Predictive Score of Nodal Involvement in Endometrial Cancer Patients: A Large Multicentre Series

Preoperative evaluation and a nomogram prediction model for pelvic lymph node metastasis in endometrial cancer

OBJECTIVE

The primary objective of this study is to explore the preoperative risk factors of pelvic lymph node metastasis (PLNM) in endometrial cancer patients, and construct a nomogram prediction model.

MATERIALS AND METHODS

We retrospectively collected various preoperative clinical characteristics of patients and analyzed their relationship with PLNM. Logistic regression analysis was used to screen for independent risk factors for PLNM of endometrial cancer. A nomogram prediction model was constructed, the receiver operating characteristic (ROC), calibration curve and decision curve analysis (DCA) were constructed and used to assess discrimination, calibration, and net benefit.

RESULTS

Out of the 276 patients, 74 (26.81%) with postoperative pathological confirmation of PLNM. Multivariate logistic regressive analysis demonstrated that preoperative depth of myometrial invasion (DIM) ≥50% determined by Magnetic Resonance Imaging (MRI) (p = 0.003), carbohydrate antigen 125 (CA125) (p = 0.030), carbohydrate antigen 19-9 (CA 19-9) (p = 0.044), and platelet/lymphocyte ratio (PLR) (p = 0.025) could serve as independent risk factors for PLNM. A risk factors-based nomogram prediction model was constructed, which showed good discrimination (AUC = 0.841, p < 0.001) and good efficacy (C-index = 0.842) and good calibration (mean absolute error = 0.046). DCA showed that the model can provide clinical benefits.

CONCLUSIONS

Preoperative DIM ≥50% determined by MRI, serum CA 19-9, CA125 and PLR could be utilized to predict PLNM in endometrial cancer patients. This nomogram prediction model can provide preoperative help for evaluation and identification of patients with endometrial cancer, and provide a theoretical basis for clinical intervention.

Risk factors for pelvic and para-aortic lymph node metastasis in non-endometrioid endometrial cancer

PURPOSE

The aim of this study was to evaluate the risk factors for pelvic lymph node metastasis (LNM) and para-aortic LNM in non-endometrioid endometrial cancer (non-EEC).

METHODS

A total of 283 patients with non-EEC hospitalized in the First Affiliated Hospital of Zhengzhou University from January 2012 to December 2020 were included. Various characteristics were retrospectively analyzed in relation to LNM.

RESULTS

Univariable and multivariable logistic regression analysis revealed cervical stromal invasion (OR = 3.441, 95% CI = 1.558-7.6, p = 0.002), myometrial invasion ≥1/2 (OR = 2.661, 95% CI = 1.327-5.337, p < 0.006), lymphovascular space involvement (LVSI) (OR = 4.118, 95% CI = 1.919-8.837, p < 0.001), positive peritoneal cytology (OR = 2.962, 95% CI = 1.344-6.530, p = 0.007), CA125 (OR = 1.002, 95% CI = 1-1.004, p = 0.026) were the independent risk factors for pelvic LNM. And myometrial invasion ≥1/2 (OR = 5.881, 95% CI = 2.056-16.427, p = 0.001), LVSI (OR = 4.962, 95% CI = 1.933-12.740, p = 0.001), adnexal (OR = 5.921, 95% CI = 2.003-17.502, p = 0.001) were the independent risk factors for para-aortic LNM. With the increase of independent risk factors, the rates of LNM were increased significantly.

CONCLUSIONS

Cervical stromal invasion, myometrial invasion ≥1/2, LVSI, positive peritoneal cytology, and CA125 were risk factors for pelvic LNM. Myometrial invasion ≥1/2, LVSI and involvement of the adnexa were risk factors for para-aortic LNM which could provide a good basis to help predict which non-EEC patients are at higher risk for LNM.

Advancing Tailored Treatments: A Predictive Nomogram, Based on Ultrasound and Laboratory Data, for Assessing Nodal Involvement in Endometrial Cancer Patients

Assessing lymph node metastasis is crucial in determining the optimal therapeutic approach for endometrial cancer (EC). Considering the impact of lymphadenectomy, there is an urgent need for a cost-effective and easily applicable method to evaluate the risk of lymph node metastasis in cases of sentinel lymph node (SLN) biopsy failure. This retrospective monocentric study enrolled EC patients, who underwent surgical staging with nodal assessment. Data concerning demographic, clinicopathological, ultrasound, and surgical characteristics were collected from medical records. Ultrasound examinations were conducted in accordance with the IETA statement. We identified 425 patients, and, after applying exclusion criteria, the analysis included 313 women. Parameters incorporated into the nomogram were selected via univariate and multivariable analyses, including platelet count, myometrial infiltration, minimal tumor-free margin, and CA 125. The nomogram exhibited good accuracy in predicting lymph node involvement, with an AUC of 0.88. Using a cutoff of 10% likelihood of nodal involvement, the nomogram displayed a low false-negative rate of 0.04 (95% CI 0.00-0.19) in the training set. The adaptability of this straightforward model renders it suitable for implementation across diverse clinical settings, aiding gynecological oncologists in preoperative patient evaluations and facilitating the design of personalized treatments. However, external validation is mandatory for confirming diagnostic accuracy.

