Uterine Neoplasms, Version 1.2023, NCCN Clinical Practice Guidelines in Oncology

Innovations in laparoscopic management of endometrial cancer

INTRODUCTION

Endometrial cancer is one of the most common gynecologic malignancies, with increasing incidence, in developed countries. Advances in minimally invasive surgery, particularly laparoscopic with or without the use of computer-assisted ('robotic') platforms, have transformed its management, improving surgical outcomes and patient recovery.

AREAS COVERED

This review explores recent innovations in laparoscopic management of endometrial cancer, including robotic-assisted laparoscopic surgery, sentinel lymph node mapping, and the integration of artificial intelligence in surgical navigation. A comprehensive literature search was conducted using PubMed and clinical trial databases to assess the impact of these advancements on surgical precision, oncologic outcomes, and patient recovery. Major studies comparing robotic-assisted laparoscopy, traditional laparoscopy, and open surgery are reviewed, along with new technologies that support real-time decision-making during surgery.

EXPERT OPINION

Minimally invasive approaches have become the standard of care for early-stage endometrial cancer, offering superior perioperative outcomes. While robotic-assisted surgery provides technical advantages, cost and accessibility remain challenges. Sentinel lymph node mapping reduces morbidity compared to full lymphadenectomy, and artificial intelligence holds promise in optimizing surgical precision. Future research should focus on refining these technologies, improving patient selection criteria, and ensuring equitable access to advanced surgical techniques.

Endometrial Stromal Sarcoma: An Update

Endometrial stromal sarcoma (ESS) is a rare malignant tumor of uterine mesenchyme, accounting for 15-20% of uterine sarcomas. It is classified into low-grade (LG-ESS) and high-grade (HG-ESS) subtypes, each defined by distinct histopathological and molecular features. LG-ESS exhibits slow progression, resembling proliferative-phase endometrial stroma, with genetic alterations like JAZF1-SUZ12 fusions. HG-ESS is more aggressive, characterized by high mitotic activity, necrosis, and genetic markers such as BCOR internal tandem duplication, often leading to advanced-stage diagnosis. Surgical resection is the cornerstone for managing early-stage ESS. A total hysterectomy with bilateral salpingo-oophorectomy (BSO) is recommended to prevent recurrence. Fertility-preserving approaches may be considered in LG-ESS but are associated with high recurrence rates. Lymphadenectomy is not routinely performed, given its limited prognostic value. HG-ESS, due to its aggressiveness, often requires additional treatment, including chemotherapy. Adjuvant therapy varies by subtype. LG-ESS responds well to hormonal treatments such as aromatase inhibitors and progestins, while tamoxifen is contraindicated. HG-ESS, lacking hormonal receptor expression, is managed with chemotherapy, often incorporating doxorubicin-based regimens. Radiotherapy may improve local control in select cases but shows limited impact on overall survival. Advanced-stage ESS treatment focuses on complete cytoreduction, supplemented by systemic therapies. Hormonal therapy remains the standard for advanced LG-ESS, whereas HG-ESS relies on chemotherapy. Prognosis depends on the subtype and stage. LG-ESS has favorable outcomes, with five-year survival exceeding 90% in early stages, but recurrent disease remains common. HG-ESS is associated with poorer survival due to its aggressive nature. Advances in molecular profiling offer promising avenues for personalized therapies, integrating genomic insights with targeted treatments to improve outcomes in this rare malignancy.

Comparison of laparoscopic and robotic-assisted minimally invasive surgery with sentinel lymph node navigation in low-risk endometrial cancer: a retrospective analysis

OBJECTIVE

To evaluate and compare the perioperative and oncologic outcomes of laparoscopic and robotic-assisted surgeries in patients with low-risk endometrial cancer who underwent minimally invasive surgery (MIS) for complete surgical staging, including sentinel lymph node mapping.

METHODS

A retrospective study included 190 patients diagnosed with low-risk endometrial cancer who underwent MIS combined with sentinel lymph node navigation surgery (SNNS) between December 2016 and December 2021. Among these patients, 66 underwent laparoscopic surgery, while 124 underwent robotic-assisted surgery. The analysis focused on patient characteristics, perioperative outcomes, and prognostic factors, including recurrence-free survival (RFS) and overall survival (OS). Statistical analysis was performed using Kaplan-Meier survival curves and appropriate comparative tests for outcome evaluation.

RESULTS

The median operative time and estimated blood loss were significantly longer and greater in the robotic surgery group than in the laparoscopic group (209.5 vs. 157.5 min, 20 vs. 5 mL, respectively). The identification rates of sentinel nodes were 97% and 95.2% in the laparoscopic and robotic groups, respectively, with no significant difference between the 2. Recurrence was observed in two and three cases in the laparoscopic robotic surgery groups, respectively. The 3-year RFS rates were 97.6% (95% confidence interval [CI]=0.8482-0.9769) and 93.9% (95% CI=0.9277-0.9922) for the robotic and laparoscopic groups, respectively, while the 3-year OS rates were 99.2% (95% CI=0.8561-0.9902) and 96.1% (95% CI=0.9450-0.9989), respectively, with no statistically significant differences.

CONCLUSION

MIS combined with SNNS is a highly effective approach for managing low-risk endometrial cancer, providing comparable oncologic outcomes to laparoscopy while enhancing the quality of life of patients.

The exciting journey of progress: Exploring FIGO 2023 staging for endometrial cancer at a leading ESGO institution

INTRODUCTION

The 2023 FIGO staging of endometrial cancer integrates tumor grade and histology along with molecular features that recognize the prognostic significance of p53 and POLE mutations, accounting for potential conflicts such as lymphovascular space invasion and subserosal invasion.

MATERIALS AND METHODS

In this single-institution retrospective study, data were collected on 229 endometrial cancer patients from January 2020 to September 2024 and re-stage them according to FIGO 2023 criteria.

RESULTS

From FIGO stage 2009 IA, 70 patients do not cross stage (21 are FIGO 2023 IA1 and 49 IA2), 8 patients are upgraded to FIGO IC because of aggressive histotype; 1 is upstaged because of substantial LVSI, and 12 because of aggressive myoinfiltrating tumors (23 % of upstaging). From FIGO 2009 stage IB 34 patients remain in FIGO 2023 IB, while 5 become stage IIB (LVSI) and 27 IIC (aggressive myoinfiltrating), for a total of 32 upstages (48 % of upstaging). Within FIGO 2009 stage II, no proper upstage was possible. We observed a statistical correlation between stages and BMI, as well as between stages and age, for both FIGO 2009 (p = 0.009 and p < 0.001 respectively) and FIGO 2023 (p = 0.002 and p = 0.003 respectively) classifications. Additionally, a correlation was found between tumor grade and BMI (p = 0.02).

CONCLUSIONS

The FIGO 2023 staging system is gaining importance as recent studies highlight the role of molecular classification in prognosis and personalized therapy. Updating our study's follow-up data will clarify its impact in clinical practice.

Diagnostic accuracy of TVUS and MRI in the preoperative evaluation of myometrial infiltration in patients with endometrial cancer: A meta-analysis

AIM

The incidence of endometrial cancer is on the rise worldwide. Accurate preoperative evaluation of myometrial infiltration is crucial for developing treatment strategies. This study compares the diagnostic accuracy of transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) for myometrial infiltration (MI) in endometrial cancer (EC).

MATERIALS AND METHODS

We performed a systematic review and meta-analysis of observational studies, identified by screening Web of Science, SCOPUS, MEDLINE, PubMed, Google Scholar, and EMBASE databases. Studies published between January 1964 and June 2024 comparing the diagnostic accuracy of TVUS and MRI for MI were included. The data analysis focused on sensitivity, specificity, and overall diagnostic accuracy.

RESULTS

Twenty-two studies in EC patients were included. The diagnostic odds ratio (OR) for TVUS and for MRI was 18 (95% CI: 22-26) and 20 (95% CI: 14-28), respectively. TVUS was associated with a sensitivity and specificity of 76% (95% CI: 72-82%) and 84% (95% CI: 79-88%), respectively, while MRI had a sensitivity and specificity of 79% (95% CI: 73-84%) and 84% (95% CI: 80-88%), respectively. The area under the receiver operating characteristic curve (AUCROC) was 0.88 for TVUS and 0.89 for MRI. No significant publication bias was detected.

CONCLUSIONS

Both TVUS and MRI demonstrated comparable diagnostic accuracy for the preoperative evaluation of MI in EC.

Effect of fragmentation of surgery and adjuvant treatment in high-grade nonendometrioid endometrial cancer: a population-based cohort study

BACKGROUND

Fragmented care (FC) occurs when patients receive treatment across several different hospitals. Regionalization of surgery for patients with high-grade endometrial cancer means that patients must travel longer distances to receive care; these patients often require adjuvant treatment after surgery.

OBJECTIVE

To determine whether the fragmentation of surgery and adjuvant treatment impacts survival in patients with high-grade nonendometrioid endometrial cancer.

METHODS

This population-based retrospective cohort study included patients diagnosed between 2003 and 2017 with high-grade nonendometrioid endometrial cancer who received adjuvant treatment postoperatively. Nonfragmented care was defined as receiving surgery and adjuvant treatment at the same institution. The primary outcome was overall survival.

RESULTS

We identified 1795 patients, of whom 583 (32.5%) had FC. Patients with nonfragmented care were more likely to have had surgery by a gynecologic oncologist (92.4 vs 58.8%, P<.001), surgical staging (66.6 vs 44.8%, P<.001), and less travel for surgery (mean 30.8 km vs 93.7 km, P<.001). They were less likely to receive chemotherapy (26.3 vs 30%, P<.001) and chemoradiation (38.4 vs 41.3%, P<.001). Median survival was 9 years. There was no significant difference in overall survival between patients who received FC and nonfragmented care; 92.4% and 93.5% of the patients in the FC and nonfragmented care groups were treated at a specialized gynecologic oncology center for at least part of their treatment (surgery, adjuvant treatment, or both).

CONCLUSION

We have previously shown that regionalization of surgery in high-grade endometrial cancer is associated with improved survival. Fragmentation of surgery and adjuvant treatment in this population does not have an adverse effect on survival. After receiving surgical treatment with a gynecologic oncologist, these patients may receive adjuvant treatment closer to home to decrease financial and travel burden.

Upfront and interval debulking surgery in advanced/metastatic endometrial cancer in the era of molecular classification

OBJECTIVE

To evaluate oncologic outcomes and prognostic factors of the different molecular subtypes of advanced/metastatic endometrial cancer treated with primary debulking surgery (PDS) or neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS).

METHODS

We conducted a retrospective analysis of patients with endometrial cancer and peritoneal carcinomatosis and/or "bulky" nodal metastasis surgically treated between September 2010 and February 2024. Survival outcomes were compared across four molecular subtypes (p53-mutant, MMR-deficient, NSMP, and POLE-mutant) and surgical approaches.

RESULTS

Overall, 51 patients with stage IIIC-IVB endometrial cancer underwent surgical treatment. Thirty-six (70.5 %) patients had PDS followed by adjuvant chemotherapy, while fifteen (29.5 %) received NACT followed by IDS. Most patients in both groups had FIGO stage IVB disease: 24 (66.6 %) in the PDS group and 14 (93.3 %) in the IDS group. Complete cytoreduction was achieved in 83.3 % of the PDS group and 40 % of the IDS group, with no significant differences in postoperative morbidity between the groups. Molecular profiling data were available for most patients, with p53-mutated tumors being the most common subtype (36.1 % in the PDS group and 46.6 % in the IDS group), followed by MMR-deficient tumors (30.5 % in the PDS group and 26.6 % in the IDS group). The type of surgical approach (PDS vs. IDS) did not show a statistically significant correlation with disease-free survival (p = 0.523, log-rank test) or overall survival (p = 0.123, log-rank test). Similarly, molecular classification did not predict patient outcomes in terms of disease-free survival (p = 0.397, log-rank test) or overall survival (p = 0.797, log-rank test).

CONCLUSIONS

Oncologic outcomes for patients with advanced endometrial cancer remain poor. Neoadjuvant chemotherapy continues to be a viable treatment option for patients with unresectable disease. A personalized approach to neoadjuvant therapy, taking into account histologic and molecular profiles, may improve survival outcomes in this patient population.

Navigating the future of fertility preservation: advanced predictive strategies for treatment outcomes of endometrial atypical hyperplasia and carcinoma

Due to the decreasing age of onset and the postponement of childbearing, there is a growing number of patients with endometrial carcinoma (EC) and endometrial atypical hyperplasia (EAH) seeking fertility-sparing treatments. Progestogen-based therapy serves as the principal conservative approach for EC. However, the variability in treatment outcomes hampers the potential for delivering more tailored therapies in clinical practice. To better guide the treatment of patients with fertility preservation needs, we conducted a comprehensive review of existing literature to explore factors related to molecular classification, biomarkers and artificial intelligence (AI) technology that may predict fertility-sparing treatment outcomes, we also looked ahead to future research directions in this field. The pathology before and after treatment is the primary basis for assessing the effectiveness of fertility-sparing treatment for EC and EAH. However, it is challenging to predict the therapeutic outcomes based on the pathological morphology of the initial diagnosis. Traditional immunohistochemical markers, such as estrogen and progesterone receptors, are also very limited in predicting therapeutic response. In recent years, the prognosis of fertility-sparing treatment has also been considered to be correlated with the molecular classification and gene mutation markers of EC. However, there are currently few direct clinical studies available, and our focus will be on reviewing these studies and assessing their applicability. In addition, there are some studies utilizing AI to predict the molecular classification, genes and therapeutic response of EC. The integration of these features will aid in the development of advanced predictive strategies for fertility-sparing treatment of EC and EAH.

The Role of Surgery in Management of Primary Metastatic Endometrial Cancer

For the majority of patients with endometrial cancer who are diagnosed at an early stage, high-quality evidence directs mainstay initial surgical treatment, which confers excellent long-term survival. Conversely, the 8%-15% of endometrial cancers diagnosed at a clinically advanced stage with primary metastatic disease have a significantly worse prognosis and a 5-year relative survival rate of 15%-20%. The management of primary advanced endometrial cancer is understudied with the majority of relevant evidence being retrospective, single institution, and in heterogenous populations (combined with management of recurrent endometrial cancer), and there are few prospective studies that focus solely on primary advanced disease. It appears that hysterectomy and surgical cytoreduction may improve long-term survival in metastatic endometrial cancer; however, it remains unclear which patients are most likely to benefit. Furthermore, the new integration of molecular classifications to the management of endometrial cancer has opened up new prognosis and treatment perspectives; however, the majority of current trials investigating new management paradigms based on molecular features exclude advanced-stage disease, so the implications for practice regarding this patient group are understudied. This review analyzes the current available evidence regarding surgical management of primary metastatic endometrial cancer, including current international guideline recommendations, evidence for primary cytoreductive surgery and neoadjuvant systemic treatment followed by surgery, surgical resection of distant metastases, and lymph node management.

Sepsis-related immune signature C3 in endometrial carcinoma: implications for prognosis, tumor progression through bioinformatics and experimental validation

BACKGROUND

Sepsis and uterine corpus endometrial carcinoma (UCEC) share significant immunological and molecular pathways, particularly involving dysregulated inflammatory responses and immune modulation. Although sepsis-induced organ dysfunction is well studied, its role in cancer progression, particularly in UCEC, remains poorly understood.

PURPOSE

This study investigated the sepsis-related immune signature (SRIS) C3 in UCEC to uncover its role in tumor progression and metastasis.

METHODS

RNA sequencing and clinical data from TCGA and GEO databases were analyzed using R software to identify DESRGs. Survival analysis, GO, KEGG pathway, and GSEA were performed to elucidate C3's biological functions. PPI networks, mutational analysis, methylation profiling, and immune infiltration analysis were conducted using various bioinformatics tools. MTT assays, RT-PCR, qPCR, and wound healing assays were performed to validate C3's function in HEC-1-B.

RESULTS

Downregulation of C3 expression in UCEC was associated with enhanced inflammation, immune evasion, and metastatic potential, showing mechanisms observed in sepsis-induced organ dysfunction. Pathway enrichment analysis revealed significant activation of the NF-κB, JAK-STAT, and complement cascades, contributing to a pro-tumorigenic microenvironment. Mutational analysis showed a significant contribution to UCEC development. Protein-protein interaction analysis demonstrated a positive correlation with SRISs. These findings highlight the pivotal role of sepsis-related immune pathways, mainly C3, in driving UCEC progression.

CONCLUSION

Understanding the molecular interplay between sepsis-related immune responses and tumor progression may offer novel therapeutic opportunities. Specifically, targeting C3 may provide a new treatment strategy for UCEC patients with a history of sepsis, thereby improving clinical outcomes and guiding personalized therapeutic interventions.

Prognostic Factors of Oncologic and Reproductive Outcomes in Conservative Therapy of Endometrial Hyperplasia and Endometrial Cancer: Systematic Review and Meta-Analysis

Despite broad consensus on the oncological criteria for the inclusion of patients in conservative therapy for endometrial cancer (EC), several prognostic factors affecting patients' subsequent oncological and reproductive outcomes have yet to be explored. To assess the prognostic factors influencing remission, pregnancy and recurrence in conservative therapy of endometrial hyperplasia (EH) and EC. Following the PRISMA statement and the Cochrane Handbook, the search for relevant studies was conducted in PubMed, Embase, Web of Science, Wan fang and China National Knowledge Infrastructure from the inception of the databases to 1 March 2024. Studies that met the inclusion criteria were evaluated for quality using the Newcastle-Ottawa Scale and subsequently analyzed for data extraction. This meta-analysis included 3815 patients with EC or EH treated with conservative therapy in 35 studies. The analysis revealed the overall remission rate of 92.0% (95% CI, 87.0-96.0%), pregnancy rate of 34.0% (95% CI, 32.0-36.0%), and recurrence rate of 27.0% (95% CI, 25.0-29.0%). Four study characteristics, including obesity, pathology type, lesion size, and insulin resistance were associated with remission rate. A total of 8 study characteristics were found to be associated with pregnancy rate, including obesity, pathology type, time to complete response (CR), mode of conception, intrauterine adhesion, the number of uterine manipulations, endometrial thickness and recurrence before pregnancy. Seven study characteristics were found to be associated with recurrence rate, including age over 35.0 years, obesity, family history of cancer, pathological type, abnormal menstruation, pregnancy and maintenance treatment after CR. Common prognostic factors affecting remission, pregnancy and recurrence of endometrial cancer and endometrial hyperplasia are obesity and type of pathology. Patient characteristics, medical factors, and pathological features significantly influence oncological and reproductive outcomes in patients with EH and EC undergoing conservative therapy. Consequently, careful clinical selection and individualized assessment of each candidate for conservative therapy are essential to optimally balance short-term oncological and reproductive outcomes with long-term survival prognosis.

FBXL18 promotes endometrial carcinoma progression via destabilizing DUSP16 and thus activating JNK signaling pathway

OBJECTIVE

The therapeutic options for patients with advanced endometrial carcinoma (EC) were still limited and the prognosis remained unfavorable. F-box and leucine-rich repeat protein 18 (FBXL18), belonging to the F-box protein family, was frequently altered in human cancer, while its functional role and underlying mechanisms in EC were largely unexplored.

METHODS

The expression of FBXL18 in EC tissues and cells were explored using data mining strategies and further experiments. Multiple in vitro assays, including CCK-8, colony formation, wound healing, and Transwell invasion assays, were performed to assess the function of FBXL18 on cell proliferation, migration, and invasion. Bioinformatic analyses, western blot, qRT-PCR, Co-immunoprecipitation and ubiquitination assays were employed to identify the downstream pathway and direct substrate of FBXL18.

RESULTS

FBXL18 was highly expressed in EC tissues and cell lines, and EC patients with high FBXL18 expression had poor clinical outcome. Loss- and gain-of-function assays showed that silencing FBXL18 suppressed EC cell proliferation, migration, and invasion, while overexpressing FBXL18 caused the opposite effects. Mechanistically, FBXL18 could physically interacted with DUSP16, a dual specificity phosphatase, leading to its ubiquitination and degradation, and thus activating JNK signaling pathway. Upregulation of DUSP16 in EC cells alleviated FBXL18 overexpression-induced activation of JNK signaling pathway, and reversed FBXL18 overexpression-mediated enhanced cell capacities of proliferation, migration, and invasion.

CONCLUSION

In summary, our study had showcased the elevated expression, prognostic prediction performance, and the malignant tumor-promoting role of FBXL18 in EC. The novel mechanisms underlying this phenotype are that FBXL18 promotes the ubiquitination and degradation of DUSP16, and thus activates JNK/c-JUN signaling to facilitate EC progression.

Effects of levonorgestrel-releasing intrauterine system on recurrence and fertility outcomes during assisted reproduction after complete remission of early endometrioid endometrial cancer and precancerous lesions: A retrospective cohort study

To investigate the efficacy of the levonorgestrel-releasing intrauterine system (LNG-IUS) on recurrence and fertility outcomes during controlled ovarian stimulation (COS) in patients with early stage endometrioid endometrial carcinoma (EEC) and endometrial atypical hyperplasia (EAH) following successful fertility-preserving treatment. We reviewed the patients with Grade 1 presumed Stage IA EEC or EAH who underwent in vitro fertilization and embryo transfer after successful fertility-sparing treatment. A total of 176 women were enrolled in this study, undergoing 318 cycles of COS and 290 cycles of embryo transfer (ET). Twenty-one percent (37/176) patients have an LNG-IUS insertion during the initial ovarian stimulation, and the median follow-up time for this cohort was 61.3 months (interquartile range [IQR], 39.0-76.6 months), while it was 60.5 months for the other cohort (IQR, 44.9-80.3 months). Disease recurrence was experienced by 34.7% (61/176) of the patients. Compared to the non-LNG-IUS group, the LNG-IUS group had a lower recurrence rate 1 year after COS (5.4% (2/37) versus 20.9% (29/139), p = .034). The use of LNG-IUS was associated with a reduced recurrence rate 1 year after COS (hazard ratio = 0.203, 95% confidence interval [0.042-0.984], p = .048). The overall clinical pregnancy rate reached as high as 65.3% (115/176), while the cumulative live birth rates were up to 46.6% (85/176). We found that LNG-IUS during COS did not impact oocyte yield, ET, or pregnancy outcomes. The placement of LNG-IUS during COS in EEC/EAH patients is worth considering, as it is likely to reduce the recurrence of endometrial lesions without affecting fertility outcomes.

European Society of Urogenital Radiology (ESUR) guidelines on MR imaging prior to fertility-sparing treatments in patients with cervical, endometrial, and ovarian cancers

OBJECTIVE

To establish standardised MRI protocols and structured reporting guidelines for optimal patient selection in fertility-sparing treatments for gynaecological cancers.

METHODS

The European Society of Urogenital Radiology (ESUR) Female Pelvis Working Group utilised the RAND-UCLA Appropriateness Method to develop these guidelines. A multidisciplinary panel composed of ten radiologists and two gynaecological oncologists conducted a comprehensive review of clinical and imaging literature (until 28th February 2025) and evaluated MRI protocols through a structured survey consisting of 104 questions across five sections covering MR imaging preparation, equipment specifications, protocols, and reporting standards. Recommendations achieving ≥ 80% consensus were designated as "RECOMMENDED", with those below this threshold marked as "SUGGESTED" or "NOT RECOMMENDED".

RESULTS

Consensus was reached on MRI technical requirements, including sequence selection, imaging planes, and contrast timing. Disease-specific structured reporting templates were developed with standardised criteria for cervical, endometrial and ovarian cancers.

CONCLUSIONS

These evidence-based guidelines provide a standardised framework for MRI acquisition and reporting to support optimal patient selection for fertility-sparing treatments. By harmonising imaging protocols and structured reporting, we aim to enhance diagnostic accuracy and clinical decision-making. These guidelines represent a key step toward developing comprehensive recommendations for fertility preservation, with future validation and adaptation ensuring their applicability across diverse clinical settings.

KEY POINTS

Question Fertility-sparing treatments in gynaecological cancers require adherence to strict selection criteria based on tumour stage, size, and histological subtype. Findings MRI is essential for accurately assessing eligibility criteria in cervical and endometrial cancers, and characterising adnexal masses using standardised reporting criteria. Clinical relevance MRI is valuable for the preoperative evaluation of patients considered for fertility-sparing treatments in gynaecologic cancers. Key parameters include precise tumour measurements, depth of invasion, and local tumour extent through optimised protocols combining anatomical and functional sequences.

Patterns of primary metastasis and recurrence in mismatch repair deficiency and p53 abnormal endometrial carcinoma

OBJECTIVES

Molecular classification of endometrial carcinoma(EC) provides relevant prognostication and is now being utilized to determine adjuvant therapy. It is currently unclear how molecular classification relates to disease dissemination and recurrence patterns in EC. The objective of this study was to characterize patterns of disease in mismatch repair-deficient (MMRd) and p53 abnormal (p53abn) carcinomas.

METHODS

Immunohistochemistry molecular classification was performed to relate patterns of disease spread among EC patients undergoing surgical staging/cytoreduction. Dissemination patterns were assigned according to the most distant site of disease and subdivided as carcinomatosis, visceral organ, or lymphatic locations. Standard statistical methods were employed for comparisons, including multivariate logistic regression.

RESULTS

Of 380 cases, 127 had advanced disease at presentation: 43.4 % pelvic, 44.8 % lower abdominal, 7.1 % upper abdominal and 4.7 % extra-abdominal. P53abn carcinomas were more likely to present with peritoneal-based disease compared to MMRd and p53wt tumors(30.8 %, 11.7 %, and 9.7 %, p < 0.0001). Among 128 patients with recurrence, upper abdominal spread and carcinomatosis were more common with p53abn than MMRd or p53wt tumors(49.2 %, 10 %, 8.2 %, p < 0.0001 and 60.8 %, 7.5 %, 18.9 %, p < 0.0001). MMRd tumors were associated with lymphatic recurrences compared to p53abn or p53wt(55 %, 19.6 %, 35.1 %, p = 0.001). These associations remained significant in multivariate analysis.

CONCLUSIONS

EC recurrence patterns differ based on molecular classification. Patients with p53abn cancers are more likely to present with peritoneal-based disease and experience peritoneal recurrence. Patients with MMRd cancers are more likely to experience lymphatic-based recurrences. This information provides a model of biologic behavior of molecular subtypes that can inform prospective surgical and therapeutic trials.

Integration of sentinel node mapping and molecular classification in endometrial cancer staging

Sentinel node mapping has gained popularity in surgical staging of endometrial cancer, providing a less invasive alternative to lymphadenectomy for staging purpose. Recent advances in molecular classification have deepened our understanding of endometrial cancer, leading to more personalized approaches in diagnosis and treatment. This review examined the interaction between sentinel node mapping and molecular classification in endometrial cancer, emphasizing the clinical implications. Surrogate molecular classification identified four distinct subtypes, each with different patterns of lymphatic spread and metastatic potential, overcoming the Bokhman's historic dualistic classification in type I (endometrioid) and type II (non-endometrioid) endometrial cancer. Accumulating evidence supported that integrating molecular subtypes with sentinel node mapping, would improve the accuracy of lymph node staging, allowing for more tailored therapeutic strategies. The potential for artificial intelligence and machine learning to analyze molecular signatures in real-time may further refine mapping accuracy and enable more individualized treatment plans. The development of novel molecular tracers and targeted therapies for sentinel node biopsy promises to enhance precision and minimize unnecessary lymphadenectomy. The aim of this review was to explore current methodologies, challenges, and future directions, highlighting the increasing role of molecular tools in sentinel node mapping and the personalized management of endometrial cancer.

Frequency of microsatellite instability in gynecologic cancers and the efficacy of immune checkpoint inhibitors treated: real-world data from a single gynecologic center

Objective

This study evaluated the incidence of Microsatellite Instability-High (MSI-H) in patients with gynecologic cancers in a single gynecologic center and investigated the effect of immune checkpoint inhibitors (ICIs) in treating MSI-H in advanced or recurrent gynecologic cancers.

Methods

We conducted a retrospective study of patients diagnosed with gynecological cancers between June 2021 and May 2024. We investigated their clinicopathological information, the results of microsatellite instability (MSI), the immunohistochemistry staining PD-L1 analyses, the molecular classification testing, and the tumor response to treatment with ICIs.

Results

Among 1333 patients included in the analysis, the frequency of MSI-H was 1.3% (3/223) in cervical cancer, 25.7% (280/1091) in endometrial cancer, and 10.5% (2/19) in ovarian or tubal and peritoneal cancer. When the patients were evaluated by histologic type, the frequency of MSI-H was 26.1% (241/921) in endometrioid adenocarcinoma and 35.1% (20/57) in mixed adenocarcinoma. Molecular classification results for the 1020 cases that successfully underwent the tests were 71 for the POLE mutation (POLEmut) subtype, 271 for MMR-deficiency (MMRd) subtype, 571 for the non-specific molecular profile (NSMP) subtype, and 107 for the p53 abnormality (p53abn) subtype. Thirty-five patients were treated with ICIs for at least one cycle. The objective response rate (ORR) was 34.3% (95% CI, 19.1% to 52.2%). Among the patients who achieved an objective response, the median time to respond was 2.65 months, and the median duration of response had not been reached. The median progression-free survival (PFS) was 9 months (95% CI, 4 to 10), and the median overall survival (OS) had not been reached. Additionally, in the patients with endometrial cancer, the median PFS in MSI-H patients was 5 months versus 3 months in microsatellite stable (MSS) patients (Δ = 2 months; p=0.92), and the median OS in both MSI-H and MSS patients had not been reached (p=0.89).

Conclusion

This study had shown the MSI-H frequencies for the three major types of gynecological tumors and demonstrated the clinical benefit of treatment with ICIs in patients with advanced or recurrent gynecologic cancer. Among endometrial cancer patients, the effects of immunotherapy may be consistent regardless of MSI status.

Therapeutic Challenges in the Management of Serous Endometrial Intraepithelial Carcinoma (SEIC)

OPINION STATEMENT

Serous endometrial intraepithelial carcinoma (SEIC) is an aggressive precursor and a similar biology to uterine serous carcinoma (USC). Patients diagnosed with SEIC should undergo surgical staging that includes total hysterectomy with bilateral salpingo-oophorectomy, lymph node sampling, and omentectomy. With trends in lymph node evaluation shifting towards sentinel lymph node sampling, we recommend bilateral sentinel lymph node sampling as a reasonable alternative to full pelvic and para-aortic lymphadenectomy. There is limited data to support the use of adjuvant chemotherapy, however, it is apparent that those with extrauterine disease have a higher likelihood of recurrence and decreased overall survival. Those with stage IVB SEIC have similar rates of survival to those with stage IVB USC and may be a population that could benefit from newer regimens for advanced stage endometrial cancer including immunotherapy and maintenance therapy. Unfortunately, strong data to support this will continue to be a challenge given the rare incidence of isolated SEIC without concurrent USC. The utility of adjuvant radiotherapy remains unclear and given its noninvasive nature and propensity for distant recurrence, may be of little utility. Regardless of the adjuvant therapies selected, routine surveillance like that of USC should be followed as recurrences are often noted greater than one year after initial surgery. Unlike other precursor lesions, SEIC behaves similarly to invasive carcinoma and ultimately should be treated as such for optimal disease control and outcomes.

Association of Local and Distant Organ Metastases With MELF Pattern in Endometrial Cancer

Several types of myometrial invasion in endometrioid-type endometrial adenocarcinoma (EEC) have been identified: adenomyosis-like changes; adenoma malignum; broad front, single-cell/cell clusters; and the microcystic elongated and fragmented (MELF) pattern. This study aims to investigate the effect of the MELF pattern on recurrence type and survival rate among patients with EEC. We retrospectively reviewed the records of patients diagnosed with EEC over a 10-year period from January 2011 to January 2021. Among 108 patients with EEC, 54 had recurrence (study group), and 54 did not (control group). The MELF pattern was more common in the group with recurrence than in the group without recurrence (40.7% vs. 14.8%; P =0.002). The MELF pattern was observed in 60.0% of patients with local recurrence and 29.4% of patients with extrapelvic or distant organ metastases ( P =0.027). Evaluation of 5-year disease-free survival ( P =0.003) and overall survival ( P =0.001) rates showed that MELF positivity was associated with decreased survival. Among patients with grade I-II EEC lacking uterine-localized myometrial invasion, the MELF pattern was less common in the nonrelapsed group than in the local relapse group (10.0% vs. 60.0%; P <0.001). The MELF pattern (odds ratio=19.4, 95% CI=1.2-31.2) was a significant independent negative predictor for local recurrence. The MELF pattern was more common in patients with recurrence, especially local recurrence. This finding suggests that the MELF pattern primarily impacts direct local invasion rather than hematogenous or lymphatic spread.

Preclinical Activity of Datopotamab Deruxtecan, an Antibody-Drug Conjugate Targeting Trophoblast Cell-Surface Antigen 2, in Uterine Serous Carcinoma

Uterine serous carcinoma (USC) is a rare subset of endometrial cancer with a poor prognosis and high recurrence rate. Datopotamab deruxtecan (Dato-DXd) is a novel antibody-drug conjugate (ADC). The objective of this study was to evaluate the preclinical activity of Dato-DXd in USC in vitro against primary USC cell lines with various trophoblast cell-surface antigen 2 (TROP2) expression and in vivo in TROP2-overexpressing cell line-derived mice xenografts. USC primary tumor cell lines were treated with Dato-DXd and a control ADC (CTL ADC) to evaluate cell viability following exposure. Antibody-dependent cell-mediated cytotoxicity against TROP2-overexpressing and -nonexpressing cell lines was evaluated using a 4-hour chromium release assay. USC xenografts in mice were treated with Dato-DXd, CTL ADC, datopotamab, and vehicle to assess the in vivo effects via retro-orbital Dato-DXd administration. We found USC cell lines with TROP2 overexpression to be significantly more sensitive to killing induced by Dato-DXd compared with CTL ADC in vitro (e.g., IC50: 0.11 µmol/L vs. 30.07 µmol/L, P = 0.0074 and 0.11 µmol/L vs. 48.95 µmol/L, P = 0.0127, respectively). Dato-DXd induced antibody-dependent cell-mediated cytotoxicity in the presence of peripheral blood lymphocytes from healthy donors. TROP2-nonexpressing cell lines demonstrated minimal killing by Dato-DXd; however, when admixed with TROP2-overexpressing cells, a significant bystander effect was appreciated. In vivo, mice xenografts overexpressing TROP2 treated with Dato-DXd demonstrated tumor growth suppression and longer overall survival compared with CTL ADC-treated xenografts. These data demonstrate Dato-DXd to be highly active against TROP2-overexpressing USC in vitro and in vivo. Our preclinical activity results warrant future clinical trials for patients with advanced or recurrent USC.

SIGNIFICANCE

Targeted treatment of USC using the biomarker TROP2 represents a significant opportunity for further treatment options for patients already resistant to other lines of treatment. In this study, we present data showing preclinical evidence of effectiveness of this biomarker-targeted therapy in USC.

Excess heme orchestrates progesterone resistance in uterine endometrial cancer through macrophage polarization and the IL-33/PAX8/PGR axis

Progesterone is an important drug for hormone therapy in uterine endometrial cancer (UEC). However, the therapeutic efficacy of progestogen is often limited by resistance, and the underlying mechanism remains unknown. In this study, we observed heme metabolism is more active in progesterone-insensitive patients. Heme induced macrophages (Mφs) bias towards M2-like phenotype and downregulated the expression of IL-33, resulting in increased levels of Paired box gene 8 (PAX8). Further study showed PAX8 inhibited the transcriptional activity of PGR by binding to the PGR promoter region. In addition, PGR can also act as a transcriptional factor to regulate the transcription of autophagy-related gene 7 (ATG). Low expression of PGR decreases the transcriptional activity of ATG7 promoter, which decreases cell autophagy and promotes the progression of UEC. Overall, this study reveals the important interaction between heme metabolism, IL-33 and PGR in progesterone-insensitive UEC, and is promising to provide new therapeutic targets for overcoming progesterone resistance.

Advanced MRI prediction model for anatomical site identification in uterine carcinoma: enhancing diagnostic accuracy

AIM

The uterine carcinoma is the most commonly diagnosed malignancy in the female pelvis. Accurate identification of tumour origin is crucial for determining appropriate treatment approaches. This study aims to develop a prediction model using multiple MRI parameters to accurately diagnose uterine cancer with an indistinctive origin and those involving both the endometrium and cervix prior to treatment.

MATERIAL AND METHODS

This prospective cohort study included patients who were newly diagnosed with uterine carcinoma who underwent MRI and were considered for hysterectomy within 6 months after MRI.

RESULTS

A total of 78 patients with uterine carcinoma were enrolled. Certain imaging features were found to be consistent with cervical carcinoma, included parametrial, vaginal, stromal invasion, and peripheral rim enhancement. Cervical cancer appeared hyperintense compared to the myometrium unlike endometrial cancer.

DISCUSSION

The study found that certain morphologic features were reliable indicators for detecting cervical carcinoma.

Adjuvant hormone therapy and overall survival among low-grade and apparent early-stage endometrial stromal sarcoma patients

OBJECTIVE

Surgery is the mainstay of treatment for low-grade endometrial stromal sarcoma (LG-ESS). While adjuvant hormone therapy is recommended for patients with advanced/recurrent disease, no consensus regarding its use among early-stage patients exists. We aimed to identify correlates of adjuvant hormone therapy use and associations of adjuvant hormone therapy and overall survival (OS) in stage I LG-ESS patients.

METHODS

Retrospective cohort study of patients with stage I LG-ESS who underwent hysterectomy from 2004-2019 using data from the National Cancer Database. Categorical data were compared using χ² tests. Kaplan-Meier estimates and log-rank tests were used to compare OS according to adjuvant hormone use. Hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between adjuvant hormone use and OS were estimated using Cox proportional hazards regression.

RESULTS

Of 2,386 patients included, 20.2% were treated with adjuvant hormonal therapy. Use of hormone therapy increased over time, with rates approximately doubling from 2004 to 2019 (12.6% to 24.6%). Age, tumor size, lymphovascular space invasion and adjuvant radiation were associated with adjuvant hormone therapy use. There was no association between adjuvant hormone therapy and OS (log-rank p=0.73; HR=1.05; 95% CI=0.76-1.46) for patients with LG-ESS.

CONCLUSION

Use of adjuvant hormone therapy for stage I LG-ESS has increased over time though is not associated with OS in this cohort of patients. Additional evaluation is needed to understand the impact of adjuvant hormone therapy on recurrence rates, progression rates, and quality of life to fully understand its value.

Acceptability and somatic mutations in cervicovaginal self-sampling for early endometrial cancer detection in women with Lynch syndrome

New molecular approaches are being developed to detect endometrial cancer using minimally invasive sampling methods. This study aims to evaluate the acceptability of self-collected cervicovaginal samples among women with Lynch syndrome, a group at high risk for developing endometrial cancer. Participants collected cervicovaginal self-samples and answered an at-home acceptability questionnaire in a cross-sectional study. Self-samples from a subset of these women were analyzed for somatic mutations using next-generation sequencing (NGS), targeting a panel of 47 genes. A total of 61 (88.4%) out of 69 eligible women participated in the study. The overall self-sampling experience was rated good or very good (N = 55, 90.2%). Most of the women were confident about correctly sampling (N = 58, 95.1%), and most reported no or mild pain (N = 56, 91.8%). During self-sample collection, most women reported feeling calm and comfortable and experiencing safety, privacy, and normality. In a pilot study using a subset of 15 samples, five somatic variants were identified in four self-samples (4/15, 26.7%) in ACVR2A, ARID1A, APC, and KMT2D. During follow-up, three out of four women with variants detected in the self-sample underwent prophylactic hysterectomy at a median of 9.1 months, while one out of four developed endometrial cancer after 3.9 years since the collection of the sample. Self-sampling is well-accepted and well-tolerated in women with Lynch syndrome and could potentially reduce some barriers associated with gynaecological surveillance. Further research is needed to evaluate the feasibility of implementing cervicovaginal self-collection and the accuracy of molecular testing for gynaecological surveillance in women with Lynch syndrome.

Fertility-sparing treatment for patients with endometrial cancer: a bibliometric analysis from 2000 to 2024

Introduction

The rising global incidence of endometrial cancer (EC), particularly among younger patients, has established fertility-sparing treatment as a critical focus in gynecological and reproductive medicine. Despite its clinical significance, comprehensive bibliometric analyses in this field remain limited.

Methods

This study conducted the most extensive bibliometric analysis to date, encompassing 506 publications on fertility-sparing EC treatments published between January 1, 2000, and December 22, 2024. Utilizing CiteSpace, JepaC, and VOSviewer, we systematically evaluated contributions across regions, institutions, journals, authors, and keywords to identify emerging research trends.

Results

China and the United States emerged as leading contributors, collectively accounting for 44.3% of publications. Fudan University and Cha University were identified as the most active institutions. Author Chen Xiaojun demonstrated the highest publication output, while Seok J and Seong SJ ranked as the most frequently cited researchers. Keyword analysis revealed five dominant research themes: "progestin," "reproductive outcomes," "age," "prognostic factors," and "myometrial invasion."

Discussion

This analysis delineates the evolving landscape of fertility-sparing EC research, highlighting persistent emphasis on hormonal therapies and prognostic determinants. The findings underscore the need for standardized treatment protocols and long-term fertility outcome studies. By mapping research trajectories and visualizing knowledge networks, this study provides actionable insights to guide future investigations in reproductive oncology.

Immunocytochemical examination of Akt, mTOR, and Pax-2 for endometrial carcinoma through thin-layer endometrial cytology

Objective

This study aimed to detect the expression of Akt, mTOR, and Pax-2 in differing endometrial tissue/cells, together with assessment of such molecular markers for improving accuracy within endometrial cytology screening for endometrial cancer (EC).

Methods

Overall, 92 hysteroscopy cases were included. This cohort comprised 32 endometrial carcinoma patients, 30 benign lesion patients, and 30 cases with normal endometrium. Endometrial cells were collected before hysteroscopy, for immunohistochemical (IHC) and immunocytochemical (ICC) detection of Akt, mTOR, and Pax-2. Expression levels were evaluated by semi-quantitative method, and ROC curves (Receiver Operating Characteristic Curve) were drawn to evaluate the application importance for all three biomarkers for EC diagnostics.

Results

IHC expression of Akt, mTOR, and Pax-2 was positively correlated with ICC expression within the endometrial carcinoma cohort, benign lesion cohort, and normal cohort. Using IHC and ICC, Akt/mTOR-marked upregulation was observed within the EC cohort, compared to all other cohorts. Pax-2 was also markedly upregulated within normal/benign lesion cohorts in comparison to the EC cohort (p < 0.01). The sensitivity and specificity of ICC was 73.33 and 91.53%, respectively, when Akt ≥ 190 was used as the diagnostic index for EC. When mTOR ≥ 255 was used as the diagnostic index for EC, such parameters were 84.38 and 95.00%, respectively. When Pax-2 ≤ 165 was used as the diagnostic index for EC, such parameters were 96.67 and 80.00%, respectively.

Conclusion

This investigation probed varying threshold levels pertaining to Akt, mTOR, and Pax-2, consequently assisting in endometrial lesion-type identification. IHC within ECT (endometrial cytology test) analyses for Akt, mTOR, and Pax-2 could enhance the capacity for diagnosing EC/pre-malignant lesions.

Exploring the Genetic and Clinical Landscape of Dedifferentiated Endometrioid Carcinoma

Dedifferentiated endometrioid carcinoma (DDEC) is rare, has a poor prognosis, and the genes responsible for dedifferentiation remain unclear. This study aimed to clarify the characteristics of DDEC in Japanese patients and develop treatment strategies. Eighteen DDEC cases were included; their clinicopathological features and prognoses were analyzed and compared to those of other histological subtypes. The samples were divided into well-differentiated and undifferentiated components; immunostaining and whole-exome sequencing (n = 3 cases) were conducted. The incidence of DDEC was 2.0% among endometrial cancers. The 5-year progression-free survival and the 5-year overall survival for DDEC was approximately 40% and 30%, respectively. Immunohistochemistry showed that 66.7% of patients were mismatch repair deficient. The rate of p53 mutations was higher than that reported in previous studies, and patients with p53 mutations in the undifferentiated components had a poor prognosis. Whole-exome sequencing revealed different gene mutations and mutation signatures between well-differentiated and undifferentiated components. New genetic mutations in undifferentiated regions were uncommon in all three cases. One case (case 1) exhibited homologous recombination deficiency, whereas the other two showed microsatellite instability-high and hypermutator phenotypes. Genetic analysis suggests that immune checkpoint and poly (ADP-ribose) polymerase inhibitors and drugs targeting the p53 pathway may be effective against DDEC.

Characteristics of endometrial cancer progressed to extrauterine lesions following fertility preserving medroxyprogesterone acetate therapy for young endometrial cancer patients

OBJECTIVE

Medroxyprogesterone acetate (MPA) is an effective fertility-preserving treatment for early endometrial cancer and atypical endometrial hyperplasia (AEH), and rarely leads to the development of extrauterine lesions (ELs). We aimed to clarify the characteristics of patients who developed ELs post-MPA therapy.

METHODS

We analyzed the clinicopathological factors and prognoses of 319 patients with endometrioid carcinoma grade 1 (EMG1) and AEH treated with MPA at our institution. All patients underwent imaging before MPA treatment to rule out ELs.

RESULTS

Seven patients (2.2%) with EMG1 showed EL after MPA treatment. Two patients developed EL during the initial treatment, 2 during repeated treatment, and 3 during follow-up. Two patients had peritoneal dissemination, 3 had regional lymph node metastasis, 1 had distant metastasis at the Virchow lymph node, and 1 had ovarian metastasis. ELs were diagnosed using imaging tests in 6 patients and elevated tumor markers in 3 (overlapping) patients. One patient was diagnosed with ELs pathologically after hysterectomy. Upon EL diagnosis, patients underwent standard treatment, including hysterectomy and chemotherapy, that was followed by a diagnosis of EMG1 for 5, EMG2 for 1, and EMG3 for 1 patient. One patient died 15 months after start of therapy and another died 119 months post-treatment initiation, while the others have been survived.

CONCLUSION

Only 2.2% of all patients developed ELs post-MPA treatment, but some cases were fatal. It is essential to conduct imaging tests and screen for tumor markers during and after MPA treatment regularly and also when cancer progression is suspected.

Comparison of laparoscopic vs. robotic sentinel lymph node mapping and biopsy in endometrial cancer

We compare the success of sentinel lymph node (SLN) biopsy between standard laparoscopy and robotic-assisted laparoscopy (RAL) in patients with endometrial cancer. Patients with uterine epithelial tumour types undergoing staging surgery were identified from January 2019 to March 2023. Included patients underwent a total hysterectomy, bilateral salpingo-oophorectomy and attempted bilateral SLN biopsy with indigocyanine green (ICG) dye, utilising either standard laparoscopy or RAL. 298 patients met the inclusion criteria. 211 (70.8%) had standard laparoscopy and 87 (29.2%) underwent RAL. The RAL cohort had significantly higher median body mass index (BMI) compared to standard laparoscopy (37 vs. 28 kg/m2, p < 0.001). The overall rate of successful bilateral SLN biopsy was 66.8% (n = 199), and at least one hemi-pelvis was successfully biopsied in 87.3% (n = 260) of patients. There was no significant difference in bilateral SLN biopsy success between RAL and standard laparoscopy (60.9% vs 69.2%, p = 0.17). RAL was not predictive of bilateral SLN biopsy success in multivariate analysis (OR 1.10, p = 0.76). There was no difference in SLN biopsy location, number of nodes identified, or empty-packet dissections between the surgical approaches. Increasing age (OR 0.96, p = 0.002) and BMI (OR 0.94, p < 0.001) were significantly associated with reduced bilateral SLN biopsy success. Between the learning and experienced periods of the study, the bilateral SLN biopsy success rate improved significantly for RAL (40.6 vs. 72.7%, p = 0.03), which was not found with standard laparoscopy. The decision to perform RAL should consider multiple factors including surgeon experience. Future research should be directed towards prospective, randomised and BMI-matched cohorts.

Safety and feasibility of same day discharge for robotic hysterectomy and staging for endometrial cancer

OBJECTIVES

Same day discharge (SDD) is well established for benign minimally invasive hysterectomy, but its adoption for endometrial cancer has been met with some concerns. This multicenter study investigates outcomes for endometrial cancer patients discharged on the same day following robotic hysterectomy and lymphadenectomy.

METHODS

We retrospectively reviewed endometrial cancer patients treated with robotic hysterectomy and lymphadenectomy from January 2019 to December 2021. We collected clinical, pathologic, and surgical data, and reviewed medical records for unscheduled contacts, acute visits, or readmissions within 30 days postoperatively. Logistic regression models were used to assess associations with non-SDD.

RESULTS

Of 690 patients, 208 (30.1 %) required overnight observation. Indications for observation included nausea/vomiting (14.9 %), persistent sedation (9.1 %), hypoxia (7.7 %), and urinary retention (7.2 %). In 123 patients (59.1 %), the admission reason was undocumented. Univariate analysis revealed that factors associated with overnight observation included age (OR 1.19 per 10 years, P = 0.04), BMI (OR 1.10 per 5 kg/m2, P = 0.04), ASA score ≥ 3 (OR 1.53, P = 0.01), operative time (OR 1.52 per 60 min, P < 0.01), and other comorbidities. Unscheduled contacts were most frequently due to uncontrolled pain (12 SDD patients, 14 non-SDD) and urinary tract infection (15 SDD, 13 non-SDD). Twelve SDD patients (2.5 %) and four non-SDD patients (1.9 %) were readmitted within 30 days.

CONCLUSIONS

For patients undergoing robotic hysterectomy and lymphadenectomy for endometrial cancer, no significant differences in unscheduled contact, 30-day readmission, or reoperation were observed between SDD and non-SDD cohorts. Factors associated with non-SDD included chronic kidney disease, anticoagulation, conversion to laparotomy, and procedure timing.

Diagnosis Test Accuracy of Artificial Intelligence for Endometrial Cancer: Systematic Review and Meta-Analysis

BACKGROUND

Endometrial cancer is one of the most common gynecological tumors, and early screening and diagnosis are crucial for its treatment. Research on the application of artificial intelligence (AI) in the diagnosis of endometrial cancer is increasing, but there is currently no comprehensive meta-analysis to evaluate the diagnostic accuracy of AI in screening for endometrial cancer.

OBJECTIVE

This paper presents a systematic review of AI-based endometrial cancer screening, which is needed to clarify its diagnostic accuracy and provide evidence for the application of AI technology in screening for endometrial cancer.

METHODS

A search was conducted across PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases to include studies published in English, which evaluated the performance of AI in endometrial cancer screening. A total of 2 independent reviewers screened the titles and abstracts, and the quality of the selected studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. The certainty of the diagnostic test evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

A total of 13 studies were included, and the hierarchical summary receiver operating characteristic model used for the meta-analysis showed that the overall sensitivity of AI-based endometrial cancer screening was 86% (95% CI 79%-90%) and specificity was 92% (95% CI 87%-95%). Subgroup analysis revealed similar results across AI type, study region, publication year, and study type, but the overall quality of evidence was low.

CONCLUSIONS

AI-based endometrial cancer screening can effectively detect patients with endometrial cancer, but large-scale population studies are needed in the future to further clarify the diagnostic accuracy of AI in screening for endometrial cancer.

TRIAL REGISTRATION

PROSPERO CRD42024519835; https://www.crd.york.ac.uk/PROSPERO/view/CRD42024519835.

The role of IGF2BP3/SPOP/c-Myc loop in paclitaxel resistance of endometrial cancer

Paclitaxel combination therapy is the main chemotherapy regimen for endometrial cancer (EC); however, subsequent drug resistance is a bottleneck limiting its widespread clinical application. We found that human insulin-like growth factor 2 mRNA-binding protein 3 (IGF2BP3) was abnormally elevated in paclitaxel-resistant EC cells and confirmed that the reduction of IGF2BP3 can effectively improve the sensitivity of EC cells to paclitaxel in vitro and in vivo. Mechanistically, elevated IGF2BP3 promotes the half-life of c-Myc by competitively inhibiting Speckle-type POZ protein (SPOP)-mediated ubiquitination and degradation of c-Myc. As a transcription factor, c-Myc can bind to the promoter of IGF2BP3, thus contributing to the increased transcription of IGF2BP3 via positive feedback and forming a signaling loop that ultimately causes the accumulation of c-Myc-induced paclitaxel resistance. Based on these findings, the application of c-Myc inhibitors (10058-F4) combined with paclitaxel helped paclitaxel-resistant EC cells regain paclitaxel sensitivity in vitro and in vivo. Together, we reveal the underlying mechanism of paclitaxel resistance in endometrial cancer cells and provide insights into treatment strategies for paclitaxel-resistant EC patients.

Unravelling the mystique of recurrence: A comparative analysis of surgical approaches for early-stage endometrial cancer

AIM

This study aims to compare long-term survival differences and recurrence patterns between robotic and open surgery for early-stage endometrial cancer (EC).

METHODS

This study was conducted retrospectively from 1st January 2015 to 30th June 2021 on all patients with stage I or stage II EC (FIGO 2023 Staging), irrespective of histology. The primary objective was to compare 3-year Recurrence-Free Survival (RFS) rates between robotic and laparotomy surgical approaches in patients with early-stage endometrial cancer.

RESULTS

In a study of 297 patients, 81.5 % underwent robotic surgeries and 18.5 % underwent open surgeries. Median age was 47.5 years. After a median follow-up period of 36 months, RFS rates of 92.5 % and 86.1 % in robotic and laparotomy groups, respectively (p = 0.6). Most recurrences were found at distant sites (77 %). No significant differences in recurrence sites between surgical groups (p > 0.05), but vaginal vault and para-aortic lymph node recurrences were exclusive to the robotic group. Median time to recurrence was significantly shorter in open group than robotic group (p = 0.01). Patients with focal LVSI (lymphovascular space invasion) had significantly higher recurrence rates compared to THOSE without LVSI (p = 0.04).

CONCLUSION

No significant difference in RFS rates between two surgical approaches. However, robot-assisted surgery leads to a longer median time before recurrence. Most recurrences are distant, and focal LVSI is significantly associated with these recurrences. It's important to consider focal LVSI in histopathology reports, and patients with early-stage endometrial cancer should be monitored for potential recurrences.

Survival outcomes of sentinel lymph node biopsy alone versus back-up systematic lymph node dissection in high-risk endometrial Cancer: A Turkish Gynecologic Oncology group study (TRSGO-SLN-007)

BACKGROUND AND OBJECTIVES

Investigate whether there is an oncological benefit of performing back up systematic lymphadenectomy in addition to bilateral sentinel node biopsy.

METHODS

This multicentre retrospective study included patients with high-risk endometrial cancer treated at four gynaecological oncology clinics in Turkey between 2014 and 2023. Patients were stratified according to both conventional and ESGO risk criteria, and within each category were divided into two groups respectively "Sentinel Lymph Node Biopsy Group (SLN-only)" and "Back-up Lymphadenectomy Group (Back-up LND)". Disease-free survival (DFS) and overall survival (OS) were compared using univariate and multivariable Cox regression analyses.

RESULTS

56 patients in the SLN-only group and 158 patients in the Back-up LND group comprised of the Conventional High-Risk Group (CONV-HR) in the analysis. There was no significant difference statistically in terms of DFS (Log-Rank P = 0.29) and OS (Log-Rank P = 0.99). The European Society of Gynaecologic Oncology (ESGO) High-Risk Group (ESGO-HR) consisted of 44 patients in the SLN-only group and 133 patients in the Back-up LND group were included. The median follow-up periods were 27 months (IQR = 15-38) and 28 (IQR = 16-38) months, respectively. Recurrence rate was 14.1 % and mortality rate was 9.6 %. There was no significant difference statistically in terms of DFS (Log-Rank P = 0.342) and OS (Log Rank P = 0.488).

CONCLUSION

Sentinel lymph node biopsy is a safe and effective method for lymph node assessment in high-risk and clinical early-stage endometrial cancer. The addition of systematic lymphadenectomy did not provide any oncological benefit in terms of survival outcomes.

Cold atmospheric plasma drives USP49/HDAC3 axis mediated ferroptosis as a novel therapeutic strategy in endometrial cancer via reinforcing lactylation dependent p53 expression

BACKGROUND

Endometrial cancer ranks among the most common gynecological cancers, with increasing rates of incidence and death. Cold atmospheric plasma (CAP) has become a promising novel therapeutic approach for cancer treatment. Nevertheless, the specific impact of CAP on endometrial cancer remains inadequately characterized.

OBJECTIVES

This study aimed to investigate the effect of CAP on the progression of endometrial cancer and reveal its specific regulatory mechanisms.

METHODS

Colony formation, EdU, wound-healing, and transwell assay were used to detect the effect of CAP on endometrial cancer progression. Proteomics is employed to identify potential targets and signaling pathways through which CAP impacts endometrial cancer cells. MDA, lipid ROS, and JC-1 MMP assays were used to detect ferroptosis. Immunoprecipitation-mass spectrometry, co-immunoprecipitation, immunofluorescence co-localization, and molecular docking were used to analyze USP49 and HDAC3 interactions. The tumor xenografts model determined that CAP inhibits endometrial cancer growth in vivo.

RESULTS

This study observed a significant inhibitory effect of CAP on the proliferation and migration of endometrial cancer cells and reported for the first time that CAP induces ferroptosis in endometrial cancer cells. Mechanistically, CAP activated the transcription of p53 by modulating HDAC3 mediated the histone H3K18 lactylation, resulting in upregulation of p53 driving cell ferroptosis. The interaction between USP49 and HDAC3 was validated through mass spectrometry and co-immunoprecipitation experiments. The regulation of HDAC3 by CAP is contingent upon USP49, wherein the down-regulation of USP49 augments the ubiquitination of HDAC3, consequently diminishing its protein stability. Furthermore, animal models with transplanted tumors corroborated the inhibitory impact of CAP on endometrial cancer in vivo.

CONCLUSIONS

Our findings illustrate the suppressive effect of CAP treatment on endometrial cancer and uncover a novel regulatory mechanism mediated by CAP. Specifically, CAP modulates the ferroptosis pathway through the HDAC3/H3K18la/p53 axis, presenting a novel therapeutic approach for endometrial cancer treatment.

Comparison of tracer application methods for sentinel lymph node detection in open surgery patients with endometrial cancer: a retrospective cohort study

BACKGROUND

This study aimed to evaluate the effectiveness of different tracers´ application techniques for sentinel lymph node (SLN) detection in women with endometrial cancer undergoing laparotomy. Additionally, potential risk factors for SLN detection failure were assessed.

METHODS

We retrospectively analyzed data from 248 endometrial cancer patients who underwent abdominal surgery with SLN mapping between January 2020 and March 2024. Statistical analyses were conducted using the Wilcoxon rank sum test for continuous variables and either Pearson's chi-square test or Fisher's exact test for categorical variables, with a significance level set at p < 0.05.

RESULTS

Group I + S consisted of 147 women with intracervical and subserosal tracers´application and group I + I included 101 women with intracervical and intrafundal application. Successful detection of SLN on both sides was achieved in 39.9% (99/248) of all patients, in 38.1% (56/147) in the I + S group and in 42.6% (43/101) in the I + I group, respectively. SLNs were identified in 32.7% (81/248) of all patients on only one side of the pelvis, in 31.3% (46/147) in the I + S and in 34.7% (35/101) in the I + I group, respectively. No SLNs were detected in 27.4% (68/248) of all subjects, comprising 30.6% (45/147) from the I + S and 22.8% (23/101) from the I + I group. Although the success rate of SLN detection was higher in the I + I group and on the right side of the pelvis regardless of the detection method, these differences were not statistically significant. An age exceeding 66.3 years was recognized as a critical risk factor for successful detection, other followed factors did not demonstrate a statistically significant impact on overall detection success. Additional significant risk factors were identified: depth of tumor myometrial invasion on the right side, history of pelvic surgery, and total tumor volume on the left side.

CONCLUSIONS

The study did not reveal significant differences in SLN mapping success between the groups receiving intracervical + intrafundal and intracervical + subserosal tracers´applications among endometrial cancer patients treated via open surgery. Overall, older age emerged as the most critical risk factor for SLN detection failure, while other assessed factors did not show a statistically significant impact on overall detection success.

TRIAL REGISTRATION

Institution University Hospital Královské Vinohrady, Prague, Czech Republic.

REGISTRATION NUMBER

EK-VP-21-0-2023. Date of registration 7-JUN-2023. This study was retrospectively registered in compliance with the Declaration of Helsinki.

Using Machine Learning to Predict the Prognosis of Cervical Cancer Patients with Lymph Node Metastasis: An Analysis Based on the SEER Database

Cervical cancer is one of the most common malignant tumors in women worldwide, and patients with lymph node metastasis have a poor prognosis. This study aimed to develop an effective machine learning model to predict the prognosis of these patients. Data from the SEER*Stat database (version: November 2021) was used, including 1016 female patients diagnosed with cervical cancer and lymph node metastasis from 2000 to 2020. Various machine learning models, including XGBoost, random forest, SVM, ANN, and the Cox proportional hazards model, were constructed and evaluated using metrics such as C-index, AUC, accuracy, and precision. Additionally, to validate model stability, a random sample of 200 patients from 8 registries between 1975 and 2019 was used as a validation set. XGBoost outperformed other models with an AUC of 0.787 in the validation set and C-index values of 0.900 and 0.773 for the training and testing sets, respectively. Cox regression analysis showed that surgery at the primary site significantly improved survival outcomes and reduced mortality. XGBoost demonstrated superior performance in predicting the prognosis of cervical cancer patients with lymph node metastasis, providing new support for personalized clinical management.

Comparative analysis of surgical outcomes between the hinotori™ surgical robot system and da Vinci® Xi for simple hysterectomy with sentinel lymph node biopsy in low-risk endometrial cancer

OBJECTIVES

This study aimed to compare the surgical outcomes of simple hysterectomy with sentinel lymph node biopsy for low-risk endometrial cancer performed using the hinotori™ Surgical Robot System and the da Vinci® Xi system.

MATERIALS AND METHODS

We retrospectively analyzed the data of 234 patients who underwent simple hysterectomy with sentinel lymph node biopsy at Kagoshima University Hospital between January 2017 and June 2024. Amongst them, 20 patients underwent surgery using the hinotori™ Surgical Robot System and 214 using the da Vinci® Xi. Surgical factors, including operative time, cockpit/console time, blood loss and sentinel lymph node detection, were evaluated. Statistical analyses included chi-square and Wilcoxon tests, with significance set at P < 0.05.

RESULTS

The median operative and cockpit/console times were comparable between the two systems. However, the time from roll-in to the start of cockpit/console surgery was significantly longer for the hinotori™ Surgical Robot System than for the da Vinci® Xi (P = 0.0039). No significant differences were observed for blood loss, length of hospital stay, or complication rates. The sentinel lymph node detection rates and number of sentinel lymph nodes resected were similar between the two systems, with metastatic sentinel lymph node rates of 6% in both groups.

CONCLUSION

Simple hysterectomy with sentinel lymph node biopsy performed using the hinotori™ Surgical Robot System demonstrated outcomes comparable with those using the da Vinci® Xi system, with no significant differences in key surgical factors. These results suggest that the hinotori™ Surgical Robot System is a viable alternative for minimally invasive surgery in low-risk endometrial cancer. Further studies with larger sample sizes are required to validate these findings.

Disparities in End-of-Life Outcomes: A Demographic and Geographic Analysis of Endometrial Cancer Deaths in the United States

INTRODUCTION

Endometrial cancer poses a significant public health challenge globally. With an increasing incidence, understanding end-of-life outcomes becomes crucial in navigating this landscape. This study aims to explore disparities in endometrial cancer death locations across demographic and geographic parameters.

METHODOLOGY

Using the Centre for Disease Control and Prevention - Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database, data on endometrial cancer deaths were retrieved and analysed. Logistic and linear regression models were employed to identify predictors and trends in place of death.

RESULTS

The study identified 90,140 endometrial cancer deaths from 1999 to 2020. Age-specific analysis revealed higher mortality rates in the 64-75 years age group. Geographically, the South reported the highest mortality rates. White individuals exhibited higher death rates across all settings. Age, race, and geographic disparities were evident in endometrial cancer death locations.

CONCLUSIONS

Understanding end-of-life outcomes in endometrial cancer is crucial for improving patient care. Tailored interventions addressing demographic and geographic disparities are essential for ensuring equitable and dignified end-of-life care for individuals with endometrial cancer.

Current challenges and emerging tools in endometrial cancer diagnosis

The diagnostic process of endometrial cancer includes imaging methods such as trans-vaginal ultrasound, along with procedures to obtain endometrial tissue for histologic evaluation. Common techniques for tissue sampling include Pipelle endometrial biopsy, hysteroscopy, and dilation and curettage, which are used to confirm the diagnosis, determine tumor histology, grade, and molecular profile. However, diagnostic algorithms for endometrial cancer differ significantly across countries, influenced by local resources, protocols, and the availability of diagnostic methods. These variations include differences in the endometrial thickness threshold for recommending a biopsy and the choice of the initial diagnostic test. Moreover, patients often have multiple tests and appointments before a definitive diagnosis, although only 5%-10% of women with post-menopausal bleeding are diagnosed with endometrial cancer. Current diagnostic techniques have limitations. Pipelle endometrial biopsy has a significant false-negative rate (10%-20%) and may fail to provide adequate diagnostic material in up to 30% of cases. Hysteroscopy, while useful, is associated with pain in up to 65% of patients and can delay diagnosis because of limited availability. Dilation and curettage is an invasive procedure requiring general anesthesia and has a higher complication rate. In response to these challenges, there is growing interest in developing new diagnostic tools that are less invasive and provide 1-step diagnoses, including liquid biopsies from urine, blood, cervico-vaginal and endometrial fluid samples by means of genomics and proteomics. This review will examine the current diagnostic algorithms in European and American guidelines, evaluate the sensitivity, specificity, and accuracy of current techniques, and explore new diagnostic tools under development.

Effect of substantial lymphovascular space invasion on location of first disease recurrence in surgical stage I endometrioid endometrial adenocarcinoma

OBJECTIVE

Lymphovascular invasion can predict nodal spread and recurrence in endometrioid endometrial cancer; however, the impact of lymphovascular invasion quantification on local versus distant recurrence in surgically staged patients has not yet been established.

METHODS

This multicenter, retrospective cohort study included surgically staged patients with International Federation of Obstetrics and Gynecology 2009 stage I node-negative endometrioid endometrial cancer. Patients were treated between January 2012 and December 2019 at 2 tertiary cancer centers. Staging included a total hysterectomy and lymph node assessment. The extent of lymphovascular invasion was defined using the World Health Organization criteria as focal (<5 vessels involved on at least 1 pathology slide) or substantial (≥5 vessels involved). Recurrence and death were considered as events. A competing risk analysis was performed and controlled for multicenter clustering.

RESULTS

Overall, 1555 patients met the inclusion criteria: 65 (4.2%) had substantial invasion, 119 (7.7%) had focal, and 1371 (88.2%) had no invasion. The median follow-up was 61.5 months (range; 0.8-133.9). There were 173 evaluable events among the 1554 patients: 56 local recurrences, 43 distant recurrences, and 74 deaths without recurrence. Deep (>50%) myoinvasion and grade 3 histology were more frequently observed in patients with substantial myoinvasion. Overall, 323 patients (20.8%) received adjuvant therapy. The 5-year cumulative incidence failure rates for any recurrence were 6.0% for no, 19.5% for focal, and 19.0% for substantial invasion. Compared to no lymphovascular invasion, substantial invasion was associated with an increased risk of distant recurrence (adjusted HR 2.29, 95% CI 1.17 to 4.46).

CONCLUSIONS

In patients with surgical stage I endometrioid endometrial cancer, the focal and substantial lymphovascular invasion was associated with a 3-fold increased risk of cumulative incidence failure versus no lymphovascular invasion. Patients with substantial invasion had more deeply invasive and grade 3 tumors and appeared to experience more distant than local recurrences. These findings challenge the International Federation of Obstetrics and Gynecology 2023 staging classification that combines no lymphovascular invasion and focal lymphovascular invasion into a single risk category.

The effect of isolated tumor cells on adjuvant treatment decisions for patients with endometrial cancer: A retrospective case series

Objective

Sentinel lymph node biopsy (SLNB) for endometrial cancer staging may identify isolated tumor cells (ITCs). Although guidelines do not classify nodes with ITCs as positive, earlier papers reported that a significant proportion of gynecologic oncologists treat ITCs as they would positive nodes. The objective of this study was to examine practice patterns and determine if the presence of ITCs in endometrial cancer affects adjuvant treatment decision-making.

Methods

This was a retrospective series of patients with endometrial adenocarcinoma stages I to IIIB who underwent surgical staging with SNLB from July 2016 to January 2022 at three hospitals. The primary outcome of interest was the receipt of adjuvant treatment. Chi-square, Mann-Whitney U test, and logistic regression were used with significance set at p < 0.05.

Results

Of seven hundred thirty-four patients included, ITCs were identified in 41 patients (5.6 %). Deep myometrial invasion (61.0 % vs 20.5 %, p < 0.001) and lymphovascular invasion (58.4 % vs 17.7 %, p < 0.001) were more common in patients with ITCs than in those with negative lymph nodes. Patients with ITCs were more likely to receive adjuvant treatment (30 of 41, 73.2 % vs 289 of 693, 41.7 %, p < 0.001). When controlling for age, stage, histