HE4 and CA125 levels in the preoperative assessment of endometrial cancer patients: a prospective multicenter study (ENDOMET)

The Added Value of ADC-based Nomogram in Assessing the Depth of Myometrial Invasion of Endometrial Endometrioid Adenocarcinoma

RATIONALE AND OBJECTIVES

To explore the potential value of the apparent diffusion coefficient (ADC)-based nomogram models in preoperatively assessing the depth of myometrial invasion of endometrial endometrioid adenocarcinoma (EEA).

MATERIALS AND METHODS

Preoperative magnetic resonance imaging (MRI) of 210 EEA patients were retrospectively analyzed. ADC histogram metrics derive from the whole-tumor regions of interest. Univariate and multivariate analyses were used to screen the ADC histogram metrics and clinical characteristics for nomogram model building. The diagnostic sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of two radiologists without and with the assistance of models were calculated and compared.

RESULTS

Two nomogram models were developed for predicting no myometrial invasion (NMI) and deep myometrial invasion (DMI) with area under the curves of 0.85 and 0.82, respectively. With the assistance of models, the overall accuracies were significantly improved [radiologist_1, 73.3% vs 86.2% (p = 0.001); radiologist_2, 80.0% vs 91.0% (p = 0.002)]. In determining NMI, the sensitivity and PPV were greatly improved but not significant for radiologist_1 (51.9% vs 77.8% and 46.7% vs 75.0%, p = 0.229 and 0.511), and under/near the significance level for radiologist_2 (59.3% vs 88.9% and 57.1% vs 82.8%, p = 0.041 and 0.065), while the specificity, accuracy, and NPV were significantly improved (all p < 0.001). In determining DMI, all sensitivity, specificity, accuracy, PPV, and NPV were significantly improved (all p < 0.001).

CONCLUSION

The ADC-based nomogram models can improve the diagnostic performance of radiologist in preoperatively assessing the depth of myometrial invasion and facilitate optimizing clinical individualized treatment decisions.

Discovery of the potential biomarkers for early diagnosis of endometrial cancer via integrating metabolomics and transcriptomics

Endometrial cancer (EC) is one of the most common malignant tumors in women, and the increasing incidence and mortality pose a serious threat to the public health. Early diagnosis of EC could prolong the survival period and optimize the survivorship, greatly alleviating patients' suffering and social medical pressure. In this study, we collected urine and serum samples from the recruited patients, analyzed the samples using LC-MS approach, and identified the differential metabolites through metabolomic analysis. Then, the differentially expressed genes were identified through the systematic transcriptomic analysis of EC-related dataset from Gene Expression Omnibus (GEO), followed by network profiling of metabolic-reaction-enzyme-gene. In this experiment, a total of 83 differential metabolites and 19 hub genes were discovered, of which 10 different metabolites and 3 hub genes were further evaluated as more potential biomarkers based on network analysis. According to the KEGG enrichment analysis, the potential biomarkers and gene-encoded proteins were found to be involved in the arginine and proline metabolism, histidine metabolism, and pyrimidine metabolism, which was of significance for the early diagnosis of EC. In particular, the combination of metabolites (histamine, 1-methylhistamine, and methylimidazole acetaldehyde) as well as the combination of RRM2, TYMS and TK1 exerted more accurate discrimination abilities between EC and healthy groups, providing more criteria for the early diagnosis of EC.

Development and validation of prediction model for early warning of ovarian metastasis risk of endometrial carcinoma

Ovarian metastasis of endometrial carcinoma (EC) patients not only affects the decision of the surgeon, but also has a fatal impact on the fertility and prognosis of patients. This study aimed build a prediction model of ovarian metastasis of EC based on machine learning algorithm for clinical diagnosis and treatment management guidance. We retrospectively collected 536 EC patients treated in Hubei Cancer Hospital from January 2017 to October 2022 and 487 EC patients from Tongji Hospital (January 2017 to December 2020) as an external validation queue. The random forest model, gradient elevator model, support vector machine model, artificial neural network model (ANNM), and decision tree model were used to build ovarian metastasis prediction model for EC patients. The predictive efficacy of 5 machine learning models was evaluated by receiver operating characteristic curve and decision curve analysis. For screening of candidate predictors of ovarian metastasis of EC, the degree of tumor differentiation, lymph node metastasis, CA125, HE4, Alb, LH can be used as a potential predictor of ovarian metastasis prediction model in EC patients. The effectiveness of the prediction model constructed by the 5 machine learning algorithms was between (area under curve [AUC]: 0.729, 95% confidence interval [CI]: 0.674-0.784) and (AUC: 0.899, 95% CI: 0.844-0.954) in the training set and internal verification set, respectively. Among them, the ANNM was equipped with the best prediction effectiveness (training set: AUC: 0.899, 95% CI: 0.844-0.954) and (internal verification set: AUC: 0.892, 95% CI: 0.837-0.947). The prediction model of ovarian metastasis of EC patients based on machine learning algorithm can achieve satisfactory prediction efficiency, among which ANNM is the best, which can be used to guide clinicians in diagnosis and treatment and improve the prognosis of EC patients.

Revised Cut-Off Value of Human Epididymis Protein 4 Enhances Its Use as an Ovarian Tumor Marker

OBJECTIVES

Human epididymis protein 4 (HE4), a protein secreted by ovarian tumors, has been used as an ovarian tumor marker. This study aimed to improve the usefulness of HE4 to detect malignant ovarian tumors by reviewing the cut-off values.

DESIGN

A retrospective study without intervention was conducted.

PARTICIPANTS

One hundred forty-nine healthy women (premenopausal, 126; postmenopausal, 23) and 24 patients with ovarian tumors (malignant, 12; benign, 12) participated in the study.

SETTING

The study used the Department of Obstetrics and Gynecology of a university hospital in Japan and the university hospital as a workplace from 2016 to 2018.

METHODS

The basic performance of the HE4 assay was evaluated, and the serum HE4 levels of participants were measured. Receiver operating characteristic analysis was performed using the HE4 data of the patients.

RESULTS

There were no significant differences in HE4 levels between the pre- and postmenopausal groups of healthy women. When the global cut-off values (premenopausal, 70 pmol/L; postmenopausal, 140 pmol/L) were adopted, the clinical sensitivity, specificity, positive predictive value, and negative predictive value were 41.7%, 91.7%, 83.3%, and 61.1%, respectively. Based on the results of the receiver operating characteristic analysis, we set the HE4 cut-off level at 60 pmol/L, regardless of the menopausal status. With the newly set cut-off value, the clinical sensitivity, specificity, positive predictive value, and negative predictive value were 66.7%, 91.7%, 88.9%, and 73.3%, respectively. That is, the clinical sensitivity of HE4 was improved without lowering specificity.

LIMITATIONS

The small number of subjects and the fact that the health status of the healthy women was evaluated based on questionnaires were limitations to the study.

CONCLUSION

A clinically useful cut-off value for HE4 as an ovarian tumor marker was established regardless of the menopausal status of the women, with improved clinical sensitivity, positive predictive value, and negative predictive value without lowering specificity. Currently, different cut-off values for HE4 in pre- and postmenopausal women are used globally. The cut-off value for CA125 was the same between pre- and postmenopausal women. Therefore, with the newly established cut-off value, HE4 can be used more conveniently in a non-specialized setting, especially when it is used in combination with CA125.

Endometrioid adenocarcinoma: combined multiparametric MRI and tumour marker HE4 to evaluate tumour grade and lymphovascular space invasion

AIM

To assess the value of semi-quantitative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and quantitative diffusion-weighted imaging parameters combined with human epididymis protein 4 (HE4) in predicting the pathological grade and lymphovascular space invasion (LVSI) of endometrioid adenocarcinoma (EAC).

MATERIALS AND METHODS

Between October 2018 and December 2021, 60 women (mean age, 55 [range, 32-77] years) with EAC underwent preoperative pelvic MRI and HE4 level measurements. The positive enhancement integral (PEI), time to peak, maximum slope of increase (MSI), and maximum slope of decrease were measured by manually drawing a region of interest on the neoplastic tissue. The receiver operating characteristic curve was used to calculate the diagnostic efficiency of the single parameter and combined factors.

RESULTS

Lower apparent diffusion coefficients (ADCs) were observed in high-grade tumours (G3) than in low-grade tumours (G1/G2). PEI, MSI, and HE4 levels were higher in the high-grade tumours than in the low-grade tumours (p<0.05). The area under the curve (AUC) for G3 diagnosis using multiparametric MRI combined with HE4 was 0.929. ADC values were significantly lower in the EAC with LVSI than in those without LVSI. Tumours with LVSI showed higher PEI and HE4 levels than those without LVSI (p<0.05). The AUC for LVSI-positive diagnosis using multiparametric MRI combined with HE4 was 0.814.

CONCLUSION

Semi-quantitative DCE-MRI, ADC values, and serum HE4 levels can be used to predict tumour grade and LVSI, and the prediction efficiency of multiparametric MRI combined with serum HE4 is better than that of any single factor.

Update value and clinical application of MUC16 (cancer antigen 125)

INTRODUCTION

The largest transmembrane mucin, mucin 16 (MUC16), contains abundant glycosylation sites on the molecular surface, allowing it to participate in various molecular pathways. When cells lose polarity and become cancerous, MUC16 is overexpressed, and more of the extracellular region (cancer antigen [CA]125) is released into serum and possibly, promote the development of diseases. Thus, MUC16 plays an indispensable role in clinical research and application.

AREAS COVERED

This review summarizes the update proposed role of MUC16 in carcinogenesis and metastasis. Most importantly, we prospect its potential value in targeted therapy after screening 1226 articles published within the last 10 years from PubMed. Two reviewers screened each record and each report retrieved independently. We have summarized the progress of MUC16/CA125 in basic research and clinical application, and predicted its possible future development directions.

EXPERT OPINION

As an important noninvasive co-factor in the diagnosis of gynecological diseases, MUC16 has been used for a long time, especially in the diagnosis and treatment of ovarian cancer. The overexpression of MUC16 plays a very obvious role in regulating inflammatory response, supporting immune suppression, and promoting the proliferation, division, and metastasis of cancer cells. In the next 20 years, there will be a luxuriant clinical application of MUC16 as a target for immune monitoring and immunotherapy.

Serum HE4 predicts progestin treatment response in endometrial cancer and atypical hyperplasia: A prognostic study

OBJECTIVE

To investigate serum human epididymis-4 (HE4) as a predictive biomarker of intrauterine progestin response in endometrial cancer and atypical endometrial hyperplasia (AEH).

DESIGN

Prospective prognostic factor study.

SETTING

Consecutive sample of women attending a tertiary gynaecological oncology centre in northwest England.

POPULATION

Women with AEH or early-stage, low-grade endometrial cancer who were unfit for or declined primary surgical management.

METHODS

A total of 76 women, 32 with AEH and 44 with endometrial cancer, were treated with a levonorgestrel intrauterine system (LNG-IUS) for 12 months. Endometrial biopsies and imaging were performed to assess treatment response. Pretreatment serum HE4 was analysed by chemiluminescence immunoassay and diagnostic accuracy and logistic regression analyses were performed.

MAIN OUTCOME MEASURES

Progestin response at 12 months defined by histology and imaging.

RESULTS

The median age and body mass index (BMI) of the final cohort were 52 years (interquartile range [IQR] 33-62 years) and 46 kg/m2 (IQR 38-54 kg/m2 ), respectively. Baseline serum HE4 was significantly higher in non-responders than responders (119.2 pmol/L, IQR 94.0-208.4 pmol/L versus 71.8 pmol/L, IQR 56.1-84.2 pmol/L, p < 0.001). Older age (odds ratio [OR] 0.96, 95% CI 0.93-0.99, p = 0.02), baseline serum HE4 (OR 0.97, 95% CI 0.96-0.99, p = 0.001) and endometrial cancer histology (OR 0.22, 95% CI 0.72-0.68, p = 0.009) were associated with a lower likelihood of progestin treatment response. Serum HE4 remained independently associated with progestin treatment failure when adjusted for age and histology (adjusted hazard ratio 0.97, 95% CI 0.96-0.99, p = 0.008).

CONCLUSION

Serum HE4 shows promise as a predictive biomarker of progestin treatment response in endometrial cancer and AEH.

KNL1 is a prognostic and diagnostic biomarker related to immune infiltration in patients with uterine corpus endometrial carcinoma

Background

The incidence and mortality of uterine corpus endometrial carcinoma (UCEC) are increasing yearly. There is currently no screening test for UCEC, and progress in its treatment is limited. It is important to identify new biomarkers for screening, diagnosing and predicting the outcomes of UCEC. A large number of previous studies have proven that KNL1 is crucial in the development of lung cancer, colorectal cancer and cervical cancer, but there is a lack of studies about the role of KNL1 in the development of UCEC.

Methods

The mRNA and protein expression data of KNL1 in The Cancer Genome Atlas (TCGA), Gene Expression Omnibus (GEO) and UALCAN databases and related clinical data were used to analyze the expression differences and clinical correlations of KNL1 in UCEC. A total of 108 clinical samples were collected, and the results of bioinformatics analysis were verified by immunohistochemistry. KNL1 and its related differentially expressed genes were used to draw a volcano map, construct a PPI protein interaction network, and perform gene ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), gene set enrichment analysis (GSEA) and immune infiltration analysis to predict the function of KNL1 during UCEC progression. The prognostic data of TCGA and 108 clinical patients were used to analyze the correlation of KNL1 expression with the survival of patients, and KM survival curves were drawn. The UCEC cell lines Ishikawa and Hec-1-A were used to verify the function of KNL1.

Results

KNL1 is significantly overexpressed in UCEC and is associated with a poor prognosis. KNL1 overexpression is closely related to cell mitosis, the cell cycle and other functions and is correlated with the International Federation of Gynecology and Obstetrics (FIGO) stage, histological grade and other characteristics of UCEC patients. Knockdown of KNL1 expression in UCEC cell lines can inhibit their proliferation, invasion, metastasis and other phenotypes.

Conclusion

KNL1 is a prognostic and diagnostic biomarker associated with immune evasion in patients with UCEC.

Serum CA125 and HE4 as Biomarkers for the Detection of Endometrial Cancer and Associated High-Risk Features

Early detection of endometrial cancer improves survival. Non-invasive diagnostic biomarkers would improve triage of symptomatic women for investigations. This study aimed to determine the diagnostic accuracy of serum Cancer Antigen 125 (CA125) and Human Epididymis 4 (HE4) for endometrial cancer and associated high-risk features. Serum samples from women investigated for gynaecological symptoms or diagnosed with endometrial cancer were analysed for CA125 and HE4. Conventional diagnostic metrics were calculated. In total, 755 women were included; 397 had endometrial cancer. Serum CA125 and HE4 were significantly elevated in cases compared with controls (both p < 0.001), and with pathological markers of disease severity (p < 0.05). A combination of CA125 and HE4 detected endometrial cancer with an area under the curve (AUC) of 0.77 (95% CI: 0.74−0.81). In a model with body mass index (BMI) and parity, HE4 predicted endometrial cancer in pre-menopausal women with an AUC of 0.91 [sensitivity = 84.5%, specificity = 80.9% (p < 0.001)]. In women with abnormal ultrasound, HE4 ≥ 77 pmol/L improved specificity compared with imaging alone [68.6% (95% CI: 75.0−83.6) vs. 34.4% (95% CI: 27.1−42.3), respectively], but at a cost to sensitivity. HE4 ≥ 77 pmol/L improved the detection of myometrial invasion ≥50% in women with stage I disease compared with magnetic resonance imaging (MRI) alone [sensitivity = 100% (95% CI: 54.1−100)]. CA125 ≥ 35 U/mL did not add to imaging. HE4 is a good predictor of poor prognostic features which could assist staging investigations.

CA125 as a predictor of endometrial cancer lymphovascular space invasion and lymph node metastasis for risk stratification in the preoperative setting

Endometrial cancer (EC) is the most common malignancy of the female reproductive system. Cancer antigen 125 (CA125) is a serum tumor marker widely reported in EC patients, particularly those with poor prognostic factors such as grade 3 tumors, deep myometrial invasion, lymph node metastasis (LNM), and extra-uterine disease. This retrospective study stratifies pre-operative CA125 levels to evaluate odds ratios (OR) and relative risk (RR) between CA125 levels and the likelihood of +LNM, lymphovascular space invasion (LVSI), grade, and stage. Patient charts for women 18 years or older with a diagnosis of EC and pre-operative or within one week CA125 measurement from January 2000 to January 2015 at a regional hospital were reviewed. OR and RR were determined by unconditional maximum likelihood estimation for CA125 levels as the predictor with staging, grade, +LVSI and +LNM as outcomes. The largest increase in risk for patients having stage I/II/III disease was 52% greater (1.52-fold risk) while largest increase in risk for patients having stage III/IV disease was 67% greater (1.67-fold risk), both at CA125 ≥ 222U/ml. Patients with CA125 ≥ 122U/ml had significantly increased risk of +LNM, with maximum increase in risk of 98% (1.98-fold risk) at 222U/ml. Patients with CA125 ≥ 175U/ml had significantly increased risk of +LVSI, with maximum increase in risk of 39% (1.39-fold risk) at 222U/ml. This study shows that elevated CA125 levels correspond to increased stage, +LVSI, and +LNM in patients with EC.

Prognostic values of human epididymis protein 4 expression in patients with endometrial cancer: A systematic review and meta-analysis

BACKGROUND

There is no consensus on the correlation between human epididymis protein 4 (HE4) and prognosis of endometrial cancer (EC). Therefore, we performed a meta-analysis to assess the relationship between HE4 and prognosis of EC.

METHODS

In this systematic review and meta-analysis, the databases were searched. Correlation of serum or tissue HE4 with clinicopathological characteristics was determined by odds ratio (OR) or standardized mean difference (SMD) with 95% confidence interval (CI), respectively. The hazard ratio (HR) with 95% CI was calculated to evaluate the correlation between HE4 and survival outcome.

RESULTS

A total of 38 published studies were eligible. We found that high levels of serum HE4 were associated with FIGO III-IV stage (SMD = 1.58, 95%CI: 1.18-1.98, p < 0.001), grade 3 (SMD = 0.66, 95%CI: 0.39-0.93, p = 0.001), ≥50% myometrial invasion (SMD = 0.78, 95%CI: 0.58-0.99, p < 0.001), lymphovascular space invasion (SMD = 0.82, 95%CI: 0.54-1.11, p = 0.001), lymph node metastasis (SMD = 1.27, 95%CI: 0.84-1.69, p < 0.001), cervical involvement (SMD = 0.71, 95%CI: 0.43-0.98, p = 0.003), parametrial involvement (SMD = 1.03, 95%CI: 0.71-1.35, p < 0.001) and peritoneal cytology (SMD = 0.49, 95%CI: 0.22-0.75, p < 0.001). High expression of tissue HE4 was only significantly associated with lymph node metastasis (OR = 6.19, 95%CI: 2.07-18.50, p = 0.001). High levels of serum HE4 were significantly associated with poor overall survival (univariate: HR = 3.77, 95%CI: 1.94-7.32, p < 0.001; multivariate: HR = 2.15, 95%CI: 1.65-2.80, p < 0.001) and disease-free survival (univariate: HR = 2.89, 95%CI: 2.14-3.88, p < 0.001; multivariate: HR = 2.31, 95%CI:1.20-2.67, p < 0.001) in EC. Compared with cancer antigen 125, serum HE4 may be a better prognostic indicator for EC.

CONCLUSIONS

High HE4 expression is associated with poor prognosis of EC and may be a potential prognostic biomarker for EC.

