characteristic curves, and calibration curves. External validation used data from 70 patients with early onset EC. Finally, Kaplan-Meier curves were plotted to compare survival outcomes across the risk subgroups.

RESULTS

A total of 1042 young patients and 12,991 older patients were included in this study. Younger patients were divided into training (732) and validation (310) cohorts in a 7:3 ratio. Cox regression analysis identified age, tumorsize, grade, FIGO stage(International Federation of Gynecology and Obstetrics) and surgery as independent risk factors for overall survival, and a nomogram was constructed based on these factors. Internal and external validations demonstrated the good predictive power of the nomogram. In particular, the C-index for the overall survival nomogram was 0.832 [95% confidence interval (0.797-0.844)] in the training cohort and 0.839 (0.810-0.868) in the internal validation cohort. The differences in the Kaplan-Meier curves between the different risk subgroups were statistically significant.

CONCLUSIONS

In this study, a nomogram for predicting overall survival of patients with early onset endometrial cancer based on the SEER database was developed to help assess the prognosis of patients and guide clinical treatment.

The impact of previous conservative treatment of atypical hyperplasia on pregnancy outcomes after IVF/ICSI-embryo transfer: a propensity score-matched retrospective cohort study

STUDY QUESTION

Do women have worse pregnancy and neonatal outcomes of IVF/ICSI-fresh embryo transfer (ET) after conservative treatment of atypical hyperplasia (AH)?

SUMMARY ANSWER

AH has no impact on live birth but is associated with increased risks of pregnancy loss and preterm delivery (PTD).

WHAT IS KNOWN ALREADY

AH is a precancerous lesion of endometrial cancer. Several recognized AH risk factors include nulliparity, increased body mass index, ovulation disorders, diabetes mellitus, and others. As such, patients are suggested to attempt conception upon achieving AH regression. Recently, successful pregnancies with IVF/ICSI have been increasingly reported.

STUDY DESIGN, SIZE, DURATION

Forty-two patients with AH regression and 18 700 women with no evidence of endometrial abnormality, who underwent their first autologous oocytes' retrieval and fresh ET cycles of IVF/ICSI in the Center for Reproductive Medicine, Shandong University, from May 2008 to July 2021, were retrospectively enrolled.

PARTICIPANTS/MATERIALS, SETTING, METHODS

First, 42 AH patients were propensity score matched with control women (n = 168) at a 1:4 ratio. Reproductive outcomes and maternal/neonatal complications were compared between the matched pairs. Binary logistic regression analyses were conducted to assess odds ratios (ORs) of AH for live birth, pregnancy loss, and PTD from AH women and all 18 700 eligible controls.

MAIN RESULT AND THE ROLE OF CHANCE

Patients with AH achieved a numerically lower live birth rate (LBR) as compared to the matched controls, but without significant difference (26% versus 37%, P = 0.192). However, compared with the matched controls, AH patients showed significantly higher rates of pregnancy loss (52% versus 21%, P = 0.003) and PTD (45% versus 16%, P = 0.041). Further analyses revealed a statistically significantly increased rate of late pregnancy loss (17% versus 3%, P = 0.023), but not early miscarriage (35% versus 18%, P = 0.086), in the AH group. Furthermore, after correcting for potential confounders, the likelihood of a live birth in AH patients narrowly failed to be statistically significantly different from controls (adjusted OR [aOR]: 0.51, 95% CI: 0.25-1.04, P = 0.064). Nonetheless, the logistic regression reconfirmed that AH was an independent risk factor for pregnancy loss (aOR: 3.62, 95% CI: 1.55-8.46, P = 0.003), late pregnancy loss (aOR: 9.33, 95% CI: 3.00-29.02, P < 0.001), and PTD (aOR: 5.70, 95% CI: 1.45-22.38, P = 0.013).

LIMITATIONS, REASONS FOR CAUTION

Selection bias was an inherent drawback of this study. First, because of the low AH prevalence among women receiving IVF/ICSI treatment, and consequently, limited sample size, the relationship between AH with LBR and adverse complications might be concealed and underestimated. Hence, the results should be interpreted cautiously. Similarly, the impacts of diverse clinical features of AH patients on the pregnancy outcomes need further studies in a larger population. Second, although most data used in this study were obtained by reviewing the medical records, missing data did exist and so did the recall bias. Third, although the propensity score matching and multivariable logistic models were performed collectively in order to minimize potential confounders between AH and controls, the intrinsic disadvantages of the retrospective nature of this study could not be avoided completely, and additional confirmation bias might be induced with reduplication of statistical analyses.

WIDER IMPLICATION OF THE FINDINGS

Our results highlight the necessity of adequate counseling and intensive pregnancy monitoring for AH individuals and their families.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by grants from the National Key Research & Developmental Program of China (2022YFC2703800), the Natural Science Foundation of Shandong Province (ZR2022MH009), and Projects of Medical and Health Technology Development Program in Shandong Province (202005010520, 202005010523). There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Risk for Hereditary Neoplastic Syndromes in Women with Mismatch Repair-Proficient Endometrial Cancer

Endometrial cancer (EC) is a prevalent malignancy in women, and those who are proficient in the DNA mismatch repair (pMMR) pathway may have a family history (FH) that meets the criteria for a hereditary neoplastic condition (HNS). This study aimed to estimate the risk of HNS in women with pMMR endometrial tumors by analyzing their FH. To achieve this, we collaborated with a primary study and collected FH information by telephone. The final sample comprised 42 women who responded to the Primary Screening Questionnaire. Their family pedigrees were drawn and categorized according to internationally standardized criteria for the risk of HNS. Results showed that 26 women (61%) were found to be at risk for HNS, with Bethesda criteria being met by 23%, Amsterdam criteria by 15%, and 4% met the attenuated familial adenomatous polyposis criteria. Our results emphasize the importance of FH and the need to encourage healthcare professionals to collect and document FH more frequently, even if it is self-reported. By identifying individuals with HNS, we can improve their outcomes and reduce the burden of cancer in families with a predisposition to cancer.

Epidemiological trends and risk factors of gynecological cancers: an update

Gynecological cancers, the most common cancer among women worldwide, disrupt the function of women's reproductive system, significantly impacting the quality of life. The epidemiological patterns of gynecological cancers differ in various regions and alter over time. The main challenge to deal with women's cancers is focusing on potential plans to improve patient outcomes. The epidemiology and general risk elements of gynecological cancers are important in the management of these cancers, so all of the reported risk factors in gynecological cancers have been evaluated in the present review. Due to the role of gynecological cancers in women's health, preventive measures and modifiable lifestyles together with early detection in high-risk groups are effective strategies that can reduce mortality rates. This review summarizes the epidemiology and global risk factors of gynecological cancers alongside others to better management of these malignancies and improve the quality of life in the affected patients.

Impact of ovarian preservation on survival for women with endometrial carcinoma

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

Primary objective will be to evaluate the impact of ovarian preservation on survival outcomes of women with endometrial cancer, while secondary objectives will be to evaluate the impact of ovarian preservation on adverse events and quality of life (QoL).

Is early-onset cancer an emerging global epidemic? Current evidence and future implications

Over the past several decades, the incidence of early-onset cancers, often defined as cancers diagnosed in adults <50 years of age, in the breast, colorectum, endometrium, oesophagus, extrahepatic bile duct, gallbladder, head and neck, kidney, liver, bone marrow, pancreas, prostate, stomach and thyroid has increased in multiple countries. Increased use of screening programmes has contributed to this phenomenon to a certain extent, although a genuine increase in the incidence of early-onset forms of several cancer types also seems to have emerged. Evidence suggests an aetiological role of risk factor exposures in early life and young adulthood. Since the mid-20th century, substantial multigenerational changes in the exposome have occurred (including changes in diet, lifestyle, obesity, environment and the microbiome, all of which might interact with genomic and/or genetic susceptibilities). However, the effects of individual exposures remain largely unknown. To study early-life exposures and their implications for multiple cancer types will require prospective cohort studies with dedicated biobanking and data collection technologies. Raising awareness among both the public and health-care professionals will also be critical. In this Review, we describe changes in the incidence of early-onset cancers globally and suggest measures that are likely to reduce the burden of cancers and other chronic non-communicable diseases.

Endometrial Cancer in Pre-Menopausal Women and Younger: Risk Factors and Outcome

Endometrial cancer is the sixth most common malignancy in women, and it is known to be a disease among postmenopausal women, but there is rising in the number of endometrial cancers among premenopausal women. This study aims to determine the clinical characteristic, risk factors, outcomes, and survival in pre and postmenopausal women with endometrial cancer in Malaysia. A retrospective study was conducted in Hospital Melaka that involved all women who were diagnosed with endometrial cancer in Hospital Melaka from January 2002 until July 2020. All subjects’ histopathological examination result was confirmed, and their clinical data were extracted and transferred into a standardized data checklist and analysed. A total number of 392 cases was obtained from the Annual Cancer Registry Hospital Melaka. However, only 281 cases were studied, including 44.8% premenopausal and 55.2% postmenopausal women. In the premenopausal group, there were higher incidence of obesity (30.8 + 8.6 vs. 28.9 + 7.1), younger age at menarche (12.7 + 1.5 vs. 13.3 + 1.6), lesser parity (1.47 vs. 3.26), and a higher number of nulliparous women (46.8% vs. 19.4%) as compared to postmenopausal group. The premenopausal group tends to be presented with a well-differentiated grading of tumour (52.4%) and a higher incidence of having concomitant endometrial hyperplasia (41.3%). The mean survival among the premenopausal group (200.3 + 7.9 months) is higher compared to postmenopausal group (153.9 + 6.5 months). These findings correlate with good survival and prognosis among the premenopausal group compared to the postmenopausal group.

Retreatment with progestin for recurrence after complete response with fertility-sparing treatment in patients with endometrial cancer

OBJECTIVE

To assess the outcomes of retreatment using progestin for recurrence after a complete response with fertility-sparing treatment in patients with early endometrial cancer.

METHODS

We retrospectively reviewed the data of patients with presumed stage IA, grade 1 endometrioid endometrial cancer who developed intra-uterine recurrence after a complete response with fertility-sparing treatment using progestin. Oncological and pregnancy outcomes were analyzed after repeated fertility-sparing treatment. Logistic and Cox regression analyses were performed to analyze the prognostic factors associated with a complete response with secondary fertility-sparing treatment and recurrence-free survival after secondary fertility-sparing treatment, respectively.

RESULTS

Fifty patients with a median age of 31 years (range 23-40) underwent secondary fertility-sparing treatment. With a median secondary progestin treatment duration of 9 months (range 3-55), the complete response rate was 78% (39/50) and no patients had extra-uterine spread of disease. Among the 26 (67%) patients who attempted to conceive after complete response, 10 became pregnant (3 spontaneous abortions, 7 live births). Eighteen (46.1%) patients had a second recurrence, with a median recurrence-free survival after secondary fertility-sparing treatment of 14 months (range 3-36); 15 patients received tertiary fertility-sparing treatment and nine (60%) achieved a complete response. Polycystic ovary on ultrasound (OR 5.82, 95% CI 1.1 to 30.6, p=0.037) was associated with an increased complete response rate with secondary fertility-sparing treatment. Multivariable analysis revealed that recurrence-free survival after initial hormonal treatment >6 months (HR 0.11, 95% CI 0.02 to 0.51, p=0.005) and pregnancy after secondary fertility-sparing treatment (HR 0.27, 95% CI 0.08 to 0.98; p=0.047) were significantly associated with longer recurrence-free survival after secondary fertility-sparing treatment.

CONCLUSIONS

Repeated progestin treatment was associated with a 78% response rate and it was safe in patients with intra-uterine recurrent endometrial cancer. Thus, it might help preserve fertility after first and second recurrences.

The Diagnostic value of Serum YKL-40 in Endometrial Cancer: a meta-analysis

BACKGROUND

Serum YKL-40 is a promising noninvasive biomarker for the early diagnosis of endometrial cancer (EC), but its value is disputed.

OBJECTIVE

To investigate the serum YKL-40 in the early diagnostic value of EC.

METHODS

Databases were systematically searched again before April 2021 and 14 studies were finally included in this meta-analysis. Pooled sensitivity, specificity, negative likelihood ratio (NLR), positive likelihood ratio (PLR), diagnostic odds ratio (DOR), and summary receiver operating characteristic (SROC) curve analyses were assessed. This meta-analysis investigated the source of heterogeneity using sensitivity analysis, subgroup analysis, and meta-regression.

RESULTS

Databases were systematically searched again before April 2021 and 14 studies were finally included in this meta-analysis. First, the SROC curve presented an area under the curve (AUC) of 0.853 (SE =0.0213) for YKL-40 alone and an AUC of 0.946 (SE =0.0268) for YKL-40 combined with other biomarkers. Second, diagnostic types might be related to the diagnostic accuracy and is a significant source of heterogeneity (P = 0.035).

CONCLUSION

Serum YKL-40 helped diagnose EC, and its combination with other biomarkers was better than itself alone.

Characterisation of Levonorgestrel-Resistant Endometrial Cancer Cells

Background

Endometrial cancer (EC) is the most common gynaecologic malignancy in the developed world, and incidence is increasing in premenopausal women. The levonorgestrel intrauterine system (LNG-IUS) is gaining traction as an alternative treatment for hyperplasia and early-stage EC for women who are unable to undergo surgery. Thirty to 60% of the women do not respond to this treatment, making the unknown mechanisms of levonorgestrel (LNG) resistance a critical obstacle for the conservative management of EC. This study aimed to characterise LNG-IUS treatment resistance in early-stage endometrial cancer in cell-line models.

Methods

LNG-resistant endometrial cancer cell lines (MFE296^R and MFE319^R) and cultures from three early stage endometrial cancer patients were developed. The behavioural profile of MFE296^R and MFE319^R was analysed using proliferation, adhesion, migration (wound healing and transwell) and invasion (spheroid) assays. LNG-sensitive cell lines (MFE296^S and MFE319^S) were compared to LNG^R cell lines (MFE296^R and MFE319^R). A literature search was conducted to identify possible candidate biomarkers of LNG resistance. RT-qPCR was used to analyse the mRNA expression of 17 candidate biomarkers in MFE296^R and MFE319^R. mRNA expression of the top differentially expressed genes was measured using RT-qPCR in primary cultures.

Results

LNG resistance did not affect proliferation or invasion in immortalised endometrial cancer cells. Transwell migration was significantly increased in MFE319^R cells (p=0.03). Cellular adhesion significantly decreased in both MFE296^R cells (p=0.012) and MFE319^R cells (p=0.04). mRNA expression of KLF4 and SATB2 was significantly amplified in MFE296^R and MFE319^R cells. mRNA expression of KLF4 was significantly upregulated LNG-resistant primary cell lines.

Conclusion

LNG-resistant cells may have more oncogenic potential than their LNG-sensitive counterparts. Significant changes in the mRNA expression of KLF4 and SATB2 of LNG-resistant cells is a promising preliminary result in biomarker discovery for guiding LNG-IUS treatment of early stage endometrial cancer.

Identification of risk factors for the prognosis of Chinese patients with endometrial carcinoma

This study aimed to retrospectively analyze risk factors for the prognosis of Chinese patients with endometrial carcinoma.Total 600 patients who were admitted to the Department of Gynecology, the Fourth Hospital of Hebei Medical University and were pathologically diagnosed as endometrial carcinoma after surgery from January 1, 1997 to December 31, 2006 were selected, and the related factors affecting their prognosis were analyzed.The survival of 600 patients with endometrial carcinoma was 2 to 136.5 months (average survival 57.39 ± 33.55 months), and 109 cases (18.2%) died from endometrial cancer. The overall survival rate of 1, 3, and 5 years after surgery was 96.8%, 89.9%, and 82.1%, respectively. Univariate analysis showed that age, menopausal status, pathological type, histological grade, pathological staging, tumor size, myometrial invasion, cervical involvement, ovarian metastasis, lymph node metastasis, and treatment method were the factors affecting the prognosis of endometrial carcinoma. Multivariate regression analysis showed that pathological type, histological grade, pathological staging, and cervical involvement were independent risk factors for the prognosis of endometrial carcinoma. The patients with high-grade and deep myometrial invasion, cervical involvement, full cavity tumor, and lymph node metastasis had a high incidence of ovarian metastasis.Pathological type, histological grade, pathological staging, and cervical involvement are independent risk factors affecting the prognosis of Chinese patients with endometrial carcinoma.

Increased risk of second primary malignancies among endometrial cancer survivors receiving surgery alone: A population-based analysis

Background

Women with endometrial cancer (EC) have favorable prognoses, leaving them vulnerable to the development of second primary cancers (SPCs). We investigated the SPC risk and survival outcomes among EC patients treated with surgery alone in order to exclude the impact of adjuvant treatment on the results.

Methods

Data from the Taiwan Cancer Registry from 1995 to 2013 were analyzed. Standardized incidence ratios (SIRs) of SPCs among EC survivors were calculated.

Results

Among 7725 women enrolled, 478 developed an SPC. The overall SIR for SPCs in EC survivors was 2.84 (95% confidence interval [CI] 2.59–3.10) compared with the general female population. Women diagnosed with EC at age <50 years had a higher SIR for an SPC than those diagnosed at age ≥50 years (SIR = 4.38 vs. 1.28). The most frequent site of an SPC was the small intestine (SIR = 8.39, 95% CI 2.72–19.58), followed by the kidney (SIR = 4.84, 95% CI 1.78–10.54), and oral cavity (SIR = 4.52, 95% CI 2.17–8.31). Women, regardless of age at EC diagnosis, had significantly higher SIRs for subsequent breast, colorectal, lung, and thyroid cancer, and lymphoma. Women with an SPC had shorter overall survival than those without (5‐year: 88.9 vs. 94.2%, 10‐year: 71.3 vs. 89.8%, 15‐year: 62.3 vs. 86.1%, and 20‐year: 47.6 vs. 81.1%, all ps<0.001).

Conclusions

Even women treated for EC with surgery alone, especially young EC survivors, had an increased risk of SPCs. Genetic counseling/testing is recommended for young EC patients, and all are recommended to receive regular surveillance and screening for breast, colorectal, and lung cancers.

Analysis of pregnancy-associated factors after fertility-sparing therapy in young women with early stage endometrial cancer or atypical endometrial hyperplasia

BACKGROUND

Fertility-sparing therapy is an alternative conservative treatment for patients with early stage endometrioid cancer or atypical endometrial hyperplasia. In this study, we investigated pregnancy outcomes and pregnancy-associated factors in young patients receiving hormonal therapy.

METHODS

We retrospectively analyzed 68 patients who attempted to conceive after fertility-sparing therapy and achieving complete remission (CR). They were divided into a pregnancy group and a non-pregnancy group. A Cox proportional hazard regression model was applied for univariate and multivariate analysis to determine factors associated with pregnancy. Kaplan-Meier analysis, combined with the log-rank test, was used to calculate a patient's pregnancy probability and the distribution of recurrence-free survival (RFS).

RESULTS

A total of 36 patients became pregnant with 47 pregnancies. Univariate and multivariate Cox analysis revealed that several factors were associated with pregnancy, including BMI at the time of pregnancy permission, the time to CR, prolonged treatment time, the number of hysteroscopy procedures, the endometrium thickness after CR, and relapse before pregnancy. The mean RFS of patients who achieved pregnancy, and those who did not, was 27.6 months and 14.8 months, respectively (P = 0.002). No significant difference was detected in terms of cumulative RFS when compared between assisted reproductive technology (ART) cases and those involving natural conception (NC) (P = 0.707).

CONCLUSIONS

Normal BMI, a shorter time to CR, a prolonged three-month treatment, fewer hysteroscopy procedures, and a thicker endometrium may be positive indicators for successful pregnancies, while relapse before pregnancy may have a negative effect on conception. Moreover, a successful pregnancy protects the endometrium while ART does not increase the risk of recurrence.

An ecological evaluation of the increasing incidence of endometrial cancer and the obesity epidemic

BACKGROUND

The prevalence of obesity has increased significantly in recent decades, particularly among younger women, and is a known risk factor for endometrial cancer.

OBJECTIVE

This study aimed to evaluate the trend in the prevalence of obesity and the incidence of type I endometrial cancer over time in various age categories to determine whether an ecological relationship exists.

