Transtubal spread of endometrial carcinoma: correlation of intra-luminal tumour cells with tumour grade, peritoneal fluid cytology, and extra-uterine metastasis

Novel targets and their functions in the prognosis of uterine corpus endometrial cancer patients

Aberrant mRNA expression is implicated in uterine corpus endometrial carcinoma (UCEC) oncogenesis and progression. However, effective prognostic biomarkers for UCEC remain limited. We aimed to construct a reliable multi-gene risk model using gene expression profiles. Utilizing TCGA data (543 UCEC samples, 35 controls), we identified 1517 differentially acting genes. Weighted gene co-expression complex analysis (WGCCA), hub gene screening, and risk regression analysis (RRA) were employed to determine prognosis-related genes and construct the risk model. Nomograms visualized risk scores and receiver operator characteristic (ROC) curves assessed model performance. Seven novel prognosis-related hub genes (ANGPT1, ASB2, GAL, GDF7, ONECUT2, SV2B, TRPC6) were identified. The model's concordance index (C index) by multivariate Cox regression analysis was 0.79. ROC curves yielded AUCs of 0.811 (3-year) and 0.79 (5-year), demonstrating the model's efficacy in predicting UCEC survival. Our study proposes a promising seven-biomarker risk model for predicting UCEC prognosis, offering potential clinical utility.

Undifferentiated endometrial carcinoma diagnosed during perimenopausal hormone therapy: a case report and literature review

Uterine corpus endometrial carcinoma, one of the three most frequent cancers of the female reproductive system, primarily affects women who are perimenopausal or postmenopausal. Moreover, it is an epithelial cancer that develops in the endometrium, which is classified as either estrogen-dependent (type I) or non-estrogen-dependent (type II). Non-estrogen-dependent endometrial cancers include plasma cell carcinoma and undifferentiated/dedifferentiated endometrial carcinoma. Undifferentiated endometrial carcinoma is a rare but aggressive endometrial epithelial cancer that lacks any histologic differentiation and is classified as a high-grade endometrial cancer. This case presents that a patient had uterine corpus endometrial carcinoma during perimenopausal hormone therapy, and the patient was treated with sequential estrogen-progestin treatment for 3 years. During that period, she did not undergo a follow-up examination for the last 2 years due to the pandemic. Undifferentiated endometrial carcinoma is a special type of endometrial cancer that is not hormone-dependent, and whether the occurrence of this case is related to perimenopausal hormone therapy needs to be verified by more evidence-based clinical cases and further studies.

Intraluminal tumor cells and prognostic accuracy of endometrial cancer stage criteria: A multi-institution study

OBJECTIVE

Endometrial cancer stage is a strong prognostic factor; however, the current stage classification does not incorporate transtubal spread as determined by intraluminal tumor cells (ILTCs). We examined relationships between ILTCs and survival outcomes according to histological subtype and stage and examined whether identification of ILTCs improves prognostic accuracy of endometrial cancer staging.

METHODS

We conducted a retrospective cohort study of women diagnosed with endometrial cancer at five academic hospitals between 2007 and 2012. Pathologists determined ILTC presence (no vs. yes) and location (free in lumen vs. attached to epithelial surface) based on pathology review of hematoxylin and eosin-stained sections of fallopian tubes. Associations between ILTCs with time to recurrence (TTR) and overall survival (OS) were examined with Cox proportional hazards models adjusted for other prognostic factors. Model discrimination metrics were used to assess the addition of ILTCs to stage for prediction of 5-year TTR and OS.

RESULTS

In the overall study population (N = 1303), ILTCs were not independently associated with TTR (HR = 0.95, 95% CI = 0.69-1.32) or OS (HR = 0.97, 95% CI = 0.72-1.31). Among 805 women with stage I disease, ILTCs were independently associated with worse TTR (HR = 2.31, 95% CI = 1.06-5.05) and OS (HR = 2.16, 95% CI = 1.14-4.11). Upstaging early-stage cases with ILTCs present did not increase model discrimination.

CONCLUSION

While our data do not suggest that endometrial cancer staging guidelines should be revised to include ILTCs, associations between ILTCs and reduced survival observed among stage I cases suggest this tumor feature holds clinical relevance for subgroups of endometrial cancer patients.