The Role of Human Epididymis Protein 4 in the Diagnosis and Prognosis of Diseases: An Umbrella Review of Systematic Reviews and Meta-Analyses of Observational Studies

Background

The application of human epididymis protein 4 (HE4) in diverse health diseases, especially in cancers, has been extensively studied in recent decades. To summarize the existing evidence of the aforementioned topic, we conducted an umbrella review to systematically evaluate the reliability and strength of evidence regarding the role of HE4 in the diagnostic and prognostic estimate of diverse diseases.

Methods

Electronic searches in PubMed, Web of Science, and Embase databases were conducted from inception to September 16, 2021, for meta-analyses, which focus on the role of HE4 in the diagnosis and prognosis of diseases. This study protocol has been registered at PROSPERO (CRD42021284737). We collected the meta-analysis effect size of sensitivity, specificity, positive predictive value, and negative predictive value from diagnostic studies and gathered the hazard ratio (HR) of disease-free survival, overall survival, and progression-free survival from prognostic studies. For each systematic review and meta-analysis, we used a measurable tool for evaluating systematic reviews and meta-analysis (AMSTAR) to evaluate the methodological quality. Additionally, we assessed the quality of evidence on estimating the ability of HE4 in the diagnosis and prognosis of diverse diseases by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guideline.

Results

Overall, 20 meta-analyses including a total of 331 primary studies of different diseases were examined, mainly including ovarian cancer (OC) (n = 9), endometrial cancer (EC) (n = 6), and lung cancer (LC) (n = 4). The methodological qualities of all studies were rated as moderate (45%) or high (55%) by the AMSTAR. According to the GRADE, the certainties of 18 diagnostic pieces of evidence (9 for sensitivity and 9 for specificity) were rated as moderate (34%), low (33%), and very low (33%). Moreover, outcomes from prognosis studies showed evidence (1 for disease-free survival) with high certainty in regard to cancers (such as EC, OC, and LC) with the remaining three being moderate.

Conclusion

This umbrella review suggested that HE4 was a favored biomarker in the prognosis of cancers, which was supported by high certainty of evidence. Additionally, HE4 could provide a suitable method for the diagnosis of EC, OC, and LC with moderate certainty evidence. Further large prospective cohort studies are needed to better elucidate the diagnostic and prognostic role of HE4 in diseases.

Serum HE4 and CA125 combined to predict and monitor recurrence of type II endometrial carcinoma

There is no recognized serum biomarker to predict the recurrence of endometrial carcinoma (EC). We aimed to explore serum human epididymis protein 4 (HE4) and cancer antigen 125 (CA125) as the biomarkers to predict and monitor recurrence of type II EC. 191 patients diagnosed with type II EC were involved for this retrospective study. Comparing recurrent with non-recurrent patients, HE4 levels resulted a statistically significant difference at primary diagnosis and recurrence, respectively (P = 0.002 and P = < 0.001), while CA125 levels resulted statistically significant (P = < 0.001) at recurrence. According to receiver operating characteristic curve analysis, the areas under the curve were significant for HE4 levels at primary diagnosis and recurrence predicting recurrence. Furthermore, CA125 levels at recurrence were significant. And the combination of both markers showed the higher sensitivity and specificity than single one. Patients with higher HE4 levels were associated with worse disease-free survival and overall survival, the opposite was true for patients with lower HE4 levels. The preoperative HE4 levels could be used to evaluate the risk factors of type II EC. Which suggested that HE4 levels might associated with the prognosis of type II EC. And combination of HE4 and CA125 could be applied to monitor recurrence during follow-up.

HE4 as a Biomarker for Endometrial Cancer

Simple Summary

There are currently no blood biomarkers approved for routine clinical use in endometrial cancer. Serum human epididymis protein 4 (HE4) is significantly higher in patients with endometrial cancer compared to patients without endometrial cancer and is associated with a poorer prognosis. This makes HE4 an attractive candidate for clinical use in endometrial cancer. The aim of this review is to summarise the evidence for the use of serum HE4 in the detection, prognosis, prediction of therapy response and recurrence monitoring in endometrial cancer. The utility of combining HE4 with other biomarkers or imaging and clinical variables, and its detection in other biofluids is also discussed, as well as potential challenges for clinical use and recommended areas for future research.

Abstract

There are currently no blood biomarkers in routine clinical use in endometrial carcinoma (EC). Human epididymis protein 4 (HE4) is a glycoprotein that is overexpressed in the serum of patients with EC, making it a good candidate for use as a diagnostic and/or prognostic biomarker. HE4 is correlated with poor prognostic factors, including stage, myometrial invasion and lymph node metastases, which means it could be used to guide decisions regarding the extent of surgery and need for adjuvant therapy. Serum HE4 has also shown promise for predicting responses to progestin therapy in early-stage EC. The use of algorithms and indices incorporating serum HE4 and other biomarkers, including clinical and imaging variables, is an area of increasing interest. Serum HE4 levels rise with age and renal dysfunction, which may affect the interpretation of results. This review covers the evidence supporting the use of HE4 as an EC biomarker for diagnosis, prognosis, recurrence monitoring, and prediction of therapy response. The evidence for combining serum HE4 with other biomarkers, including clinical and imaging variables, its value as a biomarker in other biofluids and potential challenges of its clinical use are also discussed.

Identification and characterization of endometrial carcinoma with tumor markers HE4 and CA125 in serum and endometrial tissue samples

Objective

Diagnosis of endometrial cancer (EC) is made by biopsy sampling with pathological analysis, but it is extremely important to make an accurate diagnosis in order to plan the specific treatment. We hypothesized that human epididymis protein 4 (HE4) in endometrial tissue and in serum could be beneficial for a more precise diagnosis.

Material and Methods

This prospective study compared patients with EC against non- EC, matched through several variables. The inclusion criteria were: females older than 18 years who accepted to participate; who had never undergone surgery for other oncological pathologies (ovarian, colon, cervical carcinoma or uterine sarcoma); none of them had received preoperative chemo- or radio-therapy; and no participant had any severe renal or liver pathology. All had pre-surgery blood sampling and then underwent hysterectomy. Histopathological assessment of endometrial samples was made by a pathologist who compared normal histopathological staining with HE4-antibody staining.

Results

In total there were 34 cases and 35 controls recruited. There was poor correlation between tissue HE4 in patients with and without carcinoma. However, serum HE4 was significant for the diagnosis of endometrial carcinoma (median EC: 123.1 U, median NE: 64.67 U, p=0.002), although the carbohydrate antigen 125 level was not significant (p=0.208).

Conclusion

The findings concerning the utility of HE4 contrast with earlier reports. However, the conclusions for serum measurements are positive and suggest that the tumor marker HE4 seems to be able to diagnose EC.

HE4 in the Diagnostic Approach of Endometrial Cancer in Patients with Postmenopausal Bleeding, the METRODEC Protocol: Protocol for a Multicenter Prospective Study

Background: Endometrial cancer is the most common pelvic gynecological cancer in France. The most frequent symptom is post-menopausal bleeding and is one of the primary reasons for consultation in gynecological emergencies. The treatment is very codified and consists of a surgical intervention for anatomopathological analysis. The latter is frequently reassuring. These interventions are often performed in mild situations and there is currently no element to be sufficiently reassuring to avoid surgery. This study aims to explore the sensitivity of an innovative marker: Human Epididymis 4 (HE4) in the diagnosis approach of endometrial cancer in case of postmenopausal bleedings. Methods: This is a prospective multicenter diagnostic study with three centers involved. Inclusion criteria are any patient with post-menopausal bleeding who is to undergo hysteroscopy, endometrial biopsy, or endometrial resection. In accordance with the recommendations for the management of post-menopausal bleedings, the medical conduct consists of performing a clinical examination, an ultrasound and, in general, even in case of paraclinical examination reassuring, an anatomopathological analysis. This pathological analysis can be obtained in several ways: biopsy, hysteroscopy-curettage (which is the most frequently performed surgery), and hysterectomy. Our protocol consists of taking a blood sample from each woman who will undergo one of the interventions mentioned above. The dosage of HE4 and CA125 requires the withdrawal of an additional heparinized tube during the preoperative assessment usually performed. This research is therefore classified as non-interventional. The primary outcome is to evaluate the sensitivity of the HE4 marker in patients with postmenopausal bleeding in the diagnosis of endometrial cancer. The secondary outcomes are other parameters (specificity, VPP, VPN) of HE4, Evaluating the diagnostic capabilities of the CA125 marker alone and associated with HE4, as well as those of the REM and REM-B algorithms. We aim to include 100 patients over a period of one year in three centers. Discussion: As of now, there is no biological marker used in routine practice in the diagnosis of endometrial cancer. The ultimate goal of HE4 in endometrial cancer is to avoid surgery for those who are identified as non-sick. This study is the precursor of others for use in routine practice, HE4 would represent a great help to diagnosis if our study demonstrates it as reliable in the management of these patients and avoid many unnecessary and risky surgeries.

Comparison of MRI, CA-125 and HE-4 in determining the depth of myometrial invasion in cases with endometrial cancer

Objective. Endometrial cancer is one of the most common malignancies in the world. There is no effective screening method used for predicting the clinical stage of the disease in the preoperative period and to plan the surgical procedure. The aim of this study is to compare the serum levels of CA-125 and HE-4 with MRI, to evaluate their ability to predict the depth of myometrial invasion in patients diagnosed with endometrial cancer, and to compare the specificity between these two tests. Materials and Methods. This prospective study was conducted at Dokuz Eylul University Faculty of Medicine, Department of Obstetrics and Gynecology, between February 2019 and February 2020. A total of 47 cases were included in the study. The cases were evaluated with MRI preoperatively to determine the extent of the disease. Preoperative serum CA-125 and HE-4 levels were measured by ELISA method and compared, and the superiority of the tests to each other in determining the depth of myometrial invasion was evaluated. Results. In patients with endometrioid cancer, preoperative CA-125 and HE-4 levels were found to be higher if the myometrial invasion is >50% and lymphovascular space invasion is positive, and the difference was statistically significant. A cut-off of 7,05 U/ml for CA-125 could detect the deeper myometrial invasion with a sensitivity of 83% and a specificity of 52%, respectively. A cut-off of 94,25 pmol/L for HE-4 could detect deeper myometrial invasion with a sensitivity of 75% and a specificity of 56%, respectively. The sensitivity of MRI in determining the depth of myometrial invasion was 87,1%, and the specificity was 86,7%. Conclusions. MRI, HE-4 and CA-125 were found to be valuable tests in predicting the extent of the disease and planning the surgical treatment. All three methods successfully predicted the myometrial invasion depth of the disease. The success rates of the tests in predicting the depth of myometrial invasion were MRI, HE-4 and CA-125, respectively. HE-4 and CA-125 could not reach the sensitivity and specificity of MRI in determining the depth of myometrial invasion at any cut-off value. However, it was proved in this study that they can play important roles as simpler and more cost-effective tests in determining the extent of the disease, able to contribute to surgical planning during preoperative evaluation.

