Angiogenesis in endometrial carcinoma: correlation with survival and clinicopathologic risk factors

The Expression of VEGF and CD31 in Endometrial Lesions and Its Associations with Blood Flow Parameters of Transvaginal 3D Power Doppler Ultrasonography: A Preliminary Study

Aim

To investigate the association of the blood flow parameters measured by transvaginal three-dimensional power Doppler ultrasound and the angiogenesis of endometrial cancer.

Material and Methods

The expressions of vascular endothelial growth factor (VEGF) and CD31 in benign and malignant endometrial lesions, and in malignant lesions with different clinical and pathological features were analyzed. The correlations of the blood flow parameters (vascularization index [VI], blood flow index [FI], and vascularization-blood flow index [VFI]) of transvaginal 3D power Doppler ultrasound, and VEGF expressions, microvessel density (MVD) were also evaluated.

Results

The VEGF-positive rates and the MVD values in benign and malignant endometrial lesions were significantly different (both P<0.001). The differences of VEGF-positive rates (P < 0.001) and MVD values (P = 0.021) between type I and type II lesions of endometrial cancer were statistically significant. There was no significant difference in the VEGF-positive rate and MVD value between stage IA and IB (P=0.443, P=0.311). The difference of VEGF expression and MVD in stage IA, stage IB and stage II and above was statistically significant (P=0.003, P=0.017). The VEGF-positive rate and MVD value were not significantly different in IAG1 and IAG2 lesions of endometrioid adenocarcinoma (P=0.709, P=0.792). There was no significant correlation between VI, FI, VFI and VEGF expression and MVD in endometrial cancer.

Conclusion

The VEGF-positive rates and MVD values were relatively high in malignant endometrial lesions, type II and stage II and above lesions of type I endometrial cancer, indicating that the angiogenesis of endometrial cancer tissues might play a crucial role in the tumor classification, and pelvic metastasis.

Therapeutic Targets and Opportunities in Endometrial Cancer: Update on Endocrine Therapy and Nonimmunotherapy Targeted Options

Worldwide, the incidence of endometrial cancer is increasing. Although the prognosis remains good for patients diagnosed with early-stage disease, for those diagnosed with recurrent or metastatic disease, options have been limited, and prognosis is short. Optimizing and identifying new well-tolerated treatments for women living with endometrial cancer is a top priority. A new era is dawning where we are starting to see the integration of clinically relevant genomic and pathologic data to inform and refine treatment strategies for women with endometrial cancer. Here, we focus on reviewing nonimmunotherapy-based targeted treatment options and emerging directions for women with endometrial cancer.

Phase II Trial of Cabozantinib in Recurrent/Metastatic Endometrial Cancer: A Study of the Princess Margaret, Chicago, and California Consortia (NCI9322/PHL86)

PURPOSE

The relevance of the MET/hepatocyte growth factor pathway in endometrial cancer tumor biology supports the clinical evaluation of cabozantinib in this disease.

PATIENTS AND METHODS

PHL86/NCI#9322 (NCT01935934) is a single arm study that evaluated cabozantinib (60 mg once daily) in women with endometrial cancer with progression after chemotherapy. Coprimary endpoints were response rate and 12-week progression-free-survival (PFS). Patients with uncommon histology endometrial cancer (eg, carcinosarcoma and clear cell) were enrolled in a parallel exploratory cohort.

RESULTS

A total of 102 patients were accrued. Among 36 endometrioid histology patients, response rate was 14%, 12-week PFS rate was 67%, and median PFS was 4.8 months. In serous cohort of 34 patients, response rate was 12%, 12-week PFS was 56%, and median PFS was 4.0 months. In a separate cohort of 32 patients with uncommon histology endometrial cancer (including carcinosarcoma), response rate was 6% and 12-week PFS was 47%. Six patients were on treatment for >12 months, including two for >30 months. Common cabozantinib-related toxicities (>30% patients) included hypertension, fatigue, diarrhea, nausea, and hand-foot syndrome. Gastrointestinal fistula/perforation occurred in four of 70 (6%) patients with serous/endometrioid cancer and five of 32 (16%) patients in exploratory cohort. We observed increased frequency of responses with somatic CTNNB1 mutation [four partial responses (PRs) in 10 patients, median PFS 7.6 months] and concurrent KRAS and PTEN/PIK3CA mutations (three PRs in 12 patients, median PFS 5.9 months).

CONCLUSIONS

Cabozantinib has activity in serous and endometrioid histology endometrial cancer. These results support further evaluation in genomically characterized patient cohorts.

VEGF-c expression in an in vivo model of orthotopic endometrial cancer and retroperitoneal lymph node metastasis

BACKGROUND

Retroperitoneal lymph node (RLN) metastasis is an important indicator of endometrial cancer (EC) prognosis. Because vascular endothelial growth factor c (VEGF-c) is known to influence lymphangiogenesis and thereby lymph node metastasis, this study assessed the relationship of VEGF-c mRNA expression with RLN metastasis in EC.