Endometrioid Carcinomas of the Ovaries and Endometrium Involving Endocervical Polyps: Comprehensive Clinicopathological Analyses

While synchronous ovarian and endometrial endometrioid carcinomas (ECs) have long been described in the literature, ovarian or endometrial EC involving concomitant endocervical polyp (ECP) has not yet been reported. This study aimed to investigate the histological types and prevalence of gynecological tumors co-existing with ECP and to comprehensively analyze the clinicopathological characteristics of ovarian and endometrial ECs involving ECPs. We searched for ECP cases associated with premalignant lesions or malignancies of the female genital tract occurring between March 2019 and February 2022. We then investigated the histological types and prevalence of gynecological tumors co-existing with ECP. In addition, we reviewed electronic medical records and pathology slides to collect the clinicopathological features of four patients with ovarian or endometrial EC involving ECP. We found 429 ECPs over the three-year study period. Of these, 68 (15.9%) were associated with premalignant or malignant lesions occurring in the uterine cervix, endometrium, and ovaries. Four of these cases, including two (0.5%) ovarian grade 3 ECs and two (0.5%) endometrial grade 1 ECs, involved ECPs. In the former cases (cases 1 and 2), ECs involving ECPs exhibited similar morphology and immunohistochemical staining results to those of advanced-stage ovarian EC. In the latter cases (cases 3 and 4), the histological and immunophenotypical features of EC involving ECP were identical to those of primary endometrial EC, despite the lack of tumor involvement in the myometrium, lower uterine segment, and cervical stroma as well as the absence of lymphovascular invasion and lymph node metastasis. In all cases, no evidence of benign endometriosis, endometrial hyperplasia without atypia, or atypical hyperplasia/endometrial intraepithelial neoplasm within ECP or the adjacent endocervical tissue was noted. Considering our results, the involvement of ECP by EC may have been caused by an implantation metastasis from the ovarian (cases 1 and 2) or endometrial (cases 3 and 4) EC. To the best of our knowledge, this is the first exploration of the synchronous occurrence of endometrial or ovarian EC and ECP involvement. Implantation metastasis via transtubal and trans-endometrial cavity migration may have been the pathogenic mechanism of ECP involvement.

Associations Between Intraluminal Tumor Cell Involvement in Serially Examined Fallopian Tubes and Endometrial Carcinoma Characteristics and Outcomes

Approximately 12% of routinely examined fallopian tubes of endometrial carcinoma (EC) cases have intraluminal tumor cells (ILTCs). ILTC associations with EC characteristics and outcomes are understudied, and unknown in serially examined and embedded tubal fimbriae. Glass slides of serially examined and embedded tubal fimbriae for 371 EC cases were independently reviewed by 2 pathologists who recorded ILTC presence and characterized them as mucosal if involved and floating if not. Disagreements were reviewed by a third pathologist, and agreement between any 2 determined final ILTC status. Clinico-pathologic associations and ILTC presence were tested for significance ( P <0.05) by univariable analysis, and stage and histotype determinants were included in a multivariable analysis. The Kaplan-Meier estimates and log-rank tests compared overall and EC-specific survival, and Cox proportional regression estimated hazard ratios. ILTCs were present in 56 (15.1%) cases: 30 mucosal and 26 floating. FIGO stage 3/4, lymph-vascular space invasion, deep myometrial invasion, nonendometrioid histotype, and adjunctive chemotherapy were significantly associated with ILTC presence, and only stage was significant in the multivariable analysis. Overall, 61 women died: 30 of whom died of EC. ILTCs were nonsignificantly associated with higher overall and EC-specific mortality and mucosal ILTCs had the highest hazard ratios (1.64 and 1.89, respectively). Serially examined and embedded tubal fimbriae have a higher prevalence of ILTCs than routinely examined tubes, and high FIGO stage is an independent determinant. A prognostic effect was not found, but the higher trending hazard ratios suggest additional study is needed to determine whether ILTCs and in particular mucosal ILTCs adversely affect prognosis.

