Endometrial cancer in the elderly: does age influence surgical treatments, outcomes, and prognosis?

Surgical and oncologic outcomes in surgically treated women 80 years and older with endometrioid endometrial cancer as a function of their comorbidities

Objective

To describe the surgical and oncologic outcomes in surgically treated oldest old women (≥80 years) with endometrioid endometrial cancer as a function of their comorbidities.

Methods

In this retrospective cohort study, patients aged 80-99 years who underwent surgical management of stage I endometrioid endometrial cancer between 2006 and 2018 were included. Low- and high-intermediate risk disease was defined using the Gynecologic Oncology Group-99 criteria. The validated, Combined Age-Charlson Comorbidity Index (CA-CCI) was used to quantify comorbidity burden. Logistic regression was used to identify the independent predictors of various surgical and oncologic outcomes. Kaplan-Meier survival analysis was performed to compare survival distributions based on mortality cause and comorbidity status.

Results

We identified 64 women who met the eligibility criteria. Median age was 84 years (IQR 80, 94 years). Among oldest old women undergoing a hysterectomy with or without lymph node dissection, women with a CA-CCI score of ≥7 had an 8 times higher risk of postoperative infections compared with oldest old women with a <7 score (95% CI 1.53-48.91, P = 0.015). Women with a CA-CCI score of ≥8 were 45% less likely to survive at 3 years (aRR 0.55, 95% CI 0.004-0.87; P = 0.039) than those with a lower CA-CCI score (three-year overall survival 73% vs 96%).

Conclusion

Surgical and oncologic outcomes in oldest old women with early stage endometrioid endometrial cancer are largely determined by comorbidity status. Less comorbid women (CA-CCI score < 8) had a significantly higher five-year survival at 87% than their more comorbid counterparts. Use of age-comorbidity risk scoring such as CA-CCI, preoperative optimization, and careful selection for and counseling of patients about surgical treatment are paramount in providing optimal recovery and survival advantages in the oldest old.

Multi-institutional study on the role of post-operative radiotherapy in elderly patients with endometrial cancer

OBJECTIVE

To investigate the prognostic factors for survival and toxicities in elderly (≥65 years) patients with endometrial cancer who underwent post-operative radiotherapy. Additionally, to compare the treatment outcomes between the older elderly (≥75 years) and younger elderly (65-74 years) patients.

METHODS

Medical records of patients with enometrial cancer treated between January 1998 and July 2019 were reviewed. Patients with stage IA to IIIC2, all histology subtypes, and any grade were included. All patients underwent total abdominal hysterectomy and received adjuvant radiotherapy with or without chemotherapy. All but 67 (8.4%) of 801 patients had lymph node dissection. Clinicopathological factors and treatment strategies were compared between the two age groups. The prognostic factors for overall survival and progression-free survival were investigated.

RESULTS

A total of 801 patients with enometrial cancer, 627 patients (78.3%) younger elderly and 174 patients (21.7%) in the older elderly group were included. Median follow-up was 74.3 months (range 0.4-224.6). The older elderly patients had significantly higher rates of grade 3 tumors (51.7% vs 40.8%; p=0.04), cervical glandular involvement (21.8% vs 14.0%; p=0.03), and cervical stromal invasion (34.5% vs 27.9%; p=0.04) than the younger elderly patients. The rates of lymph node dissection (p=0.2), radiotherapy modalities (p=0.92), and systemic chemotherapy (p=0.2) did not differ between the two groups. The 5-year locoregional control and distant metastasis rates were 88.3% and 23.8%, respectively. The 5-year cause-specific survival and progression-free survival rates for younger and older elderly patients, were 79.8% vs 74.3% (p=0.04) and 67.5% vs 57.8% (p<0.001), respectively. In multivariate analysis, larger tumor size, non-endometrioid histology, cervical stromal involvement, and stage III disease were associated with poor cause-specific survival and progression-free survival. Age was an independent predictor of worse progression-free survival, but not of cause-specific survival. There was no significant difference in acute and late gastrointestinal and genitourinary toxicities between age groups.

CONCLUSIONS

Post-operative radiotherapy for elderly patients with endometrial cancer is effective and well tolerated. Advanced age should not preclude appropriate treatment, especially in those with adequate quality of life, life expectancy, and functional status.

