The role of prolonged progestin treatment and factors predicting successful fertility-sparing treatment for early endometrial endometrioid adenocarcinoma

Fertility-preserving treatment for stage IA endometrial cancer: a systematic review and meta-analysis

OBJECTIVE

The increasing use of fertility-preserving treatments in reproductive-aged patients with early-stage endometrial cancer necessitates robust evidence on the effectiveness of oral progestins and levonorgestrel-releasing intrauterine device. We conducted a systematic review and meta-analysis to examine the outcomes following these 2 primary progestin-based therapies in reproductive-aged patients with early-stage endometrial cancer.

DATA SOURCES

We conducted a systematic review of observational studies and randomized controlled trials following the Cochrane Handbook guidance. We conducted a literature search of 5 databases and 1 trial registry from inception of the study to April 16, 2024.

STUDY ELIGIBILITY CRITERIA

Studies reporting complete response within 1 year in reproductive-aged patients with clinical stage IA endometrioid cancer undergoing progestin therapy treatment were included. We used data from both observational and randomized controlled studies.

STUDY APPRAISAL AND SYNTHESIS METHODS

The primary exposure assessed was the type of progestational treatment (oral progestins or LNG-IUD). The primary outcome was the pooled proportion of the best complete response (CR) within 1 year of primary progestational treatment. We performed a proportional meta-analysis to estimate the treatment response. Sensitivity analyses were performed by removing studies with extreme effect sizes or removing grade 2 tumors. The risk of bias was assessed in each study using the Joanna Briggs Institute critical appraisal checklist.

RESULTS

Our analysis involved 754 reproductive-aged patients diagnosed with endometrial cancer, with 490 receiving oral progestin and 264 receiving levonorgestrel-releasing intrauterine device as their primary progestational treatment. The pooled proportion of the best complete response within 12 months of oral progestin and levonorgestrel-releasing intrauterine device treatment were 66% (95% CI, 55-76) and 86% (95% CI, 69-95), respectively. After removing outlier studies, the pooled proportion was 66% (95% CI, 57-73) for the oral progestin group and 89% (95% CI, 75-96) for the levonorgestrel-releasing intrauterine device group, showing reduced heterogeneity. Specifically, among studies including grade 1 tumors, the pooled proportions were 66% (95% CI, 54-77) for the oral progestin group and 83% (95% CI, 50-96) for the levonorgestrel-releasing intrauterine device group. The pooled pregnancy rate was 58% (95% CI, 37-76) after oral progestin treatment and 44% (95% CI, 6-90) after levonorgestrel-releasing intrauterine device treatment.

CONCLUSION

This meta-analysis provides valuable insights into the effectiveness of oral progestins and levonorgestrel-releasing intrauterine device treatment within a 12-month timeframe for patients with early-stage endometrial cancer who desire to preserve fertility. These findings have the potential to assist in personalized treatment decision-making for patients.

Integrated Identification and Immunotherapy Response Analysis of the Prognostic Signature Associated With m6A, Cuproptosis-Related, Ferroptosis-Related lncRNA in Endometrial Cancer

BACKGROUND

Endometrial cancer (EC) stands as the predominant gynecological malignancy impacting the female reproductive system on a global scale. N6-methyladenosine, cuproptosis- and ferroptosis-related biomarker is beneficial to the prognostic of tumor patients. Nevertheless, the correlation between m6A-modified lncRNAs and ferroptosis, copper-induced apoptosis in the initiation and progression of EC remains unexplored in existing literature.

AIMS

In this study, based on bioinformatics approach, we identified lncRNAs co-expressing with cuproptosis-, ferroptosis-, m6A- related lncRNAs from expression data of EC. By constructing the prognosis model in EC, we screened hub lncRNA signatures affecting prognosis of EC patients. Furthermore, the guiding value of m6A-modified ferroptosis-related lncRNA (mfrlncRNA) features was assessed in terms of prognosis, immune microenvironment, and drug sensitivity.

METHOD

Our research harnessed gene expression data coupled with clinical insights derived from The Cancer Genome Atlas (TCGA) collection. To forge prognostic models, we adopted five machine learning approaches, assessing their efficacy through C-index and time-independent ROC analysis. We pinpointed prognostic indicators using the LASSO Cox regression approach. Moreover, we delved into the biological and immunological implications of the discovered lncRNA prognostic signatures.

RESULTS

The survival rate for the low-risk group was markedly higher than that for the high-risk group, as evidenced by a significant log-rank test (p < 0.001). The LASSO Cox regression model yielded concordance indices of 0.76 for the training set and 0.77 for the validation set, indicating reliable prognostic accuracy. Enrichment analysis of gene functions linked the identified signature predominantly to endopeptidase inhibitor activity, highlighting the signature's potential implications. Additionally, immune function and drug density emphasized the importance of early diagnosis in EC.

CONCLUSION

Five hub lncRNAs in EC were identified through constructing the prognosis model. Those genes might be potential biomarkers to provide valuable reference for targeted therapy and prognostic assessment of EC.

Prediction of complete regression in fertility-sparing patients with endometrial cancer and apical hyperplasia: the GLOBAL model in a large Chinese cohort

BACKGROUND

Fertility preservation treatment is increasingly essential for patients with apical endometrial hyperplasia (AEH) and early endometrial cancer (EEC) worldwide. Complete regression (CR) is the main endpoint of this treatment. Accurately predicting CR and implementing appropriate interventions during treatment are crucial for these patients.

METHODS

We conducted a retrospective study involving 193 patients diagnosed with atypical AEH or EEC, enrolled from January 2012 to March 2022 at our center. We evaluated 24 clinical parameters as candidate predictors and employed LASSO regression to develop a prediction model for CR. Subsequently, a nomogram was constructed to predict CR after the treatment. We evaluated the performance of the nomogram using receiver operator characteristic (ROC) curve and decision curve analysis (DCA) to assess its predictive accuracy. Additionally, we employed cumulative curves to determine the CR rate among patients.

RESULTS

Out of the 193 patients, 173 achieved CR after undergoing fertility preservation treatment. We categorized features with similar properties and provided a list of formulas based on their coefficients. The final model, named GLOBAL (including basic information, characteristics, blood pressure, glucose metabolism, lipid metabolism, immunohistochemistry, histological type, and medication), comprised eight variables identified using LASSO regression. A nomogram incorporating these eight risk factors was developed to predict CR. The GLOBAL model exhibited an AUC of 0.907 (95% CI 0.828-0.969). Calibration plots demonstrated a favorable agreement between the predicted probability by the GLOBAL model and actual observations in the cohort. The cumulative curve analysis revealed varying cumulative CR rates among patients in the eight subgroups. Categorized analysis demonstrated significant diversity in the effects of the GLOBAL model on CR among patients with different total points (p < 0.05).

CONCLUSION

We have developed and validated a model that significantly enhances the predictive accuracy of CR in AEH and EEC patients seeking fertility preservation treatment.