The effect of surgical approach on the outcomes and prognosis of high-risk histologic endometrioid carcinomas

Background

High-risk histologic endometrioid carcinomas include poorly differentiated endometrial carcinoma (PDEC), uterine clear cell carcinoma (UCCC), uterine carcinosarcoma (UCS), and uterine papillary serous carcinomas (UPCS). The purpose of this study was to investigate and compare the effect of open surgery and minimally invasive surgery on the prognosis of patients with high-risk endometrial cancer tissue types.

Methods

A retrospective analysis was conducted to investigate 57 UCS or UPCS, 53 UCCC, and 110 PDEC patients receiving initial treatment at the Department of Gynecology in Shaanxi Provincial Tumor hospital and the Affiliated Hospital of Medical College of Xi'an Jiaotong University between February 2010 and January 2015. Prognostic factors were determined using univariate/multivariate analysis, and survival rates were assessed using the Kaplan-Meier method. The Cox regression model was adopted to assess the independent prognostic factors.

Results

Two hundred and twenty patients who met the criteria were included in this study. At the end of follow-up period, 94 patients were still alive. Univariate analysis found that the survival time of the patients was related to staging, adjuvant therapy, and surgical approach. Multivariate analysis revealed that surgical approach, staging, pathology, and adjuvant therapy were independent prognostic factors.

Conclusions

Minimally invasive surgery has a shorter survival time compared to open surgery in women with PDEC, UCCC, UCS, and UPCS. Multivariate analysis confirmed that staging, pathological type, surgical approach, and postoperative adjuvant therapy are independent risk factors for prognosis and affect the survival of women with PDEC, UCCC, UCS, and UPCS.

ACR Appropriateness Criteria® Pretreatment Evaluation and Follow-Up of Endometrial Cancer

To date, there is little consensus on the role of pelvic imaging in assessing local disease extent during initial staging in patients with endometrial carcinoma, with practices differing widely across centers. However, when pretreatment assessment of local tumor extent is indicated, MRI is the preferred imaging modality. Preoperative imaging of endometrial carcinoma can define the extent of disease and indicate the need for subspecialist referral in the presence of deep myometrial invasion, cervical extension, or suspected lymphadenopathy. If distant metastatic disease is clinically suspected, preoperative assessment with cross-sectional imaging or PET/CT may be performed. However, most patients with low-grade disease are at low risk of lymph node and distant metastases. Thus, this group may not require a routine pretreatment evaluation for distant metastases. Recurrence rates in patients with endometrial carcinoma are infrequent. Therefore, radiologic evaluation is typically used only to investigate suspicion of recurrent disease due to symptoms or physical examination and not for routine surveillance after treatment. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Metastases to the ovary arising from endometrial, cervical and fallopian tube cancer: recent advances

The introduction of genomic studies has enabled assessment of the clonality of synchronous tumours involving the ovary and other sites in the female genital tract in a definitive way. This has led to the abandonment of conventional approaches to primary site assignment, and the recognition that most such synchronous neoplasms are clonally related single tumours with metastatic spread, rather than independent primary tumours. These discoveries have implications for diagnostic practice, analogous to the gradual change over the last few decades in our approach to mucinous neoplasms of the ovary metastatic from the gastrointestinal tract. In this review, we first examine the routes of metastasis to the ovary, and then discuss the diagnostic and clinical implications of concurrent ovarian carcinomas arising in combination with endometrial, endocervical and tubal carcinomas. It is proposed that cases of primary low-grade endometrioid endometrial carcinoma with a secondary unilateral ovarian tumour, both with indolent characteristics, may be classified as 'FIGO stage IIIA-simulating independent primary tumours', with a comment that conservative management would be appropriate. It should be recognised that human papillomavirus-associated endocervical adenocarcinomas may result in synchronous or metachronous ovarian metastases that appear to be unrelated to the primary tumour, and that these may be managed conservatively in the absence of other sites of disease. In cases of tubo-ovarian high-grade serous carcinoma, tubal intraepithelial or contralateral adnexal involvement should count as a pelvic disease site for staging purposes.

High-grade Pelvic Serous Carcinoma Within the Fallopian Tube Lumen: Real or Artifact?