Prognostic value of serum HE4 level in the management of endometrial cancer: A pilot study

BACKGROUND

Human epididymis protein 4 (HE4) has shown promising utility as a prognostic biomarker in endometrial cancer. Increased serum HE4 levels may be associated with deeper myometrial invasion, extrauterine disease and poorer prognosis.

AIM

To evaluate the use of serum HE4 level, compared to and alongside other investigations, to accurately guide management in apparent early-stage endometrial cancer.

MATERIALS AND METHODS

This is a single-site prospective study of 100 patients with histologically confirmed endometrial cancer. All patients underwent preoperative measurements of HE4 and CA125 levels and a preoperative magnetic resonance imaging (MRI) to assess the depth of invasion, nodal status and tumour size. Correlation was sought between serum HE4 level, CA125 level, MRI findings and intra-operative frozen section with tumour type, grade and stage.

RESULTS

While both median HE4 and CA125 levels were higher with worsening clinicopathological features, serum HE4 level showed a more consistent association with high-risk features. Patients with a low-grade biopsy preoperatively and a low HE4 level (<70 pmol/L) demonstrated an 86.8% likelihood of having low-risk disease on final histopathology. In comparison, preoperative MRI or intraoperative frozen section alongside a low-grade biopsy demonstrated a similar likelihood of 86.2 and 87.7%, respectively.

CONCLUSIONS

When used in conjunction with an initial low-grade endometrial biopsy, serum HE4 level demonstrated a similar likelihood to both preoperative MRI and intraoperative frozen section in identifying low-risk disease on final histopathology. As a triaging tool this may be significant given that a preoperative, serum-based assay would likely be the least invasive, least resource-intensive and most cost-effective approach.

The diagnostic value of human epididymis protein 4 for endometrial cancer is moderate

Human epididymis protein 4 (HE4) has been used as a biomarker of endometrial cancer (EC) in clinical practice. However, there remains a lack of systemic research on the critical values of HE4 for diagnosing different clinical stages and pathological types of EC. This study investigated the accuracy of human epididymis protein 4 (HE4) in the diagnosis of EC. Patients who were hospitalized for a chief complaint of abnormal vaginal hemorrhage at Xinjiang Uyghur Autonomous Region People's Hospital between 2014 and 2019 were consecutively included. Pathological biopsy confirmed the diagnosis of EC; there were a total of 136 EC patients and 127 non-EC patients. The accuracy of HE4 in the diagnosis of EC was assessed with SPSS software. The accuracy of HE4 for diagnosing different clinical stages and pathological types of EC was also explored. The critical value of HE4 for endometrial cancer was 52.40 mmol/L, with a sensitivity of 57.35% and a specificity of 76.38%. For different stages of EC, the critical value was 36.9 mmol/L, and the sensitivity and specificity were 28% and 87.39%, respectively. For different pathological types, the critical value was 30.60 mmol/L, and the sensitivity and specificity were 93.85% and 33.33%, respectively. The diagnostic value of HE4 for EC is moderate, and the serum HE4 level cannot reflect the stage and type of EC.

Endometrial cancer: A systematic review of HE4, REM and REM-B

INTRODUCTION

Endometrial cancer, one of the most frequent pelvic gynecologic cancer worldwide, currently has no biomarker used to assess it in daily practice. Nonetheless, human epididymis 4 (HE4) appears to offer the best prospects, alone or combined with CA125. This study sought to systematically review the work on HE4 from the first publications in 2008 until now.

MATERIAL AND METHODS

Two independent reviewers searched the PubMed database with the terms "HE4″, "endometrial cancer", "endometrial carcinoma", and HE4 or human epididymis protein 4. Only original clinical research articles and meta-analyses, published in English, were included, with literature reviews and case reports excluded.

RESULTS

Studies were organized into 3 categories: diagnosis, prognosis, and recurrence/survival. Overall we identified 117 articles dealing with HE4 and endometrial cancer and selected 52 relevant texts: 46 articles, 6 meta-analyses. The sensitivity of HE4 for the diagnosis of endometrial cancer varied from 44.2% to 91% and its specificity from 65.5 to 100%, versus 24.1 to 71.5% and from 65.6 to 100% for CA125. Two meta-analyses of their combination produced areas under the curve (AUC): 0.83 and 0.86. Two available algorithms - the REM (risk of endometrial malignancy) and REM-B (risk of endometrial malignancy associated with BMI) scores - require more study. HE4 is also strongly associated with prognostic factors such as myometrial invasion, tumor grade, FIGO stage, and lymph node involvement. It also predicts recurrence and can serve as a monitoring tool, as reported by a 2018 meta-analysis with a hazard ratio of 2.15 (P < 0.001).

CONCLUSION

HE4, alone or associated with CA125, appears to be an important tool in the management of endometrial cancer, initially for diagnosis, but for assessing prognosis and survival. Other prospective and multicenter studies are necessary to confirm these hopes and be able to recommend the use of HE4 in regular practice.

HE4 and CA125 as preoperative risk stratifiers for lymph node metastasis in endometrioid carcinoma of the endometrium: A retrospective study in a cohort with histological proof of lymph node status

OBJECTIVES

To investigate whether HE4 and CA125 could identify endometrioid adenocarcinoma patients who might most benefit from full staging surgery with lymphadenectomy.

METHODS

Sequential patients with a preoperative banked serum and histology of endometrioid adenocarcinoma of endometrium who had undergone surgical staging with lymph node dissection over a 5-year period between 2011 and 2016 were included from a tertiary Gynaecological Cancer Centre, Dublin, Ireland. Preoperative serum HE4 and CA125 were measured using ELISA, with the cut-offs HE4 81 pmol/L and CA125 35 U/ml. Predictive values were estimated using AUC, sensitivity, specificity and odds ratios.

RESULTS

9.5% of the cohort had lymph node metastases. A HE4 cut-off of 81 pmol/L yielded a sensitivity of 78.6% and specificity of 53.4% for predicting lymph node metastases. Sensitivity of CA125 at 35 U/ml was 57% and specificity 91.4%. The AUC was 0.66 (0.52-0.80) for HE4 and 0.74 (0.58-0.91) for CA125. Sensitivity was 92.8% and specificity 51.1% when an elevation of either HE4 or CA125 was included, AUC was 0.72 (0.61-0.83), this combination yielded the highest NPV of 98.6%. Sensitivity was 42.9% and specificity 93.8% if both markers were elevated simultaneously, AUC was 0.68 (0.51-0.86). Preoperative clinical predictors of high-grade preoperative histology and radiology had sensitivities of 21.4% and 41.7%, respectively. Patients with a HE4 above 81 pmol/L had an odds ratio of 4.2 (1.12-15.74), p < 0.05, of lymph node metastases and CA125 had an odds ratio of 14.2 (4.16-48.31), p < 0.001.

CONCLUSIONS

Serum HE4 and CA125 improved on existing methods for risk stratification of endometrioid carcinomas and warrant further investigation.

Diagnostic and Prognostic Values of Serum EpCAM, TGM2, and HE4 Levels in Endometrial Cancer

Objectives: This study aims to investigate the diagnostic and prognostic values of EpCAM, TGM2, and HE4 in endometrial cancer (EC).

Methods: In this study, 42 patients diagnosed with EC (EC group), 41 patients diagnosed with myoma (benign group), and 43 healthy women (healthy group), who applied to Affiliated Hospital of Xuzhou Medical University between March 2018 - September 2019 were recruited. Serum EpCAM, TGM2, and IL-33 levels were measured by ELISA, while serum HE4 and CA-125 levels were measured by ECLIA. The serum markers listed above were also measured in 12 paired pre- and post-operative EC patients. The diagnostic and prognostic values of serum markers were analyzed.

Results: The serum EpCAM, TGM2, HE4, CA-125, and IL-33 levels were significantly higher in the EC group. The sensitivity and specificity of combined detection of EpCAM and HE4 was 92.86 and 69.05%, which were significantly higher than using a single marker or other combinations. Among these markers, serum HE4 levels were significantly higher in patients with myometrial invasion, metastasis, and lymphovascular invasion (p = 0.006, p = 0.0004, p = 0.0004, respectively). And serum TGM2 levels were significantly decreased in post-operative than that of pre-operative EC patients (p < 0.001).

Conclusions: The combination of EpCAM and HE4 showed the highest specificity and sensitivity in the diagnosis of EC. HE4 was successful in the detection of high-risk individuals preoperatively. Additionally, TGM2 might be a prognostic factor for EC.

Preoperative markers for the prediction of high-risk features in endometrial cancer

BACKGROUND

Preoperative evaluations aiming to assess high-risk features in clinical stage 1 endometrial cancer patients are crucial to refer these patients to gynecologic oncologists. Cancer antigen 125 (CA125) and human epididymis protein 4 (HE4) have been reported in endometrial cancer patients with poor prognostic factors.

AIM

To evaluate the association between preoperative levels of CA125 and HE4 and high-risk features and establish optimal cut-off values in clinical stage 1 endometrial cancer.