STUDY DESIGN

Data from the Surveillance, Epidemiology, and End Results Program and the National Health and Nutrition Examination Survey were used. The overall trend in the incidence of type 1 endometrial cancer and prevalence of obesity were observed over time from 1988 to 2016 and further categorized by age group (<45, 45-54, and ≥55 years).

RESULTS

The prevalence of obesity has increased for all women, but most significantly for women younger than 45 years with a 16.3% increase among women aged 20 to 34 years and a 17.9% increase for women aged 35 to 44 years. The incidence of endometrial cancer has also increased across all age categories, and although it has increased in patients younger than 45 years by more than 14-fold (from <0.1 per 100,000 in 1988 to 1.4 per 100,000 in 2016), a more pronounced increase of 63-fold and 50-fold was observed among women aged 45 to 54 years (0.2 per 100,000 in 1988 to 12.6 per 100,000 in 2016) and women aged 55 years and older (from 0.6 per 100,000 in 1988 to 30 per 100,000 in 2016), respectively. The mean age of women diagnosed as having endometrial cancer also decreased from 64.1 years from 1988 to 1990 to 61.0 years from 2014 to 2016.

CONCLUSION

The prevalence of obesity has increased significantly in women of all ages. This increase, particularly among women aged <45 years, occurred simultaneously with an increase in the incidence of endometrial cancer in young women, with an even more pronounced increase among women aged ≥45 years.

Detection of microRNA in urine to identify patients with endometrial cancer: a feasibility study

OBJECTIVE

To find dysregulated urinary microRNAs associated with endometrial cancer as a first step in finding a non-invasive new diagnostic biomarker. The second objective is to determine the correlation of urinary microRNAs with clinicopathological characteristics.

METHODS

A prospective cohort study of patients presenting with abnormal bleeding between March and November 2019 was performed at the Royal Cornwall Hospital Trust Truro. Urine samples were obtained from women diagnosed with endometrial cancer and benign endometrial sampling. MicroRNA was isolated and quantitative real time PCR was used to detect expression levels of microRNAs.

RESULTS

A total of 61 women were included in this study: 24 endometrial cancer patients, and 37 controls. Median age was 64 years (range 45-94) and median body mass index was 29 kg/m² (range 17-54). MiR-223 was significantly up-regulated in urine of endometrial cancers patients (p=0.003). Furthermore, let7-i, miR-34a, and miR-200c were significantly down-regulated and miR-424 was up-regulated in obese women. In addition, miR-148a and miR-222 were significantly down-regulated in elderly women, and miR-16, miR-26b, and miR-200c were significantly deregulated in women with multiple comorbidities.

CONCLUSION

MicroRNA expression levels in urine can potentially be used as a non-invasive diagnostic test for endometrial cancer. Furthermore, aberrant microRNA expression in urine is associated with patient characteristics. Further research in larger trials is needed to validate the potential utility of urinary microRNAs.

Fertility preservation in early-stage endometrial cancer and endometrial intraepithelial neoplasia: A single-center experience

OBJECTIVE

The purpose of this study was to define the pregnancy and oncologic outcomes after fertility-sparing treatment of atypical hyperplasia (AH)/endometrial intraepithelial neoplasia (EIN) and early-stage endometrioid endometrial cancer (EEC).

MATERIALS AND METHODS

The retrospective cohort study included patients who had applied to Başkent University's Ankara Hospital between January 2007 and October 2018 with either AH/EIN (n: 27; Group A) or EEC (n: 30; Group B), and who had the desire to preserve their fertility. The medical records of all patients included in the study were reviewed retrospectively from the hospital records.

RESULTS

There were 2 (7.4%) and 5 (16.7%) recurrences, whereby one patient from Group A and two patients from Group B underwent staging surgery. In Group A, 8 patients attempted pregnancy after their treatment and 4 of them (50%) became pregnant, while 3 of them (37.5%) had a live birth. In Group B, there were 17 patients who wanted to become pregnant following treatment of the disease; 8 of them (47%) became pregnant after treatment, 5 of them (16.6%) had a live birth, 1 experienced intrauterine exitus (at 21st gestational week, 350 g), and 2 currently have ongoing pregnancies.

CONCLUSION

Hysteroscopic resection of visible lesions and full endometrial curettage prior to hormonal therapy as a fertility-preserving approach for women of reproductive age with endometrial malignancies can achieve promising oncologic and obstetric responses.

The role of sarcopenic obesity in high-grade endometrial cancer

OBJECTIVE

To investigate the relationship between obesity and sarcopenia in relation to overall survival (OS) and disease-specific survival (DSS) in high-grade endometrial cancer patients.

METHODS

We conducted a retrospective study in women diagnosed with high-grade endometrial cancer (EC) between February 2006 and August 2017 in the Royal Cornwall Hospital who had abdominal computerized tomography (CT)-scan as part of routine staging work-up. Sarcopenia was assessed by measuring psoas-, paraspinal- and abdominal wall muscles on CT and defined by skeletal muscle index ≤41 cm² /m² . Sarcopenic obesity was defined as sarcopenia combined with body mass index (BMI) ≥30 kg/m² .

RESULTS

A total of 176 patients with median age of 70 years and median BMI of 29.4 kg/m² were included in the study. The majority of patients (38%) had endometrioid type histology. Sarcopenia was not associated with OS (P = 0.951) or DSS (P = 0.545) However, in multivariate analysis, sarcopenic obesity was associated with reduced OS in endometrioid endometrial cancer (EEC) patients (P = 0.048).

CONCLUSION

Sarcopenic obesity is associated with OS in high-grade EEC patients, while sarcopenia without obesity is not related to OS or DSS in high-grade EC. In non-endometrioid endometrial cancer, there is no association between sarcopenic obesity and survival.

The effect of frailty on postoperative readmissions, morbidity, and mortality in endometrial cancer surgery

OBJECTIVES

To determine the impact of frailty on postoperative readmission, morbidity, and mortality among patients undergoing surgery for endometrial cancer.

METHODS

Patients with endometrial cancer undergoing hysterectomy between 2010 and 2014 were identified using the Nationwide Readmissions Database. Frailty was classified using criteria outlined by the Johns Hopkins Adjusted Clinical Groups Frailty Diagnoses Indicators. Primary outcomes were divided by index surgical admission (intensive level of care, mortality, non-routine discharge), 30-days (readmission and mortality), and 90-days (readmission and mortality) after discharge. Multivariable log linear regression models were fit to analyze the effect of frailty on these outcomes, adjusting for patient, hospital, and clinical factors.

RESULTS

From 2010 to 2014, there were 144,809 surgical endometrial cancer cases with a 1.8% frailty rate. Frailty was associated with an increased risk of intensive level of care (aRR = 3.61, 95% CI: 2.95, 4.42), non-routine discharge (aRR = 1.59, 95% CI: 1.51, 1.68), and inpatient mortality (aRR = 2.05, 95% CI: 1.68, 2.51) during index admission. Frail patients were more likely to be readmitted within 30 days (RR 1.33, 95% CI 1.22-1.47) and 90-days (RR 1.21, 95% CI 1.12, 1.32), and were at increased risk of mortality during their 30-day readmission (aRR = 1.75, 95% CI: 1.28-2.39). Frailty was not associated with 90-day mortality. Hospitalization costs for frail patients were significantly higher than for non-frail patients during index admission and readmissions within 30 and 90 days (p < 0.05 for all).