Recent management of endometrial cancer: a narrative review of the literature

Endometrial cancer is a common female gynecological neoplasia and its incidence rate has increased in the past years. Due to its predominant symptoms, most women will present uterine bleeding. It is usually diagnosed at an early stage and surgery has an important role in the treatment plan. The prognosis and quality of life of these patients can be quite favorable, if proper treatment is offered by surgeons. Traditionally, more invasive approaches and procedures were offered to these patients, but recent data suggest that more conservative and minimal invasive choices can be adopted in the treatment algorithm. Minimal invasive surgery, such as laparoscopy and robotic surgery, should be considered as an acceptable alternative, compared to laparotomy with less comorbidities and similar oncological and survival outcomes. Furthermore, sentinel lymph node biopsy has emerged in the surgical staging of endometrial cancer, in order to replace comprehensive lymphadenectomy. It is associated with less intra- and postoperative complications, while preliminary data show no difference in survival rates. However, sentinel lymph node biopsy should be offered within a strict algorithm, to avoid residual metastatic disease. The aim of this review is to analyze all the available data for the application of minimal invasive surgery in early endometrial cancer and especially the role of sentinel lymph node biopsy.

Retrospective analysis of the 18F-FDG PET/CT cutoff value for metabolic parameters was performed as a prediction model to evaluate risk factors for endometrial cancer

PURPOSE

The study retrospectively analyzed the accuracy and predictive ability of preoperative integrated whole-body 18F-FDG PET/CT for the assessment of high-risk factors in patients with endometrial carcinoma (EC).

MATERIALS AND METHODS

A total of 205 patients with endometrial cancer who underwent preoperative PET/CT at Shanghai General Hospital from January 2018 to December 2021 were retrospectively evaluated and last follow-up was June 2023. Our study evaluated the ability and optimal cutoff values of three metabolic and volumetric parameters-standardized uptake value (SUV), metabolic tumor volume (MTV) and total lesion glycolysis (TLG)-to predict deep myometrial invasion (DMI), endocervical stroma invasion (ESI) and lymph node metastases (LNM) in endometrial cancer. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PET/CT were used to assess the diagnostic performance for the prediction.

RESULTS

Our study demonstrated a significant relationship between SUVmax (11.29, 17.38, 9.47), SUVmean (5.20, 6.12, 4.49), MTV (38.15, 36.28, 33.79 ml), and TLG (199.30, 225.10, 156.40 g) on PET/CT and histologically confirmed DMI, ESI and LNM in endometrial carcinoma (EC), with sensitivity, specificity, accuracy, PPV, and NPV of 100%/100%/100%, 96.53%/98.89%/87.14%, 97.56%/99.02%/91.22%, 92.42%/92.85%/78.31%, and 100%/100%/100%, respectively. Our study showed a risk model based on optimal cutoff values for MTV and TLG of 19.6 ml/126.3 g, 20.54 ml/84.80 g and 24 ml/49.83 g to preoperatively predict DMI, ESI, and LNM, respectively, in endometrial carcinoma. The 4-year OS (HR) for Stage IA, IB, II, III and IV according to 2009 FIGO was 98.00% (0.22), 95.20% (0.04), 83.90% (0.18), 90.50% (0.09) and 60% (0.51). Accordingly, estimated 4-year DFS (HR) for the stage IA-III was 98% (0.02), 95.20% (0.05), 76.90% (0.27) and 76.30% (0.35), all the patients in stage IV occurred recurrence and progression.

CONCLUSION

The present study showed patients with MTV > = 19.6 ml of MI and PET- positive LN with MTV cutoff > = 24 ml tended to predict poor OS and PFS in endometrial carcinoma. The cutoff of MTV and TLG in PET/CT assessment could be an independent prognostic factors to predict aggressive forms of EC.