Tumor cells are occasionally observed in the lumen in histologic sections of the fallopian tube from women with gynecologic cancer. There is some evidence that this finding may be important in endometrial cancer, but its significance is unknown in women with extrauterine pelvic serous carcinomas (tubo-ovarian high-grade serous carcinoma). Fallopian tube sections from 213 women with extrauterine pelvic serous carcinoma were reviewed, and luminal tumor cells were correlated with clinical and pathologic features. Intraluminal tumor cells were found in 84 patients (39%). The presence or absence of luminal tumor cells correlated significantly with serous tubal intraepithelial carcinoma (52% and 33%, respectively, P=0.004), tubal lymphatic invasion (32% and 12%, respectively, P=0.0002), and number of tube sections reviewed (6.6 and 4.9 for lumen-positive and lumen-negative cases, respectively, P=0.0056). There was no correlation with the presence of ascites, peritoneal cytopathologic findings, lymph node metastases, or FIGO stage. In the setting of pelvic serous carcinoma, a substantial portion of fallopian tube tissue is often distorted, fibrotic, and difficult to identify. Since the identification of luminal tumor cells, serous tubal intraepithelial carcinoma and tubal lymphatic invasion all depend on identification of fallopian tube tissue, these correlates with luminal tumor cells could be a result of a higher likelihood of their observation when tubal tissue can be more readily identified and may not necessarily reflect a biologically important phenomenon. It remains unclear whether and in what proportion this finding reflects an artifact of specimen handling.

Pathologic Prognostic Factors in Endometrial Carcinoma (Other Than Tumor Type and Grade)

Although endometrial carcinoma (EC) is generally considered to have a good prognosis, over 20% of women with EC die of their disease, with a projected increase in both incidence and mortality over the next few decades. The aim of accurate prognostication is to ensure that patients receive optimal treatment and are neither overtreated nor undertreated, thereby improving patient outcomes overall. Patients with EC can be categorized into prognostic risk groups based on clinicopathologic findings. Other than tumor type and grade, groupings and recommended management algorithms may take into account age, body mass index, stage, and presence of lymphovascular space invasion. The molecular classification of EC that has emerged from the Cancer Genome Atlas (TCGA) study provides additional, potentially superior, prognostic information to traditional histologic typing and grading. This classifier does not, however, replace clinicopathologic risk assessment based on parameters other than histotype and grade. It is envisaged that molecular and clinicopathologic prognostic grouping systems will work better together than either alone. Thus, while tumor typing and grading may be superseded by a classification based on underlying genomic abnormalities, accurate assessment of other pathologic parameters will continue to be key to patient management. These include those factors related to staging, such as depth of myometrial invasion, cervical, vaginal, serosal surface, adnexal and parametrial invasion, and those independent of stage such as lymphovascular space invasion. Other prognostic parameters will also be discussed. These recommendations were developed from the International Society of Gynecological Pathologists Endometrial Carcinoma project.

High-grade Endometrial Carcinomas: Morphologic and Immunohistochemical Features, Diagnostic Challenges and Recommendations

This review of challenging diagnostic issues concerning high-grade endometrial carcinomas is derived from the authors' review of the literature followed by discussions at the Endometrial Cancer Workshop sponsored by the International Society of Gynecological Pathologists in 2016. Recommendations presented are evidence-based, insofar as this is possible, given that the levels of evidence are weak or moderate due to small sample sizes and nonuniform diagnostic criteria used in many studies. High-grade endometrioid carcinomas include FIGO grade 3 endometrioid carcinomas, serous carcinomas, clear cell carcinomas, undifferentiated carcinomas, and carcinosarcomas. FIGO grade 3 endometrioid carcinoma is diagnosed when an endometrioid carcinoma exhibits >50% solid architecture (excluding squamous areas), or when an architecturally FIGO grade 2 endometrioid carcinoma exhibits marked cytologic atypia, provided that a glandular variant of serous carcinoma has been excluded. The most useful immunohistochemical studies to make the distinction between these 2 histotypes are p53, p16, DNA mismatch repair proteins, PTEN, and ARID1A. Endometrial clear cell carcinomas must display prototypical architectural and cytologic features for diagnosis. Immunohistochemical stains, including, Napsin A and p504s can be used as ancillary diagnostic tools; p53 expression is aberrant in a minority of clear cell carcinomas. Of note, clear cells are found in all types of high-grade endometrial carcinomas, leading to a tendency to overdiagnose clear cell carcinoma. Undifferentiated carcinoma (which when associated with a component of low-grade endometrioid carcinoma is termed "dedifferentiated carcinoma") is composed of sheets of monotonous, typically dyscohesive cells, which can have a rhabdoid appearance; they often exhibit limited expression of cytokeratins and epithelial membrane antigen, are usually negative for PAX8 and hormone receptors, lack membranous e-cadherin and commonly demonstrate loss of expression of DNA mismatch repair proteins and SWI-SNF chromatin remodeling proteins. Carcinosarcomas must show unequivocal morphologic evidence of malignant epithelial and mesenchymal differentiation.

Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites

In most cases of suspected endometrial neoplasia tumor origin can be correctly assigned according to a combination of clinical, radiologic, and pathologic features, even when the latter are based upon the examination of relatively small biopsy samples. However there are well-recognized exceptions to this rule which continue to create diagnostic difficulty, and sometimes difficulties persist even after the detailed examination of resection specimens. Among the most common problems encountered in practice are the distinction of primary endometrial and primary endocervical adenocarcinomas, and the determination of tumor origin when there is synchronous, multifocal involvement of gynecologic tract sites, for example the endometrium and the ovary. However, accurate diagnosis in these cases is important because this has significant staging, management and prognostic implications. In this review we discuss the value and limitations of key morphologic, immunophenotypic and molecular findings in these diagnostic scenarios.

Expression of ELF5 in endometrial carcinoma tissues and its clinical significance

Expression of E74-like factor 5 (ELF5) in endometrial carcinoma tissues and its clinical significance were investigated. Eighty-four endometrial carcinoma tissues, 30 cases of atypical hyperplasia of endometrium and 30 cases of normal endometrial tissues were selected. Immunohistochemical method was utilized to detect the expression of ELF5 in different endometrial tissues. Moreover, its correlation with clinical pathological indexes of patients with endometrial carcinoma was analyzed. The postoperative follow-up was conducted in all the patients with endometrial carcinoma until June 30th, 2017. The Kaplan-Meier method was used for survival analysis so as to analyze the association of ELF5 expression level with clinical pathological indexes; Cox's proportional hazards regression model was utilized for univariate and multivariate analyses to screen independent risk factors for prognosis of endometrial carcinoma. In normal endometrial tissues, atypical hyperplasia and endometrial carcinoma tissues, the positive expression rates of ELF5 showed a decreased tendency (P=0.016). The positive expression rate of ELF5 in endometrial carcinoma tissues was lower in comparison to normal endometrial tissues (P=0.016). The expression of ELF5 was in accordance with the International Federation of Gynecology and Obstetrics (FIGO) staging of endometrial carcinoma (P<0.05), pathological grading (P<0.05), pathological typing (P=0.001), state of lymph node metastasis (P<0.05) and depth of myometrial invasion (P<0.05). Kaplan-Meier method for survival analysis showed that the average survival time of patients with negative ELF5 expression was shorter in comparison to the patients with positive expression (P=0.004). FIGO staging (P=0.004), pathological grading (P=0.048), depth of myometrial invasion (P=0.024) and lymph node metastasis (P=0.020) were related to the prognosis of patients with endometrial carcinoma, The univariate Cox's regression model analysis indicated that FIGO staging (P=0.010), pathological grading (P=0.040), depth of myometrial invasion (P=0.037), lymph node metastasis (P=0.029) and ELF5 (P=0.010) were associated with the prognosis of patients with endometrial carcinoma. Further, multivariate analysis revealed that ELF5 was an independent risk factor for prognosis of patients with endometrial carcinoma (P=0.035). The expression of ELF5 has a correlation with the occurrence, development and prognosis of endometrial carcinoma.

Detection of endometrial cancer cells in the fallopian tube lumen is associated with adverse prognostic factors and reduced survival

OBJECTIVE

Stage is a critical determinant of prognosis and treatment for endometrial cancer (EC) patients. Women who have had a tubal ligation for sterilization have improved EC survival, secondary to lower stage at presentation, suggesting that transtubal spread may represent an important route of metastasis. We evaluated detection of intraluminal tumor cells (ILTCs) in relation to tumor characteristics and survival.

