Correlation between pre-operative and final histological diagnosis on endometrial cancer

Quantitative Measurement of Progesterone Receptor Immunohistochemical Expression to Predict Lymph Node Metastasis in Endometrial Cancer

Background: Previous studies have shown that loss of progesterone receptor (PR) in endometrial cancer (EC) is associated with poor outcomes. Evaluating lymph node metastasis (LNM) is essential, especially before surgical staging. The aim of this study was to investigate the role of PR expression and other clinicopathological parameters in LNM and to develop a prediction model. Methods: We retrospectively evaluated endometrioid-type EC patients treated with staging surgery between January 2015 and March 2020. We analyzed PR status using immunohistochemical staining, and the expression was quantified using the H-score. We identified optimal cut-off values of H-score and CA125 for predicting LNM using receiver operating characteristic curves, and used stepwise multivariate logistic regression analysis to identify independent predictors. A nomogram for predicting LNM was constructed and validated using bootstrap resampling. Results: Of the 310 patients evaluated, the optimal cut-off values of PR H-score and CA125 were 162.5 (AUC 0.670, p = 0.001) and 40 U/mL (AUC 0.739, p < 0.001), respectively. Multivariate analysis showed that CA125 ≥ 40 U/mL (OR: 8.03; 95% CI: 3.44−18.77), PR H-score < 162.5 (OR: 5.22; 95% CI: 1.87−14.60), and tumor grade 2/3 (OR: 3.25; 95% CI: 1.33−7.91) were independent predictors. These three variables were incorporated into a nomogram, which showed effective discrimination with a concordance index of 0.829. Calibration curves for the probability of LNM showed optimal agreement between the probability as predicted by the nomogram and the actual probability. Our model gave a negative predictive value and a negative likelihood ratio of 98.4% and 0.14, respectively. Conclusions: PR H-score along with tumor grade and CA125 are helpful to predict LNM. In addition, our nomogram can aid in decision making with regard to lymphadenectomy in endometrioid-type EC.

Discordance in clinical versus pathological staging in breast cancer: Are we undermining the significance of accurate preoperative staging in the present era?

BACKGROUND

The present era of individualized treatment for breast cancer is influenced by the initial disease status including the anatomical extent, grade, and receptor status. An accurate preoperative staging is the basis of treatment planning and prognostication. Our study aims to determine the discordance between the preoperative clinical and the postoperative pathological stages of breast cancer patients.

METHODOLOGY

The medical records of all non-metastatic breast cancer patients from January 2017 to December 2018 who underwent upfront surgery were reviewed. They were staged as per the eighth AJCC and the concordance between the clinical (c) and pathological T (tumor), N (nodal), and final AJCC stage was studied. A Chi-square test was used to determine factors that significantly correlate with disease discordance.

RESULTS

A total of 307 breast cancer patients were analyzed. Among these, 43.3% were hormone receptor-positive, 30.6% were Her2 positive and 26% were triple-negative. Overall stage discordance was seen in 48.5% (n = 149) patients (upstaging in 22.1%, downstaging in 26.4%). The discordance rate was 48.9% for T stage (cT versus pT) and 57.4% for N stage (cN versus pN). Among patients with clinically node-negative disease, 53.4% were found to have positive nodes on histopathology, while 27.2% had vice versa. Overall, the factors associated with upstaging were ER-positive, Her2 positive and triple-negative status (all p < 0.05), while none of the factors showed significant association with downstaging.

CONCLUSIONS

About half of breast cancer patients had discordance between clinical and pathological staging with higher discordance in the nodal stage. This changes the disease prognosis, and may also affect the offered surgical treatment and radiotherapy. Thus highlighting the need for a precise pre-operative staging. Also, this information will aid clinicians in discussions with patients, keeping in mind the likelihood of change in disease staging and management.

Predictive Value of Serum Cytokeratin 19 Level for the Feasibility of Conserving Ovaries in Endometrial Cancer

Objective: To determine the predictive value of cytokeratin 19 (CK19) for evaluating the safety of ovarian preservation in patients with endometrial cancer (EC).

Methods: Five hundred and seventeen EC patients hospitalized from November 2010 to June 2016 were reviewed retrospectively. Pre-operative tumor biomarkers including CA125, HE4, CK19, and CA19-9 were obtained. Predictive biomarkers associated with ovarian metastasis were selected using univariate and multivariate Logistic regression. The cut-off values were determined by receiver operating characteristic (ROC) curves. Kaplan-Meier method and Cox multivariate regression model was used to perform survival analysis.

Results: Among clinical parameters and biomarkers included, age > 65, type II EC, CA125 ≥ 35 u/ml, CK19 > 3.3 ng/ml, and myometrial invasion ≥ 50% depth appeared as significant predictors of the risk of ovarian involvement in univariable logistic analysis. In multivariable analysis, CK19 > 3.3 ng/ml (OR = 11.541, 95%CI: 1.968–67.668, P = 0.007) and Type II EC (OR = 8.336, 95%CI: 1.456–47.722, P = 0.017) were independent risk predictors of ovarian metastasis in pre-menopausal women. In pre-menopausal women with Type I EC (n = 142), CK19 level could satisfactorily predict the risk of ovarian metastasis (AUC = 0.860, 95%CI: 0.792–0.912, P < 0.001), and when the cut-off point was set as 2.45 ng/ml, the negative predictive value and negative likelihood ratio were 99% and 0.19, with the maximum Youden index of 0.598.

Conclusions: The present study advocates the necessity of incorporating serum CK19 measurement into the pre-operative evaluation of EC, especially as extension of current standard approach with ovarian preservation counseling.

Nomograms of Combining Apparent Diffusion Coefficient Value and Radiomics for Preoperative Risk Evaluation in Endometrial Carcinoma

Objectives

To evaluate the value of nomogram models combining apparent diffusion coefficient (ADC) value and radiomic features on magnetic resonance imaging (MRI) in predicting the type, grade, deep myometrial invasion (DMI), lymphovascular space invasion (LVSI), and lymph node metastasis (LNM) of endometrial carcinoma (EC) preoperatively.

Methods

This study included 210 EC patients. ADC value was calculated, and radiomic features were measured on T2-weighted images. The univariate and multivariate logistic regressions and cross-validations were performed to reduce valueless features, then radiomics signatures were developed. Nomogram models using ADC combined with radiomic features were developed in the training cohort. The receiver operating characteristic (ROC) curve was performed to estimate the diagnostic efficiency of nomogram models by the area under the curve (AUC) in the training and validation cohorts.

Results

The ADC value was significantly different between each subgroup. Radiomic features were ultimately limited to four features for type, six features for grade, six features for DMI, four features for LVSI, and eight features for LNM for the nomogram models. The AUC of the nomogram model combining ADC value and radiomic features in the training and validation cohorts was 0.851 and 0.867 for type, 0.959 and 0.880 for grade, 0.839 and 0.766 for DMI, 0.816 and 0.746 for LVSI, and 0.910 and 0.897 for LNM.

Conclusions

The nomogram models of ADC value combined with radiomic features were associated with the type, grade, DMI, LVSI, and LNM of EC, and provide an effective, non-invasive method to evaluate preoperative risk stratification for EC.

Correlation between pre-operative diagnosis and final pathological diagnosis of endometrial malignancies; impact on primary surgical treatment

OBJECTIVES

to compare the accuracy of preoperative and postoperative endometrial sampling obtained by dilatation and curettage (D&C), Pipelle and hysteroscopy to diagnose endometrial malignancies and to evaluate the adequacy of surgical treatment for these patients.