KLF2 transcription suppresses endometrial cancer cell proliferation, invasion, and migration through the inhibition of NPM1

Endometrial cancer (EC) is the most common gynaecologic malignancy. This study was to explore the role of kruppel-like factor 2 (KLF2) in EC cell behaviours. The expression of KLF2 in EC and its correlation with NPM1 were first predicted on the database. Levels of KLF2 and nucleophosmin 1 (NPM1) in EC cell lines were then determined. After transfection of the overexpression vector of KLF2 or NPM1, cell proliferation, invasion, and migration were evaluated. The binding relationship between KLF2 and the NPM1 promoter was analysed. KLF2 was downregulated while NPM1 was upregulated in EC cells. KLF2 overexpression reduced the proliferation potential of EC cells and the number of invaded and migrated cells. KLF2 was enriched in the NPM1 promoter and inhibited NPM1 transcriptional level. NPM1 overexpression neutralised the effects of KLF2 overexpression on suppressing EC cell growth. Collectively, KLF2 was decreased in EC cells and KLF2 overexpression increased the binding to the NPM1 promoter to inhibit NPM1 transcription, thus suppressing EC cell growth.

The crucial value of serum ferritin in assessing high-risk factors and prognosis for patients with endometrial carcinoma

BACKGROUND

Endometrial carcinoma is a common malignant tumor in female reproductive system. At present, there is no effective and economic prognostic index. This study aimed to investigate the effect of serum ferritin levels on the prognosis of endometrial carcinoma.

METHODS

Data of 367 patients who diagnosed with endometrial carcinoma at the First Affiliated Hospital of Chongqing Medical University between January 2012 and August 2018 was retrospectively analyzed. The prediction accuracy was evaluated by receiver operating characteristics curves and Youden's J statistics. Hosmer-lemeshow test was used to confirm the goodness of fit of the model. The prognostic value of serum ferritin on disease free survival (DFS) and overall survival (OS) of endometrial carcinoma was evaluated by univariate log-rank tests and multivariate cox regression models.

RESULTS

Preoperative high serum ferritin was correlated with older age, high grade, specific histological subtypes and recurrence of endometrial carcinoma (P < 0.05). The DFS and OS of 198 patients with elevated serum ferritin levels were significantly lower than those with low serum ferritin levels (P = 0.001 and P = 0.002, respectively). In multivariate analysis, serum ferritin was an independent prognostic factor for DFS and OS in endometrial carcinoma (P = 0.012, P = 0.028).

CONCLUSION

Through our research, we found that the high expression of serum ferritin level was not only related to low DFS and OS in patients with endometrial carcinoma, but also related to the high-risk factors of endometrial carcinoma recurrence. So serum ferritin levels may be used to predict the poor prognosis of patients with endometrial carcinoma.

Metabolic syndrome score as an indicator in a predictive nomogram for lymph node metastasis in endometrial cancer

BACKGROUND

Lymph node metastasis (LNM) is an important factor affecting endometrial cancer (EC) prognosis. Current controversy exists as to how to accurately assess the risk of lymphatic metastasis. Metabolic syndrome has been considered a risk factor for endometrial cancer, yet its effect on LNM remains elusive. We developed a nomogram integrating metabolic syndrome indicators with other crucial variables to predict lymph node metastasis in endometrial cancer.

METHODS

This study is based on patients diagnosed with EC in Peking University People's Hospital between January 2004 and December 2020. A total of 1076 patients diagnosed with EC and who underwent staging surgery were divided into training and validation cohorts according to the ratio of 2:1. Univariate and multivariate logistic regression analyses were used to determine the significant predictive factors.

RESULTS

The prediction nomogram included MSR, positive peritoneal cytology, lymph vascular space invasion, endometrioid histological type, tumor size >  = 2 cm, myometrial invasion >  = 50%, cervical stromal invasion, and tumor grade. In the training group, the area under the curve (AUC) of the nomogram and Mayo criteria were 0.85 (95% CI: 0.81-0.90) and 0.77 (95% CI: 0.77-0.83), respectively (P < 0.01). In the validation group (N = 359), the AUC was 0.87 (95% CI: 0.82-0.93) and 0.80 (95% CI: 0.74-0.87) for the nomogram and the Mayo criteria, respectively (P = 0.01). Calibration plots revealed the satisfactory performance of the nomogram. Decision curve analysis showed a positive net benefit of this nomogram, which indicated clinical value.

CONCLUSION

This model may promote risk stratification and individualized treatment, thus improving the prognosis.

Development and validation of nodal staging score in pN0 patients with esophageal squamous cell carcinoma: A population study from the SEER database and a single-institution cohort

BACKGROUND

Patients with esophageal squamous cell carcinoma (ESCC) with lymph node metastasis may be misclassified as pN0 due to an insufficient number of lymph nodes examined (LNE). The purpose of this study was to confirm that patients with ESCC are indeed pN0 and to propose an adequate number for the correct nodal stage using the nodal staging score (NSS) developed by the beta-binomial model.