METHODS

One pathologist retrospectively evaluated hematoxylin and eosin sections of routinely collected fallopian tubes for ILTCs from 295 EC patients, masked to outcome. We used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between demographic (age, race) and clinical [FIGO 2009 stage, lymphovascular space invasion (LVSI), histological subtype] characteristics and ILTCs. Cox regression was used to estimate hazard ratios (HRs) and 95% CIs for associations between ILTCs and recurrence-free survival (RFS) and EC-specific survival, overall and stratified by histological subtype or stage.

RESULTS

In univariable logistic regression models, age (55-64 vs. ≥65: OR = 3.41, 95% CI = 1.48-7.84), stage (stage IV vs. stage I OR = 14.58, 95% CI = 5.27-40.35), LVSI (OR = 2.93, 95% CI = 1.42-6.04), and histological subtype (serous vs. low-grade endometrioid OR = 3.21, 95% CI = 1.08-9.58), were associated with ILTCs. Only age and stage remained significantly associated with ILTCs in adjusted models. ILTCs were significantly associated with lower EC-specific survival among women with serous EC or stage I disease; however, adjustment for age, stage, and histology attenuated these associations.

CONCLUSION

Our findings suggest that ILTCs are associated with adverse EC prognostic features and reduced survival in cases of early stage or serous histology.

Clinical Significance of Positive Pelvic Washings in Uterine Papillary Serous Carcinoma Confined to an Endometrial Polyp

Uterine papillary serous carcinoma (UPSC) represents 10% of endometrial carcinomas. Significant number of patients initially present with extrauterine disease. The role of adjuvant treatment in low stage, especially polyp-confined UPSC is controversial. This multi-institutional study evaluated the significance of positive pelvic washing (PW) and adjuvant treatment on disease recurrence in a setting of endometrial polyp-confined UPSC. Surgical pathology files from 3 institutions were searched for cases of endometrial polyp-confined UPSC. Following histologic review, cases were clinically staged as Stage I, without myoinvasion or lymphovascular invasion. Clinicopathologic characteristics, results of PW, and type of adjuvant therapy were recorded. Statistical analysis using the Kaplan-Meier method for survival and Fisher exact test were performed. Thirty-three patients were included in the study. All patients were diagnosed with polyp-confined UPSC. The size of the polyp ranged from 0.3 to 4.3 cm. PW was positive for tumor cells in 8/33 (24%) patients. Twenty-two patients (66.6%) received some type of adjuvant treatment. Six patients (18%) developed recurrent disease. There was no significant difference in disease-free survival in the patients receiving adjuvant treatment versus not (P=0.375). However, there was significant association (P=0.0013) between positive PW and disease recurrence. Data are conflicting whether positive PW affects prognosis in low-stage endometrial carcinomas. Our study showed that in UPSC, malignant cells can be present in PW without lymphovascular invasion or myoinvasion and may have negative prognostic implication. Our data also reflect the controversies in the role of adjuvant treatment in endometrium-confined UPSC.

Müllerian intra-abdominal carcinomatosis in hereditary breast ovarian cancer syndrome: implications for risk-reducing surgery

More than 40 years ago Lynch et al. described several multigenerational breast cancer family pedigrees which demonstrated autosomal dominant inheritance of a trait(s) that increased risks for both breast and ovarian cancers. Mutation carriers in at least 90 % of these hereditary breast ovarian cancer (HBOC) syndrome families have been linked to cancer-associated mutations in the genes BRCA1 and BRCA2. This review focuses on the contributions of Lynch, colleagues and collaborators and pertinent literature, toward defining the HBOC syndrome, the cancer risks that the inherited adverse mutations convey, the gynecologic tissues and organs from which the malignancy may arise to disseminate throughout the pelvic and abdominal organs and peritoneum and how this information can be used to reduce the risk and morbidities of intra-abdominal carcinomatosis in effected individuals.

