Trends in peritoneal cytology evaluation at hysterectomy for endometrial cancer in the United States

Comparison of clinical characteristics and prognosis between type I and type II endometrial cancer: a single-center retrospective study

OBJECTIVES

To explore the differences in clinical characteristics, prognosis, and risk factors between type I and type II endometrial cancer (EC).

MATERIALS AND METHODS

We retrospectively collected EC patients diagnosed with type I or type II EC from 2009 to 2021 in the First Affiliated Hospital of Zhengzhou University.

RESULTS

In total, 606 eligible EC patients (396 type I, and 210 type II) were included. Baseline analyses revealed that type II patients were older, had more advanced clinical stage, were more likely to receive chemoradiotherapy, and had higher incidence of myometrial infiltration, cervix involvement, lymph node metastasis and positive ascites cytology. Type II significantly favored poorer overall survival (OS) (HR = 9.10, 95%CI 4.79-17.28, P < 0.001) and progression-free survival (PFS) (HR = 6.07, 95%CI 2.75-13.37, P < 0.001) compared to type I. For all included EC, univariate and multivariate COX analyses revealed age, myometrial infiltration and pathological type were independent risk factors for OS and PFS. Subgroup analyses identified age, menopause, clinical stage, and lymph node metastasis as independent risk factors for type I regarding OS. While age, myometrial infiltration and chemoradiotherapy were identified as risk and protective factors for type II regrading OS. Age and cervix involvement were identified as independent risk factors for type I regarding PFS. Myometrial infiltration was identified as independent risk factor for type II regarding PFS.

CONCLUSION

Type II patients shared different clinical characteristics and worse prognosis compared to type I, and their independent risk and protective factors also varied.

Correlation between malignant peritoneal cytology and survival in patients with uterine leiomyosarcoma and endometrial stromal sarcoma

OBJECTIVE

This study aimed to examine the correlation between malignant peritoneal cytology and overall survival among patients with uterine leiomyosarcoma and endometrial stromal sarcoma.

METHODS

Patients with uterine leiomyosarcoma and endometrial stromal sarcoma between January 2010 and December 2016 were identified from the Surveillance, Epidemiology, and End Results database. The multiple imputation method was used to address missing values. Propensity score matching was conducted to balance baseline data between the malignant and negative peritoneal cytology groups. The prognostic significance of malignant peritoneal cytology was evaluated using Cox regression, random survival forest, and subgroup analyses.

RESULTS

Among 733 eligible patients, 8% (59/733) had malignant peritoneal cytology, increasing to 20% (42/209) in advanced cases. Before and after propensity score matching, patients with malignant peritoneal cytology had significantly lower 5-year overall survival rates and shorter median survival time than patients with negative peritoneal cytology. Multivariate Cox regression revealed that malignant peritoneal cytology (hazard ratio 2.03, 95% confidence interval 1.29 to 3.20, p=0.002) was an independent prognostic factor for uterine leiomyosarcoma and endometrial stromal sarcoma. Random survival forest further indicated that, among the factors analyzed, peritoneal cytology status was second only to the International Federation of Gynecology and Obstetrics (FIGO) stage in terms of prognostic prediction. Finally, subgroup analyses substantiated the correlation between malignant peritoneal cytology and unfavorable overall survival in most subgroups.

CONCLUSIONS

Malignant peritoneal cytology status was an important prognostic factor complementing FIGO stage and was associated with a reduction in overall survival. Peritoneal cytology evaluation during hysterectomy may be recommended for prognosis estimation for uterine leiomyosarcoma and endometrial stromal sarcoma.

Prognostic significance of positive peritoneal cytology in endometrial carcinoma based on ESGO/ESTRO/ESP risk classification: A multicenter retrospective study

OBJECTIVE

This study aimed to determine the prognostic significance of positive peritoneal cytology (PC) on endometrial carcinoma (EC) patients under the ESGO/ESTRO/ESP risk classification.

METHODS

This study retrospectively analyzed EC patients from 27 medical centers in China from 2000 to 2019. Patients were divided into three ESGO risk groups: low-risk, intermediate-risk and high-intermediate risk, and high-risk groups. The covariates were balanced by using the propensity score-based inverse probability of treatment weighting (PS-IPTW). The prognostic significance of PC was assessed by Kaplan-Meier curves and multivariate Cox regression analysis.