METHODS

The uterine muscularis mucosae of New Zealand white rabbits were inoculated with a VX2 tumor cell suspension after which they were sacrificed at 15, 18, 21, 24, 27 and 30 days. Control groups consisted of those receiving no treatment or an injection of saline. EC and metastatic RLN tissues along with peripheral blood samples were collected, and VEGF-c mRNA expression was evaluated using fluorescence real-time quantitative PCR.

RESULTS

The establishment of an in vivo model of EC with complete RLN metastasis was pathologically confirmed at day 21 post-injection with VX2 cells. As compared to the control groups, VEGF-c mRNA expression increased significantly over time in the tumor site, RLN, and peripheral white blood cells of EC rabbits. Significantly higher VEGF-c mRNA expression was observed in metastatic RLNs as compared to those without metastasis (P < 0.001). In addition, increased VEGF-c mRNA expression was observed in peripheral white blood cells of rabbits with RLN metastasis (P < 0.002).

CONCLUSION

Injection of a VX2 cell suspension is a simple method of establishing an in vivo EC model. VEGF-c may play an important role in the development of EC and its metastasis to RLN and may be useful marker to predict RLN metastasis.

Hypoxia contributes to development of recurrent endometrial carcinoma

Tumor hypoxia can trigger the induction of angiogenesis. High microvessel density (MVD) as well as hypoxia-inducible factor-1alpha (HIF-1alpha) have been related to recurrent disease and tumor aggressiveness, respectively. In this study, MVD and hypoxic status were investigated in primary and recurrent endometrial carcinomas. A total of 65 primary tumors of patients with recurrent endometrial carcinoma (n = 40), and without recurrent endometrial carcinoma (n = 25) were studied. Immunohistochemical analysis was performed on paraffin-embedded tumor tissue. MVD was determined by quantitative analysis of CD31/FVIII positive vessels. Tumor hypoxia was estimated by evaluating the expression of the hypoxia-regulated gene HIF-1alphaand its target gene carbonic anhydrase IX (CA-IX). An additional 23 recurrent tumors were available for determination of MVD and HIF-1alpha expression. Effects of hypoxia on tumor protein p53 (TP53) expression were evaluated in the endometrial cancer cell lines (ECC-1), Ishikawa (derived from adenocarcinomas), and AN3CA (derived from a lymph node metastasis). MVD, CA-IX, and HIF-1alpha expression were not significantly different in primary tumors of patients with recurrence compared to the control tumors. The MVD was significantly lower, and HIF-1alpha expression was significantly higher in recurrent tumors when compared with their primary tumors (paired t test, P < 0.05). HIF-1alpha expression correlated well with TP53 expression levels in primary tumors, but not in recurrences. TP53 protein levels were highest in AN3CA cells. Hypoxic conditions induced TP53 protein in ECC-1 and Ishikawa, but not AN3CA cells. We conclude that MVD, CA-IX, and HIF-1alpha expression are not independent prognostic markers for recurrent endometrial carcinoma. The low MVD, increased HIF-1alpha protein levels, dissociation of hypoxia, and TP53 protein induction in the metastatic tumor cells (AN3CA) support a role for hypoxia in the development of recurrent endometrial carcinoma.

Molecular alterations in the pathogenesis of endometrial adenocarcinoma. Therapeutic implications

Molecular genetic evidence indicates that endometrial carcinoma likely develops as the result of a multistep process of oncogene activation and tumor suppressor gene inactivation. These molecular alterations appear to be specific for Type I (endometrioid) and Type II (non endometrioid) cancers. Type I cancers are characterized by mutation of PTEN, KRAS2, defects in DNA mismatch repair, as evidenced by the microsatellite instability phenotype, and a near diploid karyotype. Type II cancers often contain mutations of TP53 and Her-2/neu and are usually nondiploid. The clinical value of many of these molecular markers is now being tested and it may help to refine diagnosis and establish an accurate prognosis. Furthermore, some of these tumor biomarkers constitute the targets for emerging therapies. Transtuzumab against Her-2/neu and bevacizumab against VEGF overexpressing carcinomas are among the promising novel treatments. Additional translational research is needed to identify molecular and genetic alterations with potential for therapeutic interventions.

A comparison of three histological grading systems in endometrial cancer

METHODS

To compare the architectural, nuclear and International Federation of Gynecology and Obstetrics (FIGO) grading systems in endometrial cancer 70 consecutive patients with endometrial cancer were retrospectively reevaluated with three grading systems.

RESULTS

Twenty-eight (40%), 27 (38.6%) and 14 (20%) cases were reported to have different grades when architectural vs nuclear, architectural vs. FIGO and nuclear vs. FIGO grading systems were compared in evaluation, respectively. Only 3 (42.8%) of the seven died patients had grade 3 in all three grading systems. Five-year survival rates were 95.7, 80, and 78.6% for architectural grade 1, 2 and 3, respectively. Same rates were 96.7, 90.5, and 78.9% for nuclear and 96, 91.7 and 81% for FIGO grading systems, respectively.

CONCLUSIONS

Grades of the tumors often change when different grading systems are used. Postoperative treatment should be considered when at least one of the grading systems indicates poor differentiation.