Vaginal implantation metastasis of endometrial carcinoma: A case report

Endometrial cancer is the most common malignancy of the female reproductive system. The three common spread patterns of endometrial cancer are local invasion, lymphatic spread and hematogenous spread. Vaginal metastasis occurs by submucosal lymphatic or vascular metastases in ~10% of patients with clinical stage I disease. Vaginal implantation metastasis of endometrial cancer is extremely rare. Here we present a case of endometrial carcinoma (International Federation of Gynecology and Obstetrics stage IA) spread to the vagina by implantation metastasis as opposed to any of the methods mentioned above. This conclusion was confirmed mainly from pathological examination. This case highlights the occurrence of vaginal implantation metastasis of endometrial carcinoma. Certain changes may be applied during surgery to prevent implantation metastasis in patients with endometrial cancer.

Prior Tubal Ligation Might Influence Metastatic Spread of Nonendometrioid Endometrial Carcinoma

OBJECTIVE

The exfoliation of endometrial carcinoma might intraperitoneally spread through the fallopian tube. We analyzed the influence of prior tubal ligation (TL) in endometrial carcinoma to evaluate whether it can prevent the process and improve patients' survival.

METHODS

A total of 562 patients with a diagnosis of endometrial carcinoma at the Peking University People's Hospital between July 1995 and June 2012 were enrolled in this study. The patients were divided into 2 groups based on the presence or absence of prior TL. International Federation of Gynecology and Obstetrics stage distributions, recurrence rates, survival status, and histopathological findings were compared between the 2 groups. Kaplan-Meier estimates and log-rank tests were used to compare the survival status based on TL in the overall population and stratified by histopathological subtypes and International Federation of Gynecology and Obstetrics stages. Cox models analysis was used to estimate the hazard ratios and 95% confidence intervals for associations between TL and carcinoma-specific mortality. All statistical tests were 2-sided.

RESULTS

Of the 562 patients, 482 (85.7%) had a diagnosis of endometrioid and 80 patients (14.2%) with nonendometrioid carcinoma. Tubal ligation was associated with negative peritoneal cytology in the total population (P = 0.015) and in patients with endometrioid carcinomas (P = 0.02) but not help to reduce carcinoma-specific mortality (P = 0.095 and P = 0.277, respectively). In the nonendometrioid group, TL was not only associated with negative peritoneal cytology (P = 0.004) but also with lower stage (P < 0.001) and lower recurrence rate(P < 0.005), resulting in improved prognosis (P = 0.022). In Cox models analysis adjusted for covariates, TL was inversely associated with lower endometrial carcinoma-specific mortality (hazard ratio, 0.47; 95% confidence interval, 0.14-2.6).

CONCLUSION

Tubal ligation was associated with lower positive peritoneal cytology, stages, and recurrence rate, and improved prognosis among patients with nonendometrioid carcinoma. Tubal ligation might influence metastatic spread of nonendometrioid endometrial carcinoma. It could also help to reduce positive peritoneal cytology among patients with endometrioid carcinoma, but lacked prognostic significance.

Associations between etiologic factors and mortality after endometrial cancer diagnosis: the NRG Oncology/Gynecologic Oncology Group 210 trial

BACKGROUND

Few studies have analyzed relationships between risk factors for endometrial cancer, especially with regard to aggressive (non-endometrioid) histologic subtypes, and prognosis. We examined these relationships in the prospective NRG Oncology/Gynecologic Oncology Group 210 trial.

METHODS

Prior to surgery, participants completed a questionnaire assessing risk factors for gynecologic cancers. Pathology data were derived from clinical reports and central review. We used the Fine and Gray subdistribution hazards model to estimate subhazard ratios (HRs) and 95% confidence intervals (CIs) for associations between etiologic factors and cause-specific subhazards in the presence of competing risks. These models were stratified by tumor subtype and adjusted for stage and socioeconomic status indicators.

RESULTS

Median follow-up was 60months after enrollment (range: 1day-118months). Among 4609 participants, a total of 854 deaths occurred, of which, 582 deaths were attributed to endometrial carcinoma. Among low-grade endometrioid cases, endometrial carcinoma-specific subhazards were significantly associated with age at diagnosis (HR=1.04, 95% CI=1.01-1.06 per year, P-trend) and BMI (class II obesity vs. normal BMI: HR=2.29, 95% CI=1.06-4.98, P-trend=0.01). Among high-grade endometrioid cases, endometrial carcinoma-specific subhazards were associated with age at diagnosis (HR=1.05, 95% CI=1.02-1.07 per year, P-trend<0.001). Among non-endometrioid cases, endometrial carcinoma-specific subhazards were associated with parity relative to nulliparity among serous (HR=0.55, 95% CI=0.36-0.82) and carcinosarcoma cases (HR=2.01, 95% CI=1.00-4.05).