RESULTS

A total of 6313 EC patients with PC results were included and positive PC was reported in 384 women (6.1%). The multivariate Cox analysis in all patients showed the positive PC was significantly associated with decreased PFS (hazard ratio [HR] 2.20, 95% confidence interval [CI] 1.55-3.13, P < 0.001) and OS (HR 2.25, 95% CI 1.49-3.40, P < 0.001),and the Kaplan-Meier curves also showed a poor survival in the intermediate and high-intermediate risk group (5-year PFS: 75.5% vs. 93.0%, P < 0.001; 5-year OS: 78.3% vs. 96.4%, P < 0.001); While in the low-risk group, there were no significant differences in PFS and OS between different PC status (5-year PFS: 93.1% vs. 97.3%, P = 0.124; 5-year OS: 98.6% vs. 98.2%, P = 0.823); in the high-risk group, significant difference was only found in PFS (5-year PFS: 62.5% vs. 77.9%, P = 0.033).

CONCLUSION

Positive PC was an adverse prognostic factor for EC, especially in the intermediate and high-intermediate risk patients. Gynecologic oncologists should reconsider the effect of positive PC on different ESGO risk groups.

Malignant peritoneal cytology in endometrial cancer: a contemporary review

INTRODUCTION

: In endometrial cancer, malignant peritoneal cytology (MPC) refers to the presence of tumor cells in the peritoneal cytologic specimen obtained at hysterectomy. MPC was once a component of uterine cancer staging criteria, but it is no longer included in the current revision. Multiple societies and organizations, however, continue to recommend peritoneal cytologic testing at the time of hysterectomy for endometrial cancer.

AREAS COVERED

This contemporary review provides a clinical summary of recent studies evaluating MPC, including risk factors and prognosis. Compared to prior studies showing a lack of impact on oncologic outcome, recent studies have larger sample sizes, use stricter inclusion criteria, and perform histology/cancer stage-specific analyses to balance risk factors and provide explicit interpretations for oncologic outcomes related to MPC. These newer data provide evidence that MPC does have a prognostic impact.

EXPERT OPINION

Three key domains related to MPC are followings: First, recognition of MPC as a prognostic factor for endometrial cancer irrespective to stage (early and advanced) and histology (endometrioid and non-endometrioid) is necessary. Second, peritoneal cytologic testing at the beginning of each staging surgery is recommended. Last, incorporation of peritoneal cytology status in adjuvant treatment algorithms is useful and merits further development.

Utilization and Outcomes of Sentinel Lymph Node Biopsy for Early Endometrial Cancer

OBJECTIVE

To examine trends, characteristics, and oncologic outcomes of sentinel lymph node biopsy for early endometrial cancer.

METHODS

This observational study queried the National Cancer Institute's Surveillance, Epidemiology, and End Results Program by examining 83,139 women with endometrial cancer who underwent primary hysterectomy with nodal evaluation for T1 disease from 2003 to 2018. Primary outcome measures were the temporal trends in utilization of sentinel lymph node biopsy and patient characteristics associated with sentinel lymph node biopsy use, assessed by multivariable binary logistic regression models. Secondary outcome measure was endometrial cancer-specific mortality associated with sentinel lymph node biopsy, assessed by propensity score inverse probability of treatment weighting.

RESULTS

The utilization of sentinel lymph node biopsy increased from 0.2 to 29.7% from 2005 to 2018 (P<.001). The uptake was higher for women with endometrioid (0.3-31.6% between 2005 and 2018) compared with nonendometrioid (0.6-21.0% between 2006 and 2018) histologic subtypes (both P<.001). In a multivariable analysis, more recent year surgery, endometrioid histology, well-differentiated tumors, T1a disease, and smaller tumor size were independently associated with sentinel lymph node biopsy use (P<.05). Performance of sentinel lymph node biopsy was not associated with increased endometrial cancer-specific mortality compared with lymphadenectomy for endometrioid tumors (subdistribution hazard ratio [HR] 0.96, 95% CI 0.82-1.13) or nonendometrioid tumors (subdistribution HR 0.85, 95% CI 0.69-1.04). For low-risk endometrial cancer, the increase in sentinel lymph node biopsy resulted in a 15.3 percentage-point (1.4-fold) increase in surgical nodal evaluation by 2018 (expected vs observed rates, 37.8 vs 53.1%).

CONCLUSION

The landscape of surgical nodal evaluation is shifting from lymphadenectomy to sentinel lymph node biopsy for early endometrial cancer in the United States, with no indication of a negative effect on cancer-specific survival.