CONCLUSIONS

Frailty affects postoperative outcomes in endometrial cancer patients and is associated with an increased rate of readmission and 30-day mortality among those who are readmitted. Gynecologic cancer providers should screen for frailty and consider outcomes in frail patients when counseling them for surgery.

Comparison between Different Diagnostic Strategies in Low-Risk Reproductive Age and Pre-Menopausal Women Presenting Abnormal Uterine Bleeding

Abnormal uterine bleeding (AUB) is a common symptom in the female population, with an estimated prevalence of 10 to 30% in fertile age and up to 90% in perimenopausal women. In most cases, AUB is due to a benign cause. However, it can also be a symptom of atypical endometrial hyperplasia or endometrial cancer, a more common disease during menopause which can also affect women in their reproductive age. Considering the high prevalence of this symptom an appropriate diagnostic algorithm is needed. Concerns about the risks, pain, and stress associated with an endometrial biopsy and its impact on the healthcare system make the choice of AUB diagnostic strategy extremely relevant. Even if the scientific community agrees on the definition of AUB, International Guidelines show some differences in the management of women of reproductive age with AUB, especially regarding the age cut-off as an independent indication for endometrial biopsy. This study compared different diagnostic strategies to identify a diagnostic pathway with high sensitivity and specificity but low impact on the health system's resources. The analysis was based on three diagnostic algorithms defined as part of the guidelines of leading scientific societies. Women of reproductive age with AUB (n = 625) and without risk of endometrial cancer were included in the study. Results showed that the best criterion to investigate AUB in women at low risk of endometrial cancer is not age cut-off but the presence or absence of focal endometrial pathology at the ultrasound and the response to the progestin therapy. This approach makes it possible to perform fewer outpatient hysteroscopic biopsies without excluding positive cases from the examination.

Endometrial cancer combined with polycystic ovary syndrome in 9 women under 40-years old: A case report

The aim of the present study was to discuss the clinicopathological characteristics of endometrial carcinoma in young females with polycystic ovary syndrome (PCOS), and to review the current literature. A total of 9 patients with histopathologically confirmed endometrial cancer in young females with PCOS at the West China Second Hospital of Sichuan University between December 2007 and September 2013 were included. The clinicopathological characteristics of the patients were analyzed. The age range of the patients was 24-38 years (median age, 29), all of the cases had abnormal vaginal bleeding and endometrioid adenocarcinoma was the most common histopathological subtype observed (8 cases, 88.9%). Of the patients, 2 had well-differentiated cases and 7 patients had moderately differentiated cases. None of the patients received regular PCOS treatments and did not turn up for regular check-ups before they were diagnosed with endometrial carcinoma. Additionally, 7 patients received staging laparotomy with a total abdominal hysterectomy and bilateral salpingo-oophorectomy, 1 patient underwent an endometrial resection under hysteroscopy and the final patient received a high-dose of medroxyprogesterone treatment without surgery. In conclusion, doctors should take into consideration that young women with PCOS may also exhibit an endometrial carcinoma, and diagnosing and treating the endometrial carcinoma as early as possible in the young patients with PCOS is necessary.

Polycystic Ovary Syndrome: Menopause and Malignancy

Polycystic ovary syndrome (PCOS) has been extensively studied in reproductive-aged women. However, accumulating research shows that PCOS can have lifelong effects on multiple aspects of women's health. PCOS can affect the onset and course of menopause and cardiovascular health in perimenopausal and postmenopausal patients. Moreover, PCOS may increase a woman's risk for both gynecologic and nongynecologic malignancies. When treating older PCOS patients, physicians should be cognizant of the syndrome's long-term effects and consider the unique needs of these women.

Endometrial cancer in young women: prognostic factors and treatment outcomes in women aged ≤40 years

OBJECTIVE

Endometrial cancer in pre-menopausal patients aged ≤40 years is rare and poses both diagnostic and management challenges. The goal of this study was to investigate the clinical and pathologic factors associated with endometrial cancer in this group and their impact on survival.

METHODS

Patients with endometrial cancer treated between January 2004 and August 2016 were retrospectively reviewed. Patients who underwent either primary surgical treatment or fertility-sparing therapy were included. Exclusion criteria were age >60 years and patients who received neoadjuvant chemotherapy or primary radiation. Age at diagnosis was used to classify patients into two groups: ≤40 and 41-60 years. Clinical and pathologic variables were compared between the groups. Progression-free survival and overall survival were estimated using Cox proportional hazards.

RESULTS

A total of 551 patients were evaluated, of which 103 (18.7%) patients were ≤40 years and 448 (81.3%) were 41-60 years. Age ≤40 years was associated with higher body mass index (38.8 vs 35.8 kg/m², p=0.008), non-invasive cancers (54.2% vs 32.6%, p<0.001), lower uterine segment involvement (27.2% vs 22.5%, p<0.001), and less lymphovascular space invasion (16.8% vs 29.1%, p=0.015). The rate of synchronous ovarian cancer was 9.2% vs 0.7% in age 41-60 years (p<0.001), and 19% of women with endometrial cancer aged ≤40 years underwent fertility-sparing therapy. Grade, stage, myometrial invasion, lymphovascular space invasion, and lymph node status were associated with survival, and fertility-sparing therapy adversely affected the recurrence rate of the age ≤40 years cohort. Among all patients aged ≤60 years, mismatch repair deficiency due to MLH1 methylation was associated with worse progression-free survival, 48.6% vs 83.3% (HR 1.98, 95% CI 1.06 to 3.17, p=0.032), and overall survival, 56.5% vs 90.0% (HR 2.58, 95% CI 1.13 to 5.90, p=0.025).

CONCLUSIONS

Patients aged ≤40 years with endometrial cancer have more favorable prognostic factors and higher rates of synchronous tumors. Fertility-sparing therapy was associated with higher recurrence rates. The prognostic value of MLH1 methylation in this population warrants further investigation.