Surgical treatment in older patients with endometrial cancer: A retrospective study

INTRODUCTION

Older patients (OP) diagnosed with endometrial cancer (EC) are less likely to receive an optimal surgical treatment compared with non-older patients (NOP). This undertreatment along with the presence of more aggressive tumours at diagnosis can explain the worse prognosis of EC in OP. There is limited evidence comparing perioperative outcomes between OP and NOP, and the benefit of applying complex procedures to OP is still controversial. The primary objective of the study was to compare intraoperative and postoperative complications between NOP and OP with EC that underwent primary surgery. Secondary objectives were to compare surgical management and survival rates.

METHODS

This is a retrospective single-centre observational study including women undergoing surgery for EC between 2010 and 2019. Patients were classified according to age as NOP (younger than 75 years) or OP (75 years or older). Basal characteristics and surgical outcomes of groups were compared using Chi-square, Fisher's exact tests, student T-tests or Mann Whitney tests. Kaplan Meier analysis was used to evaluate survival.

RESULTS

In total 281 patients underwent primary surgery for EC between 2010 and 2019 in our centre. At diagnosis, 184 patients were younger than 75 years while 97 were 75 and older. No differences were found in disease characteristics. Most of our patients (83,3%) underwent laparoscopic surgery. Pelvic (58,2% vs. 37,1%, p = 0,001) and para-aortic (46,7% vs. 23,7%, p < 0,001) lymphadenectomies were performed more frequently in NOP compared with OP. Rates of intra-operative (6,5% vs. 12,4%, p = 0,116) and post-operative (13,0% vs. 20,6%, p = 0,120) complications were not statistically different between NOP and OP, and neither was the rate of severe complications according to Clavien-Dindo classification (5,4% vs. 8,2% of complications grade III-V respectively, p = 0,387). The 5-year disease-specific survival (DSS) rate tended to be lower in the OP than in the NOP (74,8% vs. 82,5%, p = 0,071). Considering only patients in whom complete surgical staging was performed, OP presented similar DSS to NOP, with comparable complication rate.

CONCLUSIONS

OP do not present a significantly higher rate of perioperative complications compared to NOP. However, they underwent fewer lymphadenectomies and tended to present poorer DSS. Further studies are needed to standardize the surgical management of these patients.

Survival after laparoscopy versus laparotomy for apparent early-stage uterine clear cell carcinoma: Results of a large multicenter cohort study

Objective

To compare the long-term survival between laparoscopic surgery and open surgery in patients with apparent early-stage uterine clear cell carcinoma (UCCC).

Patients and methods

254 patients with apparent early-stage UCCC were reviewed. Comparisons were made between patients who underwent laparoscopic surgery versus those who underwent open surgery. Baseline data, clinicopathological data, and oncological outcomes were analyzed. 5-year disease-free survival (DFS) rate and 5-year overall survival (OS) rate were estimated and compared using the Kaplan-Meier method and the Log-rank test. The Cox proportional hazard regression model was employed to control the confounding factors.

Results

147 patients underwent laparoscopic surgery, and 107 patients were managed by open surgery. No differences in terms of recurrence rate (laparoscopy versus laparotomy: 10.9% versus 12.9%, P=0.842) and recurrence pattern were observed. For patients who underwent open surgery and patients who underwent laparoscopic surgery, the 5-year DFS rates and 5-year OS rate were 75.8% (95% CI: 65.8%-83.2%) and 69.1% (95% CI: 58.8%-77.4%), 66.0% (95% CI: 57.1%-73.5%) and 60.8% (95% CI: 52.0%-68.5%), respectively. The Cox proportional hazards regression model shown that for apparent early-stage UCCC, the approach of surgical staging was not an independent predictor for survival (laparoscopy versus laparotomy: for DFS, aHR=1.06, 95% CI=0.64-1.75, P=0.826; for OS, aHR=1.10, 95% CI=0.72-1.68, P=0.671).

Conclusion

For apparent early-stage UCCC, in terms of oncological survival, laparoscopic surgery was as safe as open surgery.