DISCUSSION

Several endometrial carcinoma risk factors are associated with prognosis, which occurs in a tumor-subtype specific context. If confirmed, these results would suggest that factors beyond histopathologic features and stage are related to prognosis. ClinicalTrials.gov Identifier: NCT00340808.

Relationships of Tubal Ligation to Endometrial Carcinoma Stage and Mortality in the NRG Oncology/ Gynecologic Oncology Group 210 Trial

BACKGROUND

Stage is a critical determinant of treatment among endometrial carcinoma patients; understanding patterns of tumor spread may suggest approaches to improve staging. Specifically, the importance of exfoliation of endometrial carcinoma cells through the fallopian tubes into the peritoneum is ill defined. We assessed the hypothesis that tubal ligation (TL), which should impede transtubal passage of cells, is associated with lower endometrial carcinoma stage at presentation and, consequently, lower mortality.

METHODS

The NRG Oncology/Gynecologic Oncology Group (GOG) 210 Trial included 4489 endometrial carcinoma patients who completed a risk factor questionnaire that included TL history. Pathology data were derived from clinical reports and central review. We used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between TL with stage and peritoneal metastasis, overall and by tumor subtype. Cox regression was used to estimate hazard ratios (HRs) and 95% confidence intervals for TL and mortality. All statistical tests were two-sided.

RESULTS

Compared with stage I, TL was inversely associated with stage III (OR = 0.63, 95% CI = 0.52 to 0.78) and stage IV carcinomas (OR = 0.14, 95% CI = 0.08 to 0.24) overall and among individual tumor subtypes. TL was inversely related to peritoneal metastasis overall (OR = 0.39, 95% CI = 0.22 to 0.68) and among serous carcinomas (OR = 0.28, 95% CI = 0.11 to 0.68). In multivariable models unadjusted for stage, TL was associated with lower endometrial carcinoma-specific mortality (HR = 0.74, 95% CI = 0.61 to 0.91); however, adjustment for stage eliminated the survival advantage. Similar relationships with all-cause mortality were observed.

CONCLUSIONS

TL is associated with lower stage and mortality among women with aggressive endometrial carcinomas, suggesting transtubal spread is clinically important. Future studies should evaluate whether detection of intraluminal tumor cells is prognostically relevant.

Endometrial Cancers in Mutation Carriers From Hereditary Breast Ovarian Cancer Syndrome Kindreds: Report From the Creighton University Hereditary Cancer Registry With Review of the Implications

Objective

The aim of this study was to categorize and report endometrial cancers in mutation carriers from hereditary breast ovarian cancer families.

Methods

Our Hereditary Cancer Registry was searched for gynecologic and peritoneal cancers linked to mutations in BRCA1 or BRCA2. Invasive cancers were registered in 101 mutation carriers with complete pathology reports. Efforts were made to secure diagnostic surgical pathology tissues for review. All records and available diagnostic slides were meticulously studied, and primary cancers were classified.

Findings

Eight malignancies were classified as primary endometrial cancers. Five of these were low- or intermediate-grade endometrioid carcinomas, and 3 were pure serous carcinomas or contained serous carcinoma elements mixed with high-grade endometrioid carcinoma. Breast cancers were diagnosed in 5 patients before and in 1 patient after endometrial carcinoma. Three endometrioid carcinomas were preceded by estrogen treatment, 2 for many years and the other for only 2 months, and 2 of the patients with serous carcinoma had been treated with tamoxifen.

Conclusions

The finding that 8 of gynecologic and peritoneal cancers in 101 mutation carriers were endometrial cancers with a smaller proportion of endometrioid carcinomas than reported in general populations is added to the current controversial literature on endometrial cancer, particularly regarding serous carcinomas, in hereditary breast ovarian cancer syndrome. Well-designed prospective programs for standardized surgical and pathologic handling, processing, and reporting are essential for working out the pathogenesis, true risks, and best management of this disease in carriers of deleterious BRCA1 and BRCA2 germline mutations.