Baseline Serum HE4 But Not Tissue HE4 Expression Predicts Response to the Levonorgestrel-Releasing Intrauterine System in Atypical Hyperplasia and Early Stage Endometrial Cancer

The levonorgestrel-releasing intrauterine system (LNG-IUS) is a conservative management option for atypical hyperplasia (AH) and low grade early stage endometrial cancer (EEC), but around 1 in 3 patients fail to respond to treatment. The aim of this study was to investigate if serum and/or tissue HE4 expression could predict response to LNG-IUS therapy. Patients with AH or presumed Stage I EEC had serum and endometrial samples taken at baseline and at 3-month intervals over 12 months post-insertion of LNG-IUS. 74 patients were recruited and baseline demographics recorded. Of 57 patients for whom response was histologically determinable, 39 (68%) were responders and 18 (32%) non-responders. Mean baseline serum HE4 was significantly lower in responders (62.1 ± 1.1 pM, 95% confidence interval (CI) 52.7–73.2), compared to non-responders (125.6 ± 1.3 pM, 95% CI 74.5–211.7, p = 0.014), including when considering age, BMI, menopausal status, smoking status, and histological grade as covariables (p = 0.005). Baseline tissue HE4 expression was not significantly different in responders compared to non-responders (p = 0.999). Responders showed a significant mean reduction (−9.8 ± 3.4%, 95% CI −16.7 to −2.8%, p = 0.008) in serum HE4 between baseline and 3 months (p = 0.008), whereas non-responders showed no significant change (p = 0.676). Neither responders nor non-responders showed a significant percentage change in serum HE4 from baseline beyond 3 months (p > 0.05). Change in serum HE4 between baseline and 3 and 6 months and tissue HE4 tissue expression between baseline and 3, 6, and 12 months was not significantly different in responders compared to non-responders (p > 0.05). This study suggests that baseline serum HE4, but not baseline tissue HE4 expression, is independently predictive of response to the LNG-IUS and could be used to guide management decisions.

The relationship between KRAS LCS6 polymorphism and endometrium cancer

The aim of this study was to investigate the relationship between KRAS LCS6 mutation and endometrial cancer (EC). The study included 105 patients who had hysterectomy for benign reasons and 99 EC patients. The patients with Type 1 EC were classified according to histological properties, cancer stage, grade, tumour dimension, myometrial invasion (MMI), lymphovascular invasion (LVI), cytology, and number of positive lymph nodes. KRAS LCS6 mutation was examined in blood samples taken from all patients in both groups. No statistically significant difference was determined between the EC patients and the control group in demographic features. Weight and the Body Mass Index (BMI) values were higher in EC group (p < .001). While the incidence of this polymorphism is 5.8% throughout the world, the polymorphism rate was found to be 16.2% in the EC group and 12.4% in the control group, with no statistically significant difference determined (p > .05). Despite the higher rate of LCS6 polymorphism incidence in EC patients in this study conducted on a relatively large sample, there was not found to be a statistically significant difference in comparison with the control group. In addition, the presence of LCS6 polymorphism was not determined to have an effect on EC histopathological characteristics.Impact statementWhat is already known on this subject? Endometrial cancer (EC) is a genital system cancer which is one of the most widespread gynecological cancers seen in the USA and other developed countries, In EC, the most frequently seen gene mutations are PTEN tumour suppressor gene, KRAS, β1 catenin, BCL-2, CTNNB and P53 mutations. KRAS LCS6(let-7 miRNA binding region polymorphism) polymorphism has a worldwide incidence of 5.8% (Chin et al. 2008).There are studies shown that KRAS LCS6 polymorphism has an effect on developing EC (Lee et al. 2014), ovarian cancer(Ratner et al. 2010)and endometriosis in women (Grechukhina et al. 2012).What do the results of this study add? In our study, LCS6 located on KRAS 3'-UTR was found at the rate of 16.2% in Type 1 EC patients. This increase is noticeable when it is considered that the incidence of this polymorphism is 5.8% in the general population. The results of the current study supports the preliminary findings of Lee et al.What are the implications of these findings for clinical practice and/or further research? These new genetic markers could help to develop gene-targeted therapies, identify genetic basis of the disease and the factors that could affect the EC prognosis.

Multi-omics profiling reveals distinct microenvironment characterization of endometrial cancer

Endometrial cancer is a heterogeneous disease with distinct molecular characteristics, however, the current clinical trials in immunotherapies have reported only a 13% response rate in endometrial cancer. In this study, we aim to estimate the relative abundance of immune cells infiltrating into the tumor tissues. The samples were clustered based on the immune cell abundance. Most of cluster-specifically mutated genes were detected in clusters I and II, while the copy number alterations were specifically detected in cluster III. Overrepresentation enrichment analysis (ORA) of the genes specifically upregulated in a specific cluster revealed that the immune-related pathways were enriched by the genes in cluster I. Moreover, immune checkpoint proteins and immune co-stimulators were also observed to be highly expressed in cluster I. In addition, we also built a multivariable Cox regression model based on the immune checkpoint genes and co-stimulators. The high-risk and low-risk groups stratified by the risk scores of the Cox model exhibited significant prognostic difference in both training and validation datasets. In summary, the systematic analysis greatly improves our understanding of the immunophenotype of endometrial cancer and its association with biomarkers and prognosis.

A calcium-dependent phospholipase A2 (cPLA2) expression is regulated by MIG-6 during endometrial tumorigenesis

The ovarian steroid hormones, estrogen (E2) and progesterone (P4), are essential regulators of uterine biology. The imbalance of these ovarian steroid hormones leads to uterine diseases such as endometrial cancer, endometriosis, and infertility. Mitogen-inducible gene 6 (MIG-6) is an adaptor protein. MIG-6 mediates P4 signaling and acts as a tumor suppressor during endometrial tumorigenesis in both humans and mice. In previous studies, we developed the conditional knockout of Mig-6 in all uterine compartments (Pgr^cre/+Mig-6^f/f; Mig-6^KO) and endometrial epithelial cell-specific Mig-6 knockout (Sprr2f^cre/+Mig-6^f/f; Mig-6^Ep-KO) mice. Both mouse models developed endometrial hyperplasia and E2-dependent endometrial cancer. P4 treatment significantly decreases aberrant epithelial proliferation and AKT signaling in Mig-6^Ep-KO mice but not in Mig-6^KO mice. In the present study, we identified a calcium-dependent phospholipase A2 (cPla2) as one of the genes down-regulated by Mig-6 in the uterus. We performed immunohistochemistry and Western Blot analysis to investigate the regulation of cPLA2 by MIG-6 as well as determine the expression patterns of cPLA2 in the uterus. While the expression of cPLA2 was stronger at the uterine epithelial cells of Mig-6^KO and Mig-6^Ep-KO mice compared to control mice, P4 suppressed the expression of cPLA2 in Mig-6^Ep-KO mice but not in Mig-6^KO mice. To determine the ovarian steroid hormone regulation of cPLA2, we examined the expression of cPLA2 in ovariectomized control, Mig-6^KO, Mig-6^Ep-KO, and PRKO mice treated with P4 or E2. After P4 treatment, cPLA2 expression was remarkably reduced in Mig-6^Ep-KO mice but not in Mig-6^KO mice. However, the expression of cPLA2 was not changed in PRKO mice. Our results identified cPLA2 as a novel target of MIG-6 in the murine uterus and identified its important role during endometrial tumorigenesis.