STUDY DESIGN

This retrospective record-based study was conducted at Gynecology Oncology Unit, Ain Shams University Maternity Hospital, Cairo, Egypt. Records of patients with an initial preoperative or a final postoperative pathological diagnosis of endometrial hyperplasia or endometrial malignancies were retrieved over a six year period from January 2013 until March 2019. The preoperative biopsy methods, results, postoperative pathology diagnosis and treatment received were recorded and analyzed.

RESULTS

Records of 395 patients were retrieved. Rates of agreement between initial and postoperative pathology for endometrial hyperplasia (with and without atypia) were 10% by D&C, 7.8% by Pipelle and zero % by hysteroscopy; for endometrioid adenocarcinoma grade 1, they were 40.7% by D&C, 40.6% by Pipelle and 20% by hysteroscopy; for endometrioid adenocarcinoma grades 2 and 3, they were 83.7% and 84.6% by D&C, 97% and 60% by Pipelle, and 100% by hysteroscopy, respectively. For type II endometrial cancer and endometrial stromal sarcoma, agreement rates were 100% by all biopsy methods. Out of 13 cases diagnosed with atrophic endometrium preoperatively, 11 cases were diagnosed as endometrial stromal sarcoma. Comparing accuracy of the three biopsy methods, D&C had highest sensitivity of 61.9%; hysteroscopy showed 100% specificity, while Pipelle was the least accurate method. Finally, 61.4% of the patients received adequate surgical treatment.

CONCLUSION

There were excellent concordance rates between initial biopsy and postoperative pathology in diagnosis of high grade endometrioid and other endometrial malignancies compared to endometrial hyperplasia and low grade endometrioid adenocarcinoma. Patients diagnosed initially with atrophic endometrium or hyperplasia warranted more surveillance before their surgical treatment. It is crucial to develop protocols for increasing accuracy of endometrial sampling such as performing molecular studies for preoperative pathology.

Obesity, an independent predictor of pre and postoperative tumor grading disagreement in endometrial cancer

INTRODUCTION

Obesity is a known independent risk factor for endometrial cancer (EC), and obese patients have a 4.7-fold increased risk compared to the general population to develop the neoplasm. To date, a general pre and postoperative tumor grading agreement from 53 % to 82 % is reported for endometrial analysis, and a consensus on which factors might influence the tumor grading discordance is still absent. Furthermore, although obesity alters the endometrial microenvironment, no studies investigated the role of obesity in the grading agreement of EC patients. This study aims to analyze the role of obesity in the pre and postoperative tumor grading agreement.

MATERIALS AND METHODS

A retrospective analysis was conducted on EC cancer women subjected to surgical treatment. Upgrading discordance was defined as higher tumor grading on final pathological analysis compared to tumor grading on the preoperative examination. Downgrading discordance was defined as a lower tumor grading at the postoperative surgical specimen analysis compared to the preoperative biopsy.

RESULTS

Of the 293 selected patients, 245 were included in the analysis. One hundred and forty nine (60.8 %) patients were tumor grade G1, 52 (21.2 %) G2, and 44 (18.0 %) G3. Grading agreement was 83.9 % for G1 patients, 51.9 % for G2 patients, and 83.3 % for G3 patients. The multivariate analysis showed obesity (BMI > 30 kg/m²) as significant factor influencing pre and postoperative grading agreement (p = 0.014, Odds Ratio 2.036, 95 % Confidence Interval 1.141-3.635).

CONCLUSIONS

Our study for the first time showed obesity as the only factor in the multivariate analysis lowering the pre and postoperative tumor grading concordance. Grade 2 tumor was the factor that most frequently disagreed with the final surgical specimen analysis both in the general and in obese patients.

Importance of pre-operative ultrasound examination and pathological tumour evaluation in the management of women with endometrial cancer

INTRODUCTION

Endometrial cancer (EC) is the most common gynaecological malignancy in developed countries. Early and accurate diagnostic assessment is crucial for appropriate treatment planning. Information obtained by pre-operative imaging with transvaginal ultrasound (TVUS) and histological endometrial biopsy assessment is often the cornerstone for further management planning. This study aimed to analyse the accuracy of this diagnostic approach for patient management decisions.