METHODS

A total of 1249 patients from the Surveillance, Epidemiology, and End Results (SEER) database between 2000 and 2017, and 1404 patients diagnosed with ESCC in our database between 2005 and 2018 were included. The NSS was developed to assess the probability of pN0 status based on both databases. The effectiveness of NSS was verified using survival analysis, including Kaplan-Meier curves and Cox models.

RESULTS

Many patients were misclassified as pN0 based on our algorithm due to insufficient LNE. As the number of LNE increased, false-negative findings dropped; accordingly, the NSS increased. In addition, NSS was an independent prognostic indicator for pN0 in patients with ESCC in the SEER database (hazard ratio [HR] 0.182, 95% confidence interval [CI] 0.046-0.730, p = 0.016) and our database (HR 0.215, 95% CI 0.055-0.842, p = 0.027). A certain number of nodes must be examined to achieve 90% of the NSS.

CONCLUSIONS

NSS could determine the probability of true pN0 status for patients, and it was sufficient in predicting survival and obtaining adequate numbers for lymphadenectomy.

Sentinel Node Biopsy for Endometrial Cancer by Retroperitoneal Transvaginal Natural Orifice Transluminal Endoscopic Surgery: A Preliminary Study

Objective

The primary objective was to determine the intraoperative and postoperative surgical complications of sentinel lymph node biopsy (SLNB) by retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES). The secondary objective was to assess the feasibility of this surgical technique.

Methods

This was a descriptive study realized in a non-university hospital in Switzerland. Seven patients with endometrial cancer or endometrial complex atypical hyperplasia underwent surgical staging with SLNB by retroperitoneal vNOTES using an indocyanine green-based near-infrared fluorescence imaging technique (October 2021–February 2022).

Results

The median operative time was 113 (81–211) minutes. The median estimated blood loss was 20 (20–400) mL. The overall bilateral detection rate was 100% (7/7). Upon histopathological examination, 5 patients presented an endometrial adenocarcinoma, and we found endometrial complex atypical hyperplasia in 2 cases. We successfully completed all procedures without significant intraoperative complications, but 1 case required conversion to conventional laparoscopy. The median postoperative stay was 2 (2–4) days, and we observed no postoperative complications during this period. We observed 1 case of postoperative deep vein thrombosis and an asymptomatic vaginal vault hematoma in the same patient.

Conclusions

Our preliminary study suggests that retroperitoneal vNOTES could be a feasible, safe, and valuable approach to perform SLNB in endometrial cancer. However, strong evidence of its feasibility, the effective benefits, and the long-term oncological outcomes is needed before expanding the use of vNOTES in endometrial cancer outside study settings.

Risk Factors and Prognosis of Early Recurrence in Stage I–II Endometrial Cancer: A Large-Scale, Multi-Center, and Retrospective Study

Objective

The aim of the present study was to determine overall survival (OS) and risk factors associated with early recurrence in patients with FIGO I–II stage endometrial carcinoma (EC).

Methods

Clinical features were retrospectively extracted from the database of China Endometrial Cancer Consortium from January 2000 to December 2019. A total of 2,974 patients with Federation International of Gynecology and Obstetrics (FIGO) I–II stage endometrial cancer were included. Kaplan-Meier survival analysis was used to assess OS and disease-specific survival. Cox proportional hazard model and Fine-Gray model were used to determine the factors related to OS. Binary logistic regression model was used to determine independent predictors of early relapse patients.

Results

Of these 2,974 ECs, 189 patients were confirmed to have relapse. The 5-year OS was significantly different between the recurrence and non-recurrence patients (p &lt; 0.001). Three quarters of the relapse patients were reported in 36 months. The 5-year OS for early recurrence patients was shorter than late recurrence [relapse beyond 36 months, p &lt; 0.001]. The grade 3 [odds ratio (OR) = 1.55, 95%CI 1.17–2.05, p = 0.002], lymphatic vascular infiltration (LVSI; OR = 3.36; 95%CI 1.50–7.54, p = 0.003), and myometrial infiltration (OR = 2.07, 95%CI 1.17—3.65, p = 0.012) were independent risk factors of early relapse. The protective factor of that is progesterone receptor (PR)-positive (OR = 0.50, 95%CI 0.27–0.92, p = 0.02). Bilateral ovariectomy could reduce recurrence risk rate (OR = 0.26, 95%CI 0.14–0.51, p &lt; 0.001).

Conclusion

The OS of early relapse EC is worse. Grade 3, LVSI, and myometrial infiltration are independent risk factors for early relapse EC. In addition, the protective factor is PR-positive for those people and bilateral salpingo-oophorectomy could reduce the risk of recurrence.