The role of biomarkers in endometrial cancer and hyperplasia: a literature review

INTRODUCTION

Endometrial cancer is the most common gynaecological cancer and its incidence is rising due to increasing obesity rates. We are also seeing an increasing trend of young women diagnosed with either endometrial cancer or its precancerous state, endometrial hyperplasia. Diagnosis is dependent on invasive testing and there is no screening tool available for either general or high-risk population groups. Whilst vast amounts of research have been undertaken in higher-profile cancers such as ovarian and cervical, endometrial cancer is comparatively less investigated.

AIM

In this literature review, we summarise the existing literature in understanding the role of tumour biomarkers for endometrial cancer and its preceding condition of endometrial hyperplasia.

METHOD

NICE Healthcare Databases Search tool was used to search Embase, Medline and PubMed databases for relevant articles.

CONCLUSION

There is currently no routinely used biomarker in endometrial cancer for diagnostic or prognostic purposes. Given the establishment of new genomic classifications of endometrial cancers, the use of biomarkers to drive therapeutic approaches will be the cornerstone for individualised cancer care in the coming decades.

MIG-6 suppresses endometrial epithelial cell proliferation by inhibiting phospho-AKT

Background

Aberrant hyperactivation of epithelial proliferation, AKT signaling, and association with unopposed estrogen (E2) exposure is the most common endometrial cancer dysfunction. In the normal uterus, progesterone (P4) inhibits proliferation by coordinating stromal-epithelial cross-talk, which we previously showed is mediated by the function of Mitogen-inducible gene 6 (Mig-6). Despite their attractive characteristics, non-surgical conservative therapies based on progesterone alone have not been universally successful. One barrier to this success has been the lack of understanding of the P4 effect on endometrial cells.

Method

To further understand the role of Mig-6 and P4 in controlling uterine proliferation, we developed a Sprr2f-cre driven mouse model where Mig-6 is specifically ablated only in the epithelial cells of the uterus (Sprr2f^cre+Mig-6^f/f). We examined P4 effect and regulation of AKT signaling in the endometrium of mutant mice.

Results

Sprr2f^cre+Mig-6^f/f mice developed endometrial hyperplasia. P4 treatment abated the development of endometrial hyperplasia and restored morphological and histological characteristics of the uterus. P4 treatment reduced cell proliferation which was accompanied by decreased AKT signaling and the restoration of stromal PGR and ESR1 expression. Furthermore, our in vitro studies revealed an inhibitory effect of MIG-6 on AKT phosphorylation as well as MIG-6 and AKT protein interactions.

Conclusions

These data suggest that endometrial epithelial cell proliferation is regulated by P4 mediated Mig-6 inhibition of AKT phosphorylation, uncovering new mechanisms of P4 action. This information may help guide more effective non-surgical interventions in the future.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4502-7) contains supplementary material, which is available to authorized users.

Racial disparities in young women with endometrial cancer

OBJECTIVE

Although racial disparities in treatment and outcome for endometrial cancer are well recognized, little work has explored disparities in young women. We performed a population-based analysis to compare survival between black and white women with endometrial cancer at <50years of age.

METHODS

We used the National Cancer Data Base to identify women <50years of age with endometrial cancer from 1998 to 2012. Clinical and demographic characteristics were compared between black and white women and survival by race analyzed using Kaplan-Meier curves and multivariable Cox proportional hazards models.

RESULTS

We identified a total of 35,850 women <50years of age including 31,947 (89.1%) white and 3903 (10.9%) black patients. Black women were more likely to have advanced stage, poorly differentiated, and non-endometrioid histology neoplasms (P<0.05 for all). In a multivariable model, survival was 19% worse for black patients than white patients (HR=1.19; 95% CI, 1.08-1.32). A similar effect was seen when limited to women with early-stage tumors (HR=1.24; 95% CI, 1.04-1.49), while among patients with advanced stage tumors, no association between race and survival was seen (HR=1.12; 95% CI, 0.89-1.41). Five-year survival rates were 90.6% (95% CI, 88.6-92.3%) for white and 81.5% (95% CI, 73.0-87.5%) for black women with stage IB tumors, and 75.1% (95% CI, 72.5-77.5%) and 63.3% (95% CI, 54.1-71.2%) for white and black women with stage III tumors, respectively.

CONCLUSIONS

Young black women are more likely to present with pathologically aggressive, advanced stage tumors. Even after adjusting for these pathologic differences, young black women with endometrial cancer have higher mortality than white women.

Analysis of endometrial carcinoma in young women at a high-volume cancer center

OBJECTIVE

To investigate the clinicopathological characteristics, treatment, survival, and prognosis of endometrial cancer in women aged ≤40 years.

METHODS

Women who underwent surgery for endometrial cancer at a single high-volume cancer center between January 1995 and December 2014 were retrospectively reviewed. Women aged >40, patients with missing data, and those who did not undergo surgical staging were excluded. Univariate and multivariate regression models were used to identify the risk factors for overall survival and progression-free survival.

RESULTS

A total of 40 patients with endometrial cancer were assessed. The median age at diagnosis was 38 (range, 21-40) years, and most of the uterine tumors found were early-stage (85%), low-grade (67.5%), and endometrioid carcinomas (97.5%). The median serum cancer antigen 125 level was 10.9 IU/mL (range, 3-1284 IU/mL). Optimal cytoreductive surgery was achieved in 35 patients (87.5%). All patients underwent total abdominal hysterectomy, and 97.5% of the patients underwent hysterectomy plus bilateral salpingo-oophorectomy. Among the total group of 40 patients, 21 (52.5%) underwent pelvic and para-aortic lymph node dissection, and 15 (37.5%) underwent only pelvic lymph node dissection. Multivariate analysis confirmed that a cancer antigen 125 level ≥35 was the only independent prognostic factor for both progression-free survival (hazard ratio, 22.997; 95% confidence interval, 1.783-296.536; p = 0.016) and overall survival (hazard ratio, 22.541; 95% confidence interval, 1.75-290.364; p = 0,017).

CONCLUSIONS

Our study demonstrated that a cancer antigen 125 level ≥ 35 is the only independent prognostic factor for both progression-free survival and overall survival in patients aged ≤40 years with endometrial cancer.

Current strategies in the diagnosis of endometrial cancer

PURPOSE

Endometrial cancer is the most common gynecological malignancy in developed countries. There are no uniform recommendations for endometrial cancer screening in the general population. Therefore, it is of paramount importance that the primary physician profoundly understands, and is familiar with the methods for prevention and early detection of endometrial cancer. The aim of this review is to provide the primary physician with a toolbox to reach these goals.

METHODS

We performed a systemic review to summarize the current strategies to diagnose and prevent endometrial cancer. Many published articles from the last years were identified and included.

RESULTS

A systematic review that summarizes the important subjects in the diagnosis and prevention of endometrial cancer.

CONCLUSION

Maintaining a high index of suspicion and obtaining endometrial biopsies from all suspected patients is the key for achieving a timely diagnosis.