METHODS

A retrospective study was conducted in clinical stage 1 endometrial cancer patients who underwent primary surgery between January 2013 and December 2018. A total of 128 patients had preoperative serum CA125 and HE4 measurements. High-risk features included grade 3 tumors, large tumor sizes (more than 2 cm), deep myometrial invasion (more than 50%), lymphovascular space invasion (LVSI), cervical involvement, extrauterine involvement and node metastasis. Receiver operating characteristic (ROC) curves were generated to analyze the optimal cut-off values.

RESULTS

The mean age of the patients was 57.4 years, and 69.5% of them were postmenopausal. Most patients presented with stage I disease (67.2%) and had the endometrioid subtype (97.7%). The median CA125 and HE4 levels in all patients were 22.1 U/mL and 104.7 pmol/L, respectively. CA125 and HE4 levels were significantly elevated in those with large tumor sizes, deep myometrial invasion, LVSI, extrauterine metastasis, and advanced stage, but node metastasis was associated with elevated CA125 only. According to the ROC curve, both serum markers had statistical significance for the prediction of high-risk features only in postmenopausal patients, with an optimal cut-off value of 20 U/mL for CA125 [area under the concentration-time curve (AUC) = 0.72, P = 0.002] and 113 pmol/L for HE4 (AUC = 0.70, P = 0.006). The combination of both serum markers had 80% sensitivity and 64.4% positive predictive value. Significantly worse 5-year disease-free survival was observed in patients with high levels of CA125 and HE4 (78.4% and 100%, respectively; P = 0.01).

CONCLUSION

Preoperative CA125 levels greater than 20 U/mL or HE4 levels greater than 113 pmol/L are associated with an increased risk of having high-risk features and present as prognostic factors in clinical stage 1 postmenopausal endometrial cancer patients. This information is helpful for general gynecologists to refer high-risk patients to gynecologic oncologists to perform complete surgical staging.

Improved preoperative risk stratification with CA-125 in low-grade endometrial cancer: a multicenter prospective cohort study

OBJECTIVES

The global obesity epidemic has great impact on the prevalence of low-grade endometrial carcinoma. The preoperative tumor serum marker cancer antigen 125 (CA-125) might contribute to improved identification of high-risk patients within this group. The study aimed to investigate the prognostic value of CA-125 in relation to established preoperative prognosticators, with a focus on identifying patients with poor outcome in low-grade endometrial carcinoma (EC) patients.

METHODS

Prospective multicenter cohort study including all consecutive patients surgically treated for endometrial carcinoma in nine collaborating hospitals from September 2011 until December 2013. All preoperative histopathological diagnoses were reviewed in a blinded manner. Associations between CA-125 and clinicopathological features were determined. Univariable and multivariable analysis by Cox regression were used. Separate analyses were performed for preoperatively designated low-grade and high-grade endometrial carcinoma patients.

RESULTS

A total of 333 patients were analyzed. CA-125 was associated with poor prognostic features including advanced International Federation of Gynecology and Obstetrics (FIGO) stage. In multivariable analysis, age, preoperative tumor and CA-125 were significantly associated with disease-free survival (DFS); preoperative grade, tumor type, FIGO and CA-125 were significantly associated with disease-specific survival (DSS). Low-grade EC patients with elevated CA-125 revealed a DFS of 80.6% and DSS of 87.1%, compared to 92.1% and 97.2% in low-grade EC patients with normal CA-125.

CONCLUSION

Preoperative elevated CA-125 was associated with poor prognostic features and independently associated with DFS and DSS. Particularly patients with low-grade EC and elevated CA-125 represent a group with poor outcome and should be considered as high-risk endometrial carcinoma.

HE4 tumor marker as a predictive factor for lymphatic metastasis in endometrial cancer

Endometrial cancer is the most common genital cancer in high-resource countries. Treatment is essentially surgical, but the role of lymphadenectomy in the treatment of low-stage and low-grade tumors has not been defined. Although no tumor factors have been validated for use as preoperative prognostic markers of endometrial cancer at yet, human epididymis protein 4 (HE4) has received much interest as a potential diagnostic and prognostic tumor marker. Since 2008, several studies have explored its utility in the management of endometrial cancer: HE4 may be a useful preoperative prognostic marker because it is associated with lymphatic metastasis and other unfavorable factors in endometrial cancer. In addition, some studies have explored a HE4 cutoff value to classify patients according to lymph node involvement. HE4 might be beneficial as a serum marker that helps clinicians in the decision-making algorithm for treatment of endometrial cancer, enabling them to perform individualized operations and decrease the adverse effects of unnecessary surgery.

The role of adjuvant radiotherapy in stage I endometrial cancer: A single-institution outcome

OBJECTIVE

Postoperative radiotherapy for early endometrial cancer has been investigated in several randomized trials. These trials demonstrate that it reduces loco-regional recurrence, but has no impact on overall survival. The aims of this study were to better understand the role of adjuvant radiotherapy and determine predictors for loco-regional recurrence or development of distant metastasis.

MATERIALS AND METHODS

A retrospective medical records review was performed on patients with surgical stage I endometrial cancer treated at Taipei Veterans General Hospital between 2006 and 2013. Multivariable analysis was conducted using Cox regression for prognostic predictors.

RESULTS

A total of 337 patients were identified. The estimated five-year overall survival and loco-regional recurrence-free survival were 96.3% and 97.9% in the non-radiotherapy group, and 91.6% and 97.1% in the radiotherapy group (p = 0.06 overall survival, p = 0.956 loco-regional recurrence-free survival). Multivariable analysis revealed that elevated preoperative serum Cancer Antigen 125 (CA-125) level (hazard ratio (HR) = 2.54), age older than 60 years old (HR = 3.34), and depth of myometrial invasion > 50% (HR = 3.37) were significant factors in overall survival. Elevated preoperative CA-125 level (HR = 5.37), age older than 60 years (HR = 6.57), positive lymphovascular space invasion (HR = 50.20), and adjuvant radiotherapy (HR = 0.05) were independent predictors of loco-regional recurrence-free survival. For distant metastasis, deep myometrial invasion was a significant risk factor.

CONCLUSIONS

Postoperative radiotherapy delivery is an independent predictor for loco-regional recurrence-free survival but has no impact on overall survival in this population. Preoperative CA-125 level is a risk factor for loco-regional recurrence, and deep myometrial invasion was correlated with distant metastasis.

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.

Diagnostic Accuracy of Clinical Biomarkers for Preoperative Prediction of Lymph Node Metastasis in Endometrial Carcinoma: A Systematic Review and Meta-Analysis

BACKGROUND

In endometrial carcinoma (EC), preoperative classification is based on histopathological criteria, with only moderate diagnostic performance for the risk of lymph node metastasis (LNM). So far, existing molecular classification systems have not been evaluated for prediction of LNM. Optimized use of clinical biomarkers as recommended by international guidelines might be a first step to improve tailored treatment, awaiting future molecular biomarkers.

AIM

To determine the diagnostic accuracy of preoperative clinical biomarkers for the prediction of LNM in endometrial cancer.

METHODS

A systematic review was performed according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Studies identified in MEDLINE and EMBASE were selected by two independent reviewers. Included biomarkers were based on recommended guidelines (cancer antigen 125 [Ca-125], lymphadenopathy on magnetic resonance imaging, computed tomography, and ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography [¹⁸FDG PET-CT]) or obtained by physical examination (body mass index, cervical cytology, blood cell counts). Pooled sensitivity, specificity, area under the curve (AUC), and likelihood ratios were calculated with bivariate random-effects meta-analysis. Likelihood ratios were classified into small (0.5-1.0 or 1-2.0), moderate (0.2-0.5 or 2.0-5.0) or large (0.1-0.2 or ≥ 5.0) impact.

RESULTS

Eighty-three studies, comprising 18,205 patients, were included. Elevated Ca-125 and thrombocytosis were associated with a moderate increase in risk of LNM; lymphadenopathy on imaging with a large increase. Normal Ca-125, cytology, and no lymphadenopathy on ¹⁸FDG PET-CT were associated with a moderate decrease. AUCs were above 0.75 for these biomarkers. Other biomarkers had an AUC <0.75 and incurred only small impact.

CONCLUSION

Ca-125, thrombocytosis, and imaging had a large and moderate impact on risk of LNM and could improve preoperative risk stratification.

IMPLICATIONS FOR PRACTICE

Routine lymphadenectomy in clinical early-stage endometrial carcinoma does not improve outcome and is associated with 15%-20% surgery-related morbidity, underlining the need for improved preoperative risk stratification. New molecular classification systems are emerging but have not yet been evaluated for the prediction of lymph node metastasis. This article provides a robust overview of diagnostic performance of all clinical biomarkers recommended by international guidelines. Based on these, at least measurement of cancer antigen 125 serum level, assessment of thrombocytosis, and imaging focused on lymphadenopathy should complement current preoperative risk stratification in order to better stratify these patients by risk.

CD44, TGM2 and EpCAM as novel plasma markers in endometrial cancer diagnosis

Background

Endometrial cancer (EC) is the most common malignancy of the female reproductive tract. Despite years of research, the accurate screening strategy is still not available in this disease and it is usually diagnosed only after the clinical signs are present. The recent technological advances in analytical methodologies enabled detection of multiple molecules in one, small sample of biological materials. Such approach was undertaken in the presented study.

Methods

Concentrations of aldehyde dehydrogenase 1 family, member A1 (ALDH1A1), carbonic anhydrase IX (CA9), CD44, epithelial cell adhesion molecule (EpCAM), hepsin, kallikrein-6, mesothelin, midkine, neural cell adhesion molecule L1 (L1CAM), and transglutaminase 2 (TGM2) were measured using MAGPIX®System in plasma samples of 45 EC, 20 healthy controls and 11 patients with endometriosis.

Results

Significantly increased concentration in EC as compared to healthy controls were found in case of CD44 (p <  0.001), EpCAM (p = 0.033) and TGM2 (p <  0.001). EpCAM and mesothelin concentrations differed based on FIGO stages. Regression analysis revealed marker panels with high accuracy in detection of EC. The highest AUC 0.937 was attributed to the 3-marker panel of CD44/TGM2/EpCAM (84% sensitivity, 100% specificity), FIGO IA samples were discriminated from more advanced stages of EC with the mesothelin/grade 1 model featuring AUC of 0.911 (95.24% sensitivity, 78.26% specificity).