An effective algorithm to detect the possibility of being MSI phenotype in endometrial cancer given the BMI status and histological subtype: a statistical study

PURPOSE

In endometrial cancer, the incidence of mutations in mismatch repair genes (MMR) is estimated at 17-30%. Patients with alterations at this level (MSI) are known to have different clinical and anatomopathological characteristics than those without this genetic alteration (MSS). In this study, we aim to identify the MSI phenotype in patients who underwent hysterectomy for endometrial cancer. We assessed the correlation of this phenotype with anatomoclinical parameters such as obesity and histological subtype.

METHODS/PATIENTS

Clinical and anatomopathological data were collected from 147 patients diagnosed with endometrial cancer and an immunohistochemical study of MMR system proteins was performed. PMS2 and MSH6 proteins were evaluated as primary screening and subsequent evaluation of MLH1 and MSH6, respectively, if the former were negative. Statistical association between the anatomopathological data and the immunohistochemical result was analyzed.

RESULTS AND CONCLUSIONS

22.4% of our patients were MSI phenotype. We obtained statistically significant differences by multivariate analysis between endometrioid subtype and higher FIGO classification grade with MSI phenotype and obesity with MSS phenotype. Given these statistical results, we propose a function for predicting the probability of being MSI phenotype taking into account the histological subtype (endometrioid/non-endometrioid carcinoma) and FIGO grade as well as obesity. This prediction may be useful prior to hysterectomy, for genetic study of the MLH1 promoter and subsequent genetic counseling.

Surgical and oncological outcomes of sentinel lymph node sampling in elderly patients with intermediate to high-risk endometrial carcinoma

OBJECTIVE

We aimed to evaluate the surgical and oncological outcomes of elderly patients with intermediate to high-risk endometrial cancer undergoing staging with sentinel lymph node (SLN) sampling and pelvic lymphadenectomy.

METHODS

We conducted a retrospective study of elderly (>65-year-old) patients diagnosed with endometrial cancer between December 2007 and August 2017. These patients had been treated at a single center in Montreal, Canada. We compared the surgical and oncological outcomes of three cohorts undergoing surgical staging in non-overlapping eras: 1) lymphadenectomy, 2) lymphadenectomy and SLN sampling, 3) SLN sampling alone. Using life tables, Kaplan-Meier survival curves and log-rank tests, we analyzed 2-year progression-free survival, overall survival, and disease-specific survival.

RESULTS

Our study included 278 patients with a median age of 73 years (range; 65-91): 84 (30.2%) underwent lymphadenectomy, 120 (43.2%) underwent SLN sampling with lymphadenectomy, and 74 (26.6%) had SLN sampling alone. The SLN sampling alone group had shorter operative times with a median duration of 199 minutes (range, 75-393) compared with 231 (range, 125-403) and 229 (range, 151-440) minutes in the SLN sampling with lymphadenectomy and lymphadenectomy cohorts; respectively (p<0.001). The SLN sampling alone group also had lower estimated blood loss with a median loss of 20 mL (range, 5-150) vs 25 mL (range, 5-800) and 40 mL (range, 5-400) in the SLN sampling with lymphadenectomy and lymphadenectomy cohorts, respectively (p=0.002). The 2 year overall survival and progression-free survival were not significantly different between the three groups (p=0.45, p=0.51, respectively). On multivariable analysis after adjusting for age, American Society of Anesthesiologists (ASA) score, stage, grade, and lymphovascular space invasion, adding SLN sampling was associated with better overall survival, (HR 0.2, CI [0.1 to 0.6], p=0.006) and progression-free survival (HR 0.5, CI [0.1 to 1.0], p=0.05).

CONCLUSION

Sentinel lymph node-based surgical staging is feasible and associated with better surgical outcomes and comparable oncological outcomes in elderly patients with intermediate and high-risk endometrial cancer.

Current and Emerging Prognostic Biomarkers in Endometrial Cancer

Endometrial cancer is the most common gynaecological malignancy in high income countries and its incidence is rising. Whilst most women with endometrial cancer are diagnosed with highly curable disease and have good outcomes, a significant minority present with adverse clinico-pathological characteristics that herald a poor prognosis. Prognostic biomarkers that reliably select those at greatest risk of disease recurrence and death can guide management strategies to ensure that patients receive appropriate evidence-based and personalised care. The Cancer Genome Atlas substantially advanced our understanding of the molecular diversity of endometrial cancer and informed the development of simplified, pragmatic and cost-effective classifiers with prognostic implications and potential for clinical translation. Several blood-based biomarkers including proteins, metabolites, circulating tumour cells, circulating tumour DNA and inflammatory parameters have also shown promise for endometrial cancer risk assessment. This review provides an update on the established and emerging prognostic biomarkers in endometrial cancer.