Combined Oral Medroxyprogesterone/Levonorgestrel-Intrauterine System Treatment for Women With Grade 2 Stage IA Endometrial Cancer

Objective

The aim of this study was to evaluate the oncologic and pregnancy outcomes of combined oral medroxyprogesterone acetate (MPA)/levonorgestrel-intrauterine system (LNG-IUS) treatment in young women with grade 2–differentiated stage IA endometrial adenocarcinoma who wish to preserve fertility.

Methods

We retrospectively reviewed the medical records of patients with grade 2 stage IA endometrial adenocarcinoma who had received fertility-sparing treatment at CHA Gangnam Medical Center between 2011 and 2015. All of the patients were treated with combined oral MPA (500 mg/d)/LNG-IUS, and follow-up dilatation and curettage were performed every 3 months.

Results

A total of 5 patients were included in the study. The mean age was 30.4 ± 5.3 years (range, 25–39 years). After a mean treatment duration of 11.0 ± 6.2 months (range, 6–18 months), complete response (CR) was shown in 3 of the 5 patients, with partial response (PR) in the other 2 patients. One case of recurrence was reported 14 months after achieving CR. This patient was treated again with combined oral MPA/LNG-IUS and achieved CR by 6 months. The average follow-up period was 44.4 ± 26.2 months (range, 12–71 months). There were no cases of progressive disease. No treatment-related complications arose.

Conclusions

Combined oral MPA/LNG-IUS treatment is considered to be a reasonably effective fertility-sparing treatment of grade 2 stage IA endometrial cancer. Although our results are encouraging, it is preliminary and should be considered with experienced oncologists in well-defined protocol and with close follow-up.

Survival endpoints for young women with early stage uterine endometrioid carcinoma: a matched analysis

OBJECTIVES

Younger age is thought to be a favorable prognostic factor in women with endometrial carcinoma (EC). Survival endpoints were compared between two matched groups of patients with early stage EC: women 45 years or younger and women older than 45 years.

METHODS AND MATERIALS

Two matched groups of patients were created based on stage, grade, lymph node dissection and adjuvant management. Recurrence-free (RFS), disease-specific (DSS) and overall survival (OS) were calculated.

RESULTS

A total of 525 patients (88 younger patients and 437 older patients, matched 1:5) were included in this study. The two groups were well balanced except for less myometrial invasion in the younger patients. There were no significant differences between younger and older patients in regards to 5-year RFS (94% vs. 91%, p=0.6902). Similarly, there was no significant difference in regards to DSS (96% vs. 97%, p=0.9000). While 5-year OS was similar for both groups (89% vs. 89%, p=0.9942), 10-year OS was longer in the younger group (83% vs. 68% with p=0.13). On multivariate analysis for RFS, the presence of lymphovascular space invasion was the only predictor of shorter RFS (p=0.0007). Tumor grade (p=0.0002) and lower uterine segment involvement (p=0.0141) were independent predictors of shorter DSS. Older age (p<0.001) and stage II (p=0.01) were the only predictors of shorter OS.

CONCLUSIONS

When matched based on tumor stage, grade and adjuvant management, our study suggests that there is no difference in survival endpoints between younger and older patients with early stage endometrial carcinoma.

Association between differential gene expression and body mass index among endometrial cancers from The Cancer Genome Atlas Project

OBJECTIVE

The Cancer Genome Atlas (TCGA) identified four integrated clusters for endometrial cancer (EC): POLE, MSI, CNL and CNH. We evaluated differences in gene expression profiles of obese and non-obese women with EC and examined the association of body mass index (BMI) within the clusters identified in TCGA.

METHODS

TCGA RNAseq data was used to identify genes related to increasing BMI among ECs. The POLE, MSI and CNL clusters were composed mostly of endometrioid EC. Patient BMI was compared between these three clusters with one-way ANOVA. Association between gene expression and BMI was also assessed while adjusting for confounding effects of potential confounding factors. p-Values testing the association between gene expression and BMI were adjusted for multiple hypothesis testing over the 20,531 genes considered.

RESULTS

Mean BMI was statistically different between the ECs in the CNL (35.8) versus POLE (29.8) cluster (p=0.006) and approached significance for the MSI (33.0) versus CNL (35.8) cluster (p=0.05). 181 genes were significantly up- or down-regulated with increasing BMI in endometrioid EC (q-value<0.01), including LPL, IRS-1, IGFBP4, IGFBP7 and the progesterone receptor. DAVID functional annotation analysis revealed significant enrichment in "cell cycle" (adjusted p-value=1.5E-5) and "DNA metabolic processes" (adjusted p-value=1E-3) for the identified genes.

CONCLUSIONS

Obesity related genes were found to be upregulated with increasing BMI among endometrioid ECs. Patients with POLE tumors have the lowest median BMI when compared to MSI and CNL. Given the heterogeneity among endometrioid EC, consideration should be given to abandoning the Type I and II classification of EC tumors.

Clinicopathological features and survival in young Taiwanese women with endometrial carcinoma

OBJECTIVE

The aim of this study is to compare the clinicopathological features and survival of young women with endometrial cancer (aged <50 years) with those of older women with endometrial cancer (aged ≥50 years).

METHODS

We conducted a retrospective cohort study of patients with histologically confirmed endometrial cancer treated at the Taipei Veterans General Hospital from 2001 to 2010.

RESULTS

One hundred forty-six patients (28.5%) were aged younger than 50 years at diagnosis. The median follow-up was 36.5 months (range, 0.9-121.7 months). Low body mass index (P < 0.001), nulliparity (P < 0.001), less medical illness (P < 0.001), synchronous primary ovarian cancer (P = 0.001), endometrioid type (P = 0.005), low tumor grade (P < 0.001), no para-aortic lymph node involvement (P < 0.047), less myometrial invasion (P < 0.001), and no vascular space invasion (P = 0.001) were common among the younger women compared with the older women. There were significant differences in the disease-free survival (P = 0.006) and overall survival (P = 0.004) between the 2 groups. In the multivariate Cox model, advanced stage had an effect on both disease-free survival (P = 0.004) and overall survival (P = 0.050).

CONCLUSIONS

Nulliparity, body mass index less than or equal to 23 kg/m, endometrioid type, low-grade tumor, synchronous primary ovarian cancer, and favorable survival were common among the younger women.

Tubal pregnancy associated with endometrial carcinoma after in vitro fertilization attempts

Endometrial carcinoma is rarely seen during reproductive ages and commonly related to infertility, polycystic ovarian syndrome (PCOS), and obesity. Pregnancy associated endometrial carcinoma is even rarer and this is the second case reported in the literature concerning tubal pregnancy associated endometrial carcinoma. We present a case of a 36-year-old woman with a history of PCOS, infertility, and several attempts of ovulation induction and in vitro fertilization, who was diagnosed with tubal pregnancy and a well differentiated endometrial carcinoma. We also review the literature about pregnancy associated endometrial carcinoma in the first trimester.