Conclusions

Novel plasma biomarkers presenting good accuracy in diagnosing EC were found with TGM2 reported for the first time as plasma marker. It was also revealed that endometriosis may share similarities in the pattern of markers alterations characteristic for EC.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5556-x) contains supplementary material, which is available to authorized users.

Preoperative Prediction of Lymph Nodal Metastases in Endometrial Carcinoma: Is it Possible?: A Literature Review

BACKGROUND

Lymph node status is one of the most important prognostic factors in endometrial cancer and crucial for deciding adjuvant therapy.

OBJECTIVE

The aim of the study was to assess the different models used to predict lymphatic nodal disease.

SEARCH STRATEGY

A literature search was conducted to detect the relevant studies.

INCLUSION CRITERIA

Relevant papers comparing the preoperative modality with the final histopathological results including randomized clinical trials, case-control studies, and any publications with a minimum of 50 patients in the report.

RESULTS

Molecular-based predictors are still far from a practical application. Preoperative radiological scans (positron emission tomography, computed tomography, magnetic resonance imaging, and ultrasound) have shown the best predictor of lymphatic dissemination. However, there is currently no ideal model available, which can be used within standard clinical care.

CONCLUSIONS

Surgical staging still remains the criterion standard in the determination of lymph node status in endometrial cancer.

Ykl-40 and cancer antigen 72-4 as new and promising diagnostic and prognostic markers for endometrial cancer

Objective:

To determine the predictive role of serum levels of YKL-40 and cancer antigen (CA) 72-4 in the diagnosis of endometrial cancer (EC).

Materials and Methods:

Forty-one patients with EC and 21 women with uterine polyps were evaluated between January and December 2015 in a prospective study.

Results:

Age, body mass index, preoperative serum YKL-40 and CA 72-4 levels were significantly higher in the malignant group compared with the control group. Serum YKL-40 levels were significantly higher in patients with superficial myometrial invasion and no lymph node involvement (p=0.042; p=0.004). No relationship between clinicopathologic factors and serum CA 72-4 levels was found.

Conclusion:

Serum CA 72-4 and YKL-40 levels are increased in women with EC compared with uterine polyps. Preoperative serum YKL-40 levels may be associated with favorable prognostic factors. The determination of YKL-40 before surgery may be helpful in the evaluation of the regional lymph nodes.

Hysteroscopic Endometrial Focal Resection followed by Levonorgestrel Intrauterine Device Insertion as a Fertility-Sparing Treatment of Atypical Endometrial Hyperplasia and Early Endometrial Cancer: A Retrospective Study

STUDY OBJECTIVE

To evaluate safety and effectiveness of the combination of hysteroscopic endometrial focal resection with levonorgestrel-releasing intrauterine device (LNG-IUD) for International Federation of Gynecology and Obstetrics stage IA G1 early endometrial cancer (EEC) and atypical endometrial hyperplasia (AEH) in young women to preserve their fertility.

DESIGN

Retrospective case series (Canadian Task Force classification II-3).

SETTING

University Federico II, Naples, Italy.

PATIENTS

The medical records of 69 consecutive patients treated from 2007 to 2017 with diagnosis of EEC (n = 14) or AEH (n = 55) meeting inclusion criteria were reviewed.

INTERVENTIONS

Patients with focal EEC were treated by hysteroscopic resection of the lesion according to Mazzon's technique; patients with AEH were treated by superficial endometrial resection, preserving the basal layer of the endometrium. An LNG-IUD was inserted in all patients after surgery. Patients were followed for 24 months with serial hysteroscopic biopsies.

MEASUREMENTS AND MAIN RESULTS

Rates of response, live birth, and recurrence were assessed. Of the 14 patients with EEC, 11 (78.6%) achieved a complete response, 2 (18.2%) of whom had subsequent relapse, 1 (7.1%) showed partial response, whereas 2 (14.3%) were nonresponders (1 stable disease and 1 progression). Of the 55 patients with AEH, 51 (92.7%) achieved a complete response, 2 (3.9%) of whom had subsequent relapse, 3 (5.5%) showed partial response, whereas only 1 (1.8%) was nonresponder with stable disease. Among 25 patients who had removed the LNG-IUD, 10 (40%) gave birth after natural conception in the last 12 months of follow-up.

CONCLUSION

The combination of hysteroscopic resection with an LNG-IUD as fertility-sparing treatment of EEC and AEH showed similar response and live birth rates compared with those reported in literature for progestins alone, but with considerably lower relapse rate. We advocate the use of this combined approach as an alternative fertility-sparing option in patients with ECC and AEH.

Beyond the Biomarker: Understanding the Diverse Roles of Human Epididymis Protein 4 in the Pathogenesis of Epithelial Ovarian Cancer

Human epididymis protein 4 (HE4) is an important clinical biomarker used for the detection of epithelial ovarian cancer (EOC). While much is known about the predictive power of HE4 clinically, less has been reported regarding its molecular role in the progression of EOC. A deeper understanding of HE4’s mechanistic functions may help contribute to the development of novel targeted therapies. Thus far, it has been difficult to recommend HE4 as a therapeutic target owing to the fact that its role in the progression of EOC has not been extensively evaluated. This review summarizes what is collectively known about HE4 signaling and how it functions to promote tumorigenesis, chemoresistance, and metastasis in EOC, with the goal of providing valuable insights that will have the potential to aide in the development of new HE4-targeted therapies.

Human epididymis protein 4 in endometrial cancer: A meta-analysis

BACKGROUND

Serum human epididymis protein 4 (HE4) is a potential marker for endometrial cancer (EC), however, the diagnostic value of HE4 for EC remains controversial. In this study, we performed a meta-analysis to estimate the diagnostic accuracy of serum HE4 for EC.

METHODS

Literature reports of the diagnostic accuracy of serum HE4 for EC were systematically identified using online data-bases. The meta-analysis was performed using STATA 12.0, Meta-Disc 1.4, and Review Manager 5.2.

RESULTS

A total of 4182 participants and 23 studies were included in our meta-analysis. The pooled sensitivity (SEN), specificity (SPE), positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the curve (AUC) were 0.65 (95% CI: 0.56-0.73), 0.91 (95% CI: 0.84-0.95), (95% CI: 4.38-12.64), 0.38 (95% CI: 0.31-0.47), 19.46 (95% CI: 11.61-32.62) and 0.84 (95% CI: 0.81 to 0.87), respectively. Our overall analysis suggested that HE4 is a useful diagnostic marker for EC. Subgroup analysis indicated that studies with benign disease controls showed higher diagnostic accuracies than those with healthy controls.

CONCLUSION

Serum HE4 may serve as a potential biomarker for EC diagnosis. Due to certain limitations, this conclusion should to be cautiously interpreted.

Preoperative Serum Human Epididymis Protein 4 Levels in Early Stage Endometrial Cancer: A Prospective Study

OBJECTIVE

The aim of the study was to evaluate the prognostic value of human epididymis protein 4 (HE4) and cancer antigen 125 markers with pathological prognostic factor to complete the preoperative clinical panel and help the treatment planning.

METHODS

This prospective multicenter study was conducted in 2 gynecologic oncology centers between 2012 and 2014 (Institute for Maternal and Child Health IRCCS Burlo Garofolo in Trieste and Catholic University of the Sacred Heart in Rome, Italy). We enrolled 153 patients diagnosed with clinical early (International Federation of Gynecology and Obstetrics stages I-II) type I endometrial cancer.

RESULTS

Human epididymis protein 4 levels seemed to be strictly related to age (P < 0.001) and menopausal status (P < 0.002). Compared with myometrial invasion (MI), the HE4 values were significantly higher in case of invasion of greater than 50% of the thickness: MI of greater than 50%, median of 94.85 pmol/L (38.3-820.8 pmol/L), versus MI of less than 50%, median of 65.65 pmol/L (25.1-360.2 pmol/L), (P < 0.001). The HE4 levels increase significantly with increasing tumor size: diameter of larger than 2 cm, median of 86.9 pmol/L (35.8-820.8 pmol/L), versus diameter of smaller than 2 cm, median of 52.2 pmol/L (33.3-146.8 pmol/L), (P < 0.001). In our population, HE4 did not correlate with the histological grade, endometrial cancer type I versus type II (P = 0.86), the lymphovascular infiltration (P = 0.12), and the cervical invasion (P = 0.6). We established a new variable, considering 3 high-risk tumor features: MI of greater than 50% and/or histological G3 and/or type II. Human epididymis protein 4 levels significantly increase in high-risk tumors (high risk HE4, 93.6 pmol/L vs low-medium risk, 65.5 pmol/L; P < 0.001).

CONCLUSIONS

A preoperative HE4 evaluation could help stratify patients with deep invasion and/or metastatic disease and is correlated with other relevant prognostic factors to be considered to tailor an adequate surgical strategy.

Metabolomic prediction of endometrial cancer

INTRODUCTION

Endometrial cancer (EC) is associated with metabolic disturbances including obesity, diabetes and metabolic syndrome. Identifying metabolite biomarkers for EC detection has a crucial role in reducing morbidity and mortality.

OBJECTIVE

To determine whether metabolomic based biomarkers can detect EC overall and early-stage EC.

METHODS

We performed NMR and mass spectrometry based metabolomic analyses of serum in EC cases versus controls. A total of 46 early-stage (FIGO stages I-II) and 10 late-stage (FIGO stages III-IV) EC cases constituted the study group. A total of 60 unaffected control samples were used. Patients and controls were divided randomly into a discovery group (n = 69) and an independent validation group (n = 47). Predictive algorithms based on biomarkers and demographic characteristics were generated using logistic regression analysis.