Oncologic outcomes in older women with endometrial carcinoma (≥70 years)

Data are limited in the management of elderly women with endometrial cancer as they are under-represented in clinical trials. The aim of this study was to evaluate the outcomes of women ≥70 years who underwent hysterectomy. One hundred and twenty-one patients met the inclusion criteria. The median age among the cohort was 75 years (range: 70-91), and 52% underwent robotic surgery. The five-year overall survival (OS) rate was 67%. The five-year cumulative incidence of recurrence was 19%. Based on univariate analysis, white race, lower ASA score, higher pre-operative and post-operative haematocrit, lower estimated blood loss, stage I and robotic surgery were associated with improved OS. On multivariable analysis, ASA score, preoperative haematocrit, estimated blood loss and stage were associated with survival.Survival rates among older women were low and disease recurrence was high. Robotic surgery was safe and appeared to improve perioperative outcomes in older women with endometrial cancer.Impact StatementWhat is already known on this subject? Endometrial cancer is the most common gynaecologic cancer with an overall survival above 90%. Surgery is the cornerstone of treatment. With an ageing population, an increased incidence of endometrial cancer is also expected. Increased frailty and comorbid conditions may prevent this population from undergoing surgery; consequently, these patients are often undertreated for a potentially curable disease.What do the results of this study add? Older women with endometrial cancer have low survival rates and high disease recurrence rates. Elderly women can tolerate robotic surgery to reduce the risk of adverse events.What are the implications of these findings for clinical practice and/or further research? It is important to develop best practices to optimise patients for minimally invasive surgery. The benefits of robotic surgery may encourage patients and surgeons to partake in this approach. A multidisciplinary approach with geriatric evaluation may improve post-operative care and survival. Future clinical trials should include elderly women.

Comparison Between Laparoscopic and Robotic Surgery in Elderly Patients With Endometrial Cancer: A Retrospective Multicentric Study

Introduction

Elderly endometrial cancer (EEC) patients represent a challenging clinical situation because of the increasing number of clinical morbidities. In this setting of patients, minimally invasive surgery (MIS) has been shown to improve surgical and clinical outcomes. The aim of this study was to evaluate the peri-operative and oncological outcomes of EEC patients who had undergone laparoscopic (LS) or robotic surgery (RS).

Materials and Methods

This is a retrospective multi-institutional study in which endometrial cancer patients of 70 years or older who had undergone MIS for EC from April 2002 to October 2018 were considered. Owing to the non-randomized nature of the study design and the possible allocation biases arising from the retrospective comparison between LS and RS groups, we also performed a propensity score-matched analysis (PSMA).

Results

A total of 537 patients with EC were included in the study: 346 who underwent LS and 191 who underwent RS. No significant statistical differences were found between the two groups in terms of surgical and survival outcomes. 188 were analyzed after PSMA (94 patients in the LS group were matched with 94 patients in the RS group). The median estimated blood loss was higher in the LS group (p=0.001) and the median operative time was higher in the RS group (p=0.0003). No differences emerged between LS and RS in terms of disease free survival (DFS) (p=0.890) and overall survival (OS) (p=0.683).

Conclusions

Our study showed that when compared LS and RS, RS showed lower blood losses and higher operative times. However, none of the two approaches demonstrated to be superior in terms of survival outcomes. For this reason, each patient should be evaluated individually to determine the best surgical approach.

Prognostic factors of endometrial cancer in elderly patient group and their effects on survival

OBJECTIVE:

The objective of the study was to investigate the prognostic factors of the elderly group and their effects on survival by examining the histopathological features, surgical treatment protocols, and treatment modalities of patients diagnosed with endometrial cancer (EC).