MATERIALS AND METHODS

This single-centre retrospective analysis included all patients with endometrial cancer treated between 2015 and 2019. Pre-operative TVUS staging assessment and histopathological endometrial biopsy examination were compared with the final surgical stage and histopathological diagnosis.

RESULTS

Pre-operative and surgical pathological assessment of Type I and Type II tumours was in agreement in 95 % (174/184) and 54 % (12/22) of cases, respectively. The sensitivity and specificity of TVUS assessment of myometrial invasion were 76 % [95 % confidence interval (CI) 66.3-84.2 %] and 81.7 % [95 % CI 73.0-88.6 %], respectively. Diagnostic accuracy was higher for Type I EC (95 %) than Type II EC (54 %). Only presumed ESMO/ESGO/ESTRO risk classification (p < 0.000) and deep myometrial invasion (p < 0.000) were significant for the prediction of lymph node involvement.

CONCLUSION

Pre-operative TVUS examination and pathological endometrial biopsy evaluation enable moderately accurate assessment of the risk of EC. Efforts should be aimed towards the development of novel and more reproducible methods, such as molecular tumour characterization, to improve the pre-operative assessment of risk in patients with EC.

Differential Impact of Systemic Lymphadenectomy Upon the Survival of Patients with Type I vs Type II Endometrial Cancer: A Retrospective Observational Cohort Study

PURPOSE

To determine whether systemic lymphadenectomy exerts a similar effect on the survival of patients with either type I or type II endometrial cancer (EC).

PATIENTS AND METHODS

In this retrospective study, 682 eligible patients diagnosed with EC were typed according to the pathological reports. The thoroughness of lymphadenectomy was evaluated by the lymph node number of which the cut-off value was determined by the receiver operator characteristic (ROC) curve and Youden index. The impact of thoroughness on the survival of both types was analyzed, respectively, by Kaplan Meier (K-M) method and further evaluated in subgroups with and without lymphatic metastasis. Independent prognostic factors of survival were selected by proportional hazard regression (Cox) model.

RESULTS

The cut-off level of lymph node number was 20. The differential impact of the lymph node number removed on survival was noted when patients with different types were analyzed separately. Among type II EC, those with >20 lymph nodes removed presented better overall survival (OS) than those with ≤20 (p=0.002). The number of lymph nodes removed >20 was proved as an independent factor for improved OS in type II EC (HR=0.329,95% CI: 0.123-0.881, p=0.0027). In the subgroup of type II with >20 lymph nodes resected, similar 5-year OS rates were observed in those with or without identified positive node (90.9% vs 92.9%, p=0.965). Type I EC seemed unbeneficial from such a procedure.

CONCLUSION

Systemic lymphadenectomy could enhance the OS of type II EC other than type I.

Scoring systems for the evaluation of adnexal masses nature: current knowledge and clinical applications

Adnexal masses are a common finding in women, with 20% of them developing at least one pelvic mass during their lifetime. There are more than 30 different subtypes of adnexal tumours, with multiple different subcategories, and the correct characterisation of the pelvic masses is of paramount importance to guide the correct management. On that basis, different algorithms and scoring systems have been developed to guide the clinical assessment. The first scoring system implemented into the clinical practice was the Risk of Malignancy Index, which combines ultrasound evaluation, menopausal status, and serum CA-125 levels. Today, current guidelines regarding female patients with adnexal masses include the application of International Ovarian Tumours Analysis simple rules, logistic regression model 1 (LR1) and LR2, OVERA, cancer ovarii non-invasive assessment of treating strategy, and assessment of Different Neoplasias in the adnexa. In this scenario, the choice of the scoring system for the discrimination between benign and malignant ovarian tumours can be complex when approaching patients with adnexal masses. This review aims to summarise the available evidence regarding the different scoring systems to provide a complete overview of the topic.