RESULTS

A total of 181 metabolites were evaluated. Extensive changes in metabolite levels were noted in the EC versus the control group. The combination of C14:2, phosphatidylcholine with acyl-alkyl residue sum C38:1 (PCae C38:1) and 3-hydroxybutyric acid had an area under the receiver operating characteristics curve (AUC) (95% CI) = 0.826 (0.706-0.946) and a sensitivity = 82.6%, and specificity = 70.8% for EC overall. For early EC prediction: BMI, C14:2 and PC ae C40:1 had an AUC (95% CI) = 0.819 (0.689-0.95) and a sensitivity = 72.2% and specificity = 79.2% in the validation group.

CONCLUSIONS

EC is characterized by significant perturbations in important cellular metabolites. Metabolites accurately detected early-stage EC cases and EC overall which could lead to the development of non-invasive biomarkers for earlier detection of EC and for monitoring disease recurrence.

Adjustment of serum HE4 to reduced glomerular filtration and its use in biomarker-based prediction of deep myometrial invasion in endometrial cancer

Background

We investigated the efficacy of circulating biomarkers together with histological grade and age to predict deep myometrial invasion (dMI) in endometrial cancer patients.

Methods

HE4ren was developed adjusting HE4 serum levels towards decreased glomerular filtration rate as quantified by the eGFR-EPI formula. Preoperative HE4, HE4ren, CA125, age, and grade were evaluated in the context of perioperative depth of myometrial invasion in endometrial cancer (EC) patients. Continuous and categorized models were developed by binary logistic regression for any-grade and for G1-or-G2 patients based on single-institution data from 120 EC patients and validated against multicentric data from 379 EC patients.

Results

In non-cancer individuals, serum HE4 levels increase log-linearly with reduced glomerular filtration of eGFR ≤ 90 ml/min/1.73 m². HE4ren, adjusting HE4 serum levels to decreased eGFR, was calculated as follows: HE4ren = exp[ln(HE4) + 2.182 × (eGFR-90) × 10^-2]. Serum HE4 but not HE4ren is correlated with age. Model with continuous HE4ren, age, and grade predicted dMI in G1-or-G2 EC patients with AUC = 0.833 and AUC = 0.715, respectively, in two validation sets. In a simplified categorical model for G1-or-G2 patients, risk factors were determined as grade 2, HE4ren ≥ 45 pmol/l, CA125 ≥ 35 U/ml, and age ≥ 60. Cumulation of weighted risk factors enabled classification of EC patients to low-risk or high-risk for dMI.

Conclusions

We have introduced the HE4ren formula, adjusting serum HE4 levels to reduced eGFR that enables quantification of time-dependent changes in HE4 production and elimination irrespective of age and renal function in women. Utilizing HE4ren improves performance of biomarker-based models for prediction of dMI in endometrial cancer patients.

RERT: A Novel Regression Tree Approach to Predict Extrauterine Disease in Endometrial Carcinoma Patients

Some aspects of endometrial cancer (EC) preoperative work-up are still controversial, and debatable are the roles played by lymphadenectomy and radical surgery. Proper preoperative EC staging can help design a tailored surgical treatment, and this study aims to propose a new algorithm able to predict extrauterine disease diffusion. 293 EC patients were consecutively enrolled, and age, BMI, children’s number, menopausal status, contraception, hormone replacement therapy, hypertension, histological grading, clinical stage, and serum HE4 and CA125 values were preoperatively evaluated. In order to identify before surgery the most important variables able to classify EC patients based on FIGO stage, we adopted a new statistical approach consisting of two-steps: 1) Random Forest with its relative variable importance; 2) a novel algorithm able to select the most representative Regression Tree (RERT) from an ensemble method. RERT, built on the above mentioned variables, provided a sensitivity, specificity, NPV and PPV of 90%, 76%, 94% and 65% respectively, in predicting FIGO stage > I. Notably, RERT outperformed the prediction ability of HE4, CA125, Logistic Regression and single cross-validated Regression Tree. Such algorithm has great potential, since it better identifies the true early-stage patients, thus providing concrete support in the decisional process about therapeutic options to be performed.

Novel algorithm including CA-125, HE4 and body mass index in the diagnosis of endometrial cancer

OBJECTIVES

To evaluate the diagnostic and prognostic potential of preoperative serum CA-125 and HE4 levels in patients with endometrial cancer.

METHODS

Prospective case-control study of 133 women who underwent surgical treatment at the University Medical Centre Ljubljana (64 patients with endometrial cancer, 69 control patients with prolapsed uterus or myoma). Serum CA-125 and HE4 levels were determined using electrochemiluminescent assays.

RESULTS

Serum CA-125 and HE4 levels were significantly higher in patients with endometrial cancer, compared to the controls (p=2.67×10^-4, 1.36×10^-7, respectively). A diagnostic model that combines serum CA-125 and HE4 levels and body mass index separated patients with endometrial cancer from controls, with AUC of 0.804, sensitivity of 66.7%, and specificity of 84.6%. Serum HE4 levels showed good prognostic potential and stratified the patients according to presence/absence of deep myometrial invasion (p=0.001) or lymphovascular invasion (p=0.003), with AUCs of 0.78 and 0.81, respectively. In low-risk patients with grade 1 and 2 endometrioid cancer for whom lymphadenectomy can be avoided, HE4 allowed stratification according to deep myometrial invasion (p=3.39×10^-4), with AUC of 0.84. Although median HE4 levels were higher in patients with lymphovascular invasion, this difference did not reach significance (p=0.06).

CONCLUSIONS

A model based on preoperative serum CA-125 and HE4 levels and body mass index has good diagnostic accuracy for separation of patients with endometrial cancer and control patients. In patients with endometrial cancer, serum HE4 levels allow prediction of deep myometrial and lymphovascular invasion.

Diagnostic Performance of Serum Human Epididymis Protein 4 in Endometrial Carcinoma: A Pilot Study

INTRODUCTION

Endometrial Cancer (EC) is a common female malignant disorder. To date, there are no specific tumour markers for EC that may be routinely used in clinical practice for diagnosis.

AIM

To evaluate the diagnostic performance of the serum Human Epididymis protein 4 (HE4) as biomarker for EC and to determine its association with clinicopathological variables.

MATERIALS AND METHODS

The study population included 60 postmenopausal women with a diagnosis of EC and 60 healthy postmenopausal female subjects (control group). Concentrations of serum HE4 and CA-125 in EC patients and control group were determined using Enzyme-Linked Immunosorbent Assays (ELISA). The value of serum HE4 and CA-125 for the diagnosis and prediction of stage, histology, myometrial invasion and lymph nodal metastasis was analysed.

RESULTS

The mean serum HE4 and CA-125 levels were significantly higher in patients with EC than those with control group (p<0.05). Comparison for HE4 and CA-125 between different stages showed a statistically significant difference. Stage I EC patients with <50% myometrial invasion had a significantly lower mean serum HE4 value than patients with >50% myometrial invasion (p=0.007). Corresponding values of CA-125 showed a similar trend (p=0.023). There were significantly higher levels of HE4 and CA-125 in cases with lymph node involvement. The levels of serum HE4 and CA-125 were higher in the non-endometroid histology, but the difference was not statistically significant. The Receiver Operating Characteristics (ROC) curve analysis for EC and control group showed that HE4 had greater Area Under Curve (AUC) when compared with CA-125. Using ROC curve, a serum HE4 concentration of 69.8 pmol/l (AUC 0.974) and/or serum CA-125 level of 34.50 U/mL (AUC 0.714) was used to predict malignancy. Sensitivity of combined biomarkers showed no additional improvement in comparison to HE4 or CA-125 alone.

CONCLUSION

Our results show that HE4 is a sensitive diagnostic serum marker for detection of EC patients, exhibiting a better diagnostic performance compared to CA-125. Good performance of HE4 in diagnosis of early stages EC indicates its usefulness as a prognostic marker and also to monitor therapy and detect early recurrence.

Sparse feature selection for classification and prediction of metastasis in endometrial cancer

Background

Metastasis via pelvic and/or para-aortic lymph nodes is a major risk factor for endometrial cancer. Lymph-node resection ameliorates risk but is associated with significant co-morbidities. Incidence in patients with stage I disease is 4–22% but no mechanism exists to accurately predict it. Therefore, national guidelines for primary staging surgery include pelvic and para-aortic lymph node dissection for all patients whose tumor exceeds 2cm in diameter. We sought to identify a robust molecular signature that can accurately classify risk of lymph node metastasis in endometrial cancer patients. 86 tumors matched for age and race, and evenly distributed between lymph node-positive and lymph node-negative cases, were selected as a training cohort. Genomic micro-RNA expression was profiled for each sample to serve as the predictive feature matrix. An independent set of 28 tumor samples was collected and similarly characterized to serve as a test cohort.

Results

A feature selection algorithm was designed for applications where the number of samples is far smaller than the number of measured features per sample. A predictive miRNA expression signature was developed using this algorithm, which was then used to predict the metastatic status of the independent test cohort. A weighted classifier, using 18 micro-RNAs, achieved 100% accuracy on the training cohort. When applied to the testing cohort, the classifier correctly predicted 90% of node-positive cases, and 80% of node-negative cases (FDR = 6.25%).

Conclusion

Results indicate that the evaluation of the quantitative sparse-feature classifier proposed here in clinical trials may lead to significant improvement in the prediction of lymphatic metastases in endometrial cancer patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12864-017-3604-y) contains supplementary material, which is available to authorized users.

Association of Serum HE4 with Primary Tumor Diameter and Depth of Myometrial Invasion in Endometrial Cancer Patients at Rajavithi Hospital

BACKGROUND

Although there are no biomarkers that are routinely used in endometrial cancer (EC) management, many studies have found that serum human epididymis protein 4 (HE4) is superior to cancer antigen 125 (CA125) in the detection of EC. The correlation of HE4 with two prognostic factors for EC, primary tumor diameter (PTD) and depth of myometrial invasion (DMI) may be useful in identifying EC patients at high risk of lymphatic dissemination.

OBJECTIVE

To evaluate the correlation of serum HE4 with PTD and DMI in patients with EC.

MATERIALS AND METHODS

A cross-sectional study was conducted on 70 EC patients who were scheduled for elective surgery at Rajavithi Hospital between 1st September 2013 and 30th May 2014. Preoperative serum levels of HE4 and CA125 were investigated, and then gross measurement of PTD was taken and postoperative pathologic slides were reviewed for DMI including histologic types, grading and staging.

RESULTS

Preoperative serum HE4 levels were strongly correlated with PTD (r=0.65, p<0.001) and moderately correlated with DMI (r=0.46, p<0.001). Moreover, serum HE4 levels were significantly elevated in EC patients with PTD >2 cm (p<0.001) and DMI > 50% (p=0.004). The performance of serum HE4 in identifying EC patients at low risk and high risk of lymph node metastasis was significantly better than that of CA125 (AUC 0.88 vs. 0.65, p=0.003). At an optimal cut-off value of 70 pM/L, serum HE4 had a sensitivity of 83.3% and a specificity of 80.0%.

CONCLUSIONS

In EC patients, preoperative serum HE4 is significantly correlated with PTD and DMI. Serum HE4 levels could be useful in identifying endometrial cancer patients at high risk of lymphatic spread who would benefit from systemic lymphadenectomy at the cut-off value of 70 pM/L.

The role of human epididymis secretory protein E4 in patients with endometrial cancer and premalignant endometrial lesions

We evaluated the concentrations of human epididymis secretory protein E4 (HE4) and Ca-125 in relation to clinicopathologic features in patients with endometrial cancer and premalignant endometrial lesions. Women with abnormal uterine bleeding (n = 167) who underwent endometrial sampling were divided into four groups. Group 1: endometrial cancer (n = 68), group 2: atypical endometrial hyperplasia (n = 12), group 3: endometrial hyperplasia without atypia (n = 39) and group 4: controls (n = 48). Women with endometrial cancer exhibited higher concentrations of HE4 levels than controls (91.4 pmol/L vs. 46.2 pmol/L, p < 0.001). HE4 levels were significantly higher in patients with lymphatic involvement, deep myometrial invasion, lymphovascular space involvement and non-endometrioid histology (p < 0.001). The sensitivity, specificity, positive and negative predictive values for HE4 in detecting endometrial cancer were 72.7%, 84.4%, 80% and 78.4%, respectively. Preoperative HE4 levels are more elevated in women with endometrial cancer than those with benign endometrium as well as in women with prognostic high-risk factors with endometrial cancer. HE4 may be used as an additional marker in combination with other clinicopathologic features for planning the treatment.

Assessment of levels of the tumor markers HE4 and CA125 considering staging, grading and histological types of endometrial cancer

Aim of the study

Aim of the study was to assess statistical differences of serum levels of HE4 and CA125 between certain endometrial cancer stages, grading and histological types.

Material and methods

A retrospective study of 52 patients admitted to our clinic for a surgical operation because of endometrial cancer was performed. HE4 and CA125 were measured for each patient. The staging was done according to FIGO. The statistical difference of serum levels of tumor markers was analyzed considering different stages, grading and histological types.

Results

Most of the patients (92.31%) were post-menopausal. Serum levels of tumor markers were significantly higher among patients with stage IB-IIIC than stage IA, among patients with stages II-III than stage I and among patients with stage IIIC than stage IA-IIIB. Only HE4 was significantly higher among patients with stage IB than stage IA and among patients with grading G2 and G3 than those with G1. Only CA125 was significantly higher among patients with stage IIIA and IIIB than those with stages I and II. There was no statistically significant difference in level of either tumor marker in differentiation of endometrioid from other histological endometrial cancer.

Conclusions

Both tumor markers HE4 and CA125 can be useful additional tools for pre-surgical differentiation between different stages of endometrial cancer. HE4 can predict advanced histological grades. Neither HE4 nor CA125 can differentiate endometrioid from other histological types of endometrial cancer.

The significance of markers in the diagnosis of endometrial cancer

Endometrial cancer is one of the most common cancers experienced by women throughout the world. It is also the most common malignancy within the female reproductive system, representing 37.7% of all disorders. The incidence increases with age, and is diagnosed most frequently in women between 45 and 65 years old. In the last few years, numerous studies have been performed to identify tumour biomarkers. Biomarkers include not only protein routinely used as tumour markers but also genes and chromosomes. The limiting factor in the use of markers in the diagnosis of endometrial cancer is their lack of specificity. However, specific markers for endometrial cancer are the subject of much research attention. Although moderately elevated levels of markers are present in a number of inflammatory or non-malignant diseases, significantly increased levels of markers indicate the development of cancer. Recently, research has been focused on the identification of molecular changes leading to different histological subtypes of endometrial cancer. In this paper the authors reviewed several currently investigated markers. Progress in these investigations is very important in the diagnostics and treatment of endometrial cancer. In particular, the identification of novel mutations and molecular profiles should enhance our ability to personalise adjuvant treatment with genome-guided targeted therapy.

External validation of non-imaging models for predicting distant metastasis in patients with endometrial cancer

OBJECTIVE

To evaluate two non-imaging models designed to predict distant metastasis (stages IIIC-IV) in endometrial carcinoma (EC). Both used preoperative histological and biological findings. One used primary tumoral size, the other did not.

METHODS

374 patients operated on for EC by hysterectomy and at least bilateral pelvic lymphadenectomy were included. Patient's characteristics, preoperative histological, biological findings and primary tumoral size were used to calculate for each patient two scores (one for each model) for distant metastasis. The accuracy of the models was evaluated in terms of areas under the receiver operating characteristic curves (AUCs), rates of false negatives, and number of patients in the group at low risk to predict stages IIIC-IV.

RESULTS

309 and 65 patients had FIGO stages IA-IIIB and IIIC-IV respectively. Thrombocytosis and leukocytosis were not significantly different between patients who had distant metastasis and those who did not. CA125 serum level was significantly higher in patients who had distant metastasis (71.2 vs 32.0U/mL, p<0.001). High-risk preoperative histology and primary tumor diameter >3cm were more frequently observed in patients who had distant metastasis (55.4% and 39.9%, p=0.02 and 21.3% and 8.5%, p=0.003). The AUC were 0.65 [0.63-0.67] and 0.68 [0.63-0.67] with 54% and 93.4% sensitivity, 64% 19.1% specificity. Two hundred and twenty nine patients (61.2%) and 62 (17.0%) were classified as low risk; among them, 30 patients (13.2%) and 4 (6.4%) had final stage IIIC or IV.

CONCLUSION

Both models turned out to have a low discrimination power in our population. However, the score using primary tumoral size permits to identify a subgroup of patients in whom metastatic probability is low and lymphadenectomy unnecessary. Preoperative CA125 level, histological findings and primary tumoral size remain prognostic factors of stages IIIC-IV and should be included in predictive models.

Utility of HE4 to identify patients with endometrioid endometrial cancer who may require lymphadenectomy

PURPOSE

The aim of the study was to establish whether preoperative serum levels of HE4 and CA125 could be a good predictor for lymphadenectomy in the early stage of endometrioid adenocarcinoma of the uterus.

MATERIAL AND METHODS

Preoperative serum HE4 and CA125 were measured in 78 postmenopausal patients treated surgically. The ROC curves were generated to determine the optimal cutoff values of HE4 and CA125 levels with optimum sensitivity and specificity for the prediction of lymphadenectomy.

RESULTS

Based on ROC curve, we found that the HE4 value of 78pmol/l is the best cutoff to identify candidates who may require lymphadenectomy with the sensitivity of 86.6% and the specificity of 67.2% (NPV=88.4% and PPV=51.2%). The area under the curve (AUC) equals 0.814 (95% CI=0.721-0.886). The cutoff level of CA125 that shows the prognostic indices is 26U/ml, with the sensitivity of 66.6% and the specificity of 61.2% (NPV=69.4% and PPV=44.3%). For CA125 the AUC amounts to 0.671 (95% CI=0.568-0.764). We also found a statistically significant difference, comparing HE4 and CA125 AUC (0.814 vs. 0.671, respectively, p<0.001). The combination of HE4 and CA125 established in our study as the cutoff point has the sensitivity of 81.2% and the specificity of 65.9% with NPV=83.4% and PPV=47.9%.

CONCLUSIONS

Our findings indicate that in the early stage of endometrioid endometrial cancer, HE4 can serve as a preoperative tool that can help to identify postmenopausal women who may require lymphadenectomy.

ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer: Diagnosis, Treatment and Follow-up

The first joint European Society for Medical Oncology (ESMO), European SocieTy for Radiotherapy & Oncology (ESTRO) and European Society of Gynaecological Oncology (ESGO) consensus conference on endometrial cancer was held on 11-13 December 2014 in Milan, Italy, and comprised a multidisciplinary panel of 40 leading experts in the management of endometrial cancer. Before the conference, the expert panel prepared three clinically-relevant questions about endometrial cancer relating to the following four areas: prevention and screening, surgery, adjuvant treatment and advanced and recurrent disease. All relevant scientific literature, as identified by the experts, was reviewed in advance. During the consensus conference, the panel developed recommendations for each specific question and a consensus was reached. Results of this consensus conference, together with a summary of evidence supporting each recommendation, are detailed in this article. All participants have approved this final article.

ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer: diagnosis, treatment and follow-up

The first joint European Society for Medical Oncology (ESMO), European SocieTy for Radiotherapy & Oncology (ESTRO) and European Society of Gynaecological Oncology (ESGO) consensus conference on endometrial cancer was held on 11-13 December 2014 in Milan, Italy, and comprised a multidisciplinary panel of 40 leading experts in the management of endometrial cancer. Before the conference, the expert panel prepared three clinically relevant questions about endometrial cancer relating to the following four areas: prevention and screening, surgery, adjuvant treatment and advanced and recurrent disease. All relevant scientific literature, as identified by the experts, was reviewed in advance. During the consensus conference, the panel developed recommendations for each specific question and a consensus was reached. Results of this consensus conference, together with a summary of evidence supporting each recommendation, are detailed in this article. All participants have approved this final article.