Controversy on Positive Peritoneal Cytology of Endometrial Carcinoma

Endometrial carcinoma (EC) is one of the most common gynecological malignancies. Its incidence rate has been increasing year by year. The prognostic factors and treatment strategies of EC have aroused wide concern. The effects of peritoneal cytology on the prognosis and treatment of EC remain controversial. Some factors, such as differentiation degree, muscle invasion, and tumor size, are related to positive peritoneal cytology. Hysteroscopy is commonly used in the diagnosis and treatment of endometrial cancer, but hysteroscopic surgery may cause the tumor to spread into the abdominal cavity, resulting in positive peritoneal cytology. In this review, we discuss the factors related to positive peritoneal cytology and the influence of positive peritoneal cytology on the prognosis of endometrial cancer. Suspicious positive peritoneal cytology may be an independent risk factor for endometrial cancer. The positive rate of peritoneal tumor cells in type II endometrial cancer is higher than other cells and is an independent risk factor for type II endometrial cancer. We also discuss the effects of peritoneal cytology on treatment decisions. Aggressive treatments seem to be more beneficial for patients with positive ascites cytology, but there is a lack of large-scale prospective clinical studies on their effectiveness and safety. The application of peritoneal cytology for endometrial cancer has been decreased in recent years. We believe that peritoneal cytology is necessary for this type of cancer. However, more studies on peritoneal cytology in endometrial cancer should be carried out.

Sentinel lymph node biopsy for stage II endometrial cancer: Recent utilization and outcome in the United States

OBJECTIVE

To examine trends and outcomes related to sentinel lymph node (SLN) biopsy for stage II endometrial cancer.

METHODS

This is a retrospective observational cohort study querying the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. The study population was 6,314 women with T2 endometrial cancer who underwent hysterectomy from 2010-2018. Exposure allocation was based on nodal evaluation type: lymphadenectomy (LND; n=4,915, 77.8%), SLN biopsy (n=340, 5.4%), or no surgical nodal evaluation (n=1,059, 16.8%). The main outcomes were (i) trends and characteristics related to nodal evaluation assessed by multinomial regression, and (ii) overall survival (OS) assessed by an inverse probability of treatment weighting propensity score analysis. A sensitivity analysis was performed to examine concurrent LND in women who underwent SLN biopsy.

RESULTS

The utilization of SLN biopsy increased from 1.6% to 16.1%, while the number of LND decreased from 81.5% to 65.7% between 2010-2018 (P<0.05). In multivariable analysis, the utilization of SLN biopsy increased 45% annually (adjusted-odds ratio 1.45, 95% confidence interval [CI] 1.37-1.54, P<0.001). The frequency of SLN biopsy alone exceeded the frequency of SLN biopsy with concurrent LND in 2017 (6.8% versus 3.4%), followed by continued increase in SLN biopsy alone (11.2% versus 4.9%) in 2018. In the weighted model, the 3-year OS rate was 79.9% for the SLN biopsy group and 78.6% for the LND group (hazard ratio 0.98, 95%Cl 0.80-1.20, P=0.831). Similarly, the SLN biopsy alone without concurrent LND had comparable OS compared to the LND group (hazard ratio 0.90, 95%CI 0.59-1.36, P=0.615).

CONCLUSION

Utilization of SLN biopsy in stage II endometrial cancer increased significantly over time, and SLN biopsy-incorporated nodal assessment was not associated with worsened short-term survival outcome.

Clinico-pathological significance of suspicious peritoneal cytology in endometrial cancer

BACKGROUND AND OBJECTIVES

Suspicious peritoneal cytology refers to the result of peritoneal cytology testing that is insufficient in either quality or quantity for a definitive diagnosis of malignancy. This study examined characteristics and survival outcomes related to suspicious peritoneal cytology in endometrial cancer.

METHODS

A population-based retrospective study by querying the National Cancer Institute's Surveillance, Epidemiology, and End Results Program was conducted. A total of 41,229 women with Stage I-III endometrial cancer who had peritoneal cytologic sampling at hysterectomy from 2010 to 2016 were examined. A Cox proportional hazard regression model and a competing risk analysis with Fine-Gray model were fitted to assess survival outcome related to suspicious peritoneal cytology.

RESULTS

Suspicious peritoneal cytology was seen in 702 (1.7%) cases. In multivariable models, suspicious peritoneal cytology was associated with increased risk of endometrial cancer mortality (subdistribution-hazard ratio [HR] 1.69, 95% confidence interval [CI] 1.29-2.20, p < 0.001) and all-cause mortality (adjusted-HR: 1.55, 95% CI: 1.27-1.90, p < 0.001) compared with negative peritoneal cytology. Sensitivity analysis demonstrated that suspicious peritoneal cytology had discrete overall survival improvement compared with malignant peritoneal cytology in a propensity score weighting model (HR: 0.85, 95% CI: 0.72-0.99, p = 0.049).

CONCLUSION

Our study suggests that suspicious peritoneal cytology may be a prognostic factor for decreased survival in endometrial cancer.