METHODS:

The records of 397 EC patients who completed their treatment and follow-up at a single center between 2012 and 2019 were evaluated retrospectively. The patients were evaluated in two groups as <70 years old (n: 301; 75.8%) and >70 years old (n: 96; 24.2%). Following the evaluation of histopathological features and treatment protocols, independent risk factors influencing survival were investigated with the Cox regression model.

RESULTS:

The incidence of non-endometrioid histology (16.3% vs. 32.3%, p: 0.001), high-grade tumors (50.5% vs. 69.8%; p: 0.001), and >50 myometrial invasion (19.6% vs. 36.5%, p: 0.003) in the >70 age group was more frequent than that in the <70 age group. The independent risk factors on overall survival in the >70 age group were determined as non-endometrioid histology (HR: 5.9; 95% CI: 1.4– 24.7) and lymph node metastasis (HR: 6.4; 95% CI:1.6–25.0). In the <70 age group, non-endometrioid histology (HR: 11.3; 95% CI: 4.0–32.0) was identified as the only independent risk factor affecting 5-year survival.

CONCLUSION:

EC, with non-endometrioid histology, which is observed at a higher rate in elderly patients despite equal surgery and adjuvant therapy, is the primary factor that affects survival.

Clinical significance and role of up-regulation of SERPINA3 expression in endometrial cancer

BACKGROUND

Serpin peptidase inhibitor, clade A member 3 (SERPINA3) belongs to the serpin family with an inhibitory activity against proteases. Its aberrant expression has been observed in a wide range of tumor cells. However, its clinical significance and biological function in endometrial cancer have been rarely studied. We designed a study to determine the levels of SERPINA3 and its significance in patients with endometrial cancer.

AIM

To investigate the clinical significance and role of SERPINA3 expression in endometrial cancer cells.

METHODS

Eighty endometrial tissue samples collected from patients with endometrial cancer were included in an observation group and 80 paraffin-embedded tissues samples collected from patients with normal endometrial tissues undergoing myomectomy were employed as a control group between January 2014 and December 2018. The expression of SERPINA3 mRNA was detected by quantitative polymerase chain reaction (PCR) for all endometrial tissues included in the study.

RESULTS

The positive expression rate of SERPINA3 protein in endometrial cancer cells was 71.25% in the observation group, which was significantly higher than that in the control group (31.25%; P < 0.05). There was no correlation between SERPINA3 protein in endometrial cancer cells and the age range at which women experienced menopause (P > 0.05). However, it was associated with pathological grade, clinical stage, vascular invasion, and lymph node metastasis (P < 0.05). Pathological grade, clinical stage, vascular invasion, and lymph node metastasis were independent prognostic factors for endometrial cancer.

CONCLUSION

The follow-up study of SERPINA3 can be used as a prognostic biomarker for endometrial cancer and as one of the targets for bio-targeted therapy for endometrial cancer.

Lymphadenectomy and prognosis for elderly females with stage I endometrioid endometrial cancer

PURPOSE

The potential therapeutic benefits of lymphadenectomy in endometrial cancer (EC) patients are still ambiguous. Therefore, a population-based retrospective analysis was conducted to determine the association between lymphadenectomy and survival in elderly female patients with stage I endometrioid EC.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) program database was retrospectively analyzed, and data of 63,372 female patients with early-stage type I EC from 1988 to 2013 were collected. The main patient and tumor characteristics included marital status, age, ethnicity, time of diagnosis, tumor grade, radiotherapy, and lymphadenectomy status. Kaplan-Meier and Cox proportional hazard regression analyses were performed to determine the association between lymph node dissection and the overall survival (OS) and cancer-specific survival in women older than 50 years with stage I endometrioid EC.

RESULTS

The majority (83.7%) of the patients who met the inclusion criteria for the study were older than 50 years. In both grade 1 and 2 patients aged over 50 years, lymph node conservation was associated with a higher mortality risk compared to lymphadenectomy (all P < 0.005). Multivariate analysis indicated that lymphadenectomy was an independent predictor of improved OS in early-stage type 1 EC patients, with hazard ratios of 0.893 and 0.827 for the grade 1 and grade 2 patients, respectively (P < 0.0001).

CONCLUSIONS

Lymphadenectomy could improve long-term OS in women older than 50 years with grade 1 and 2 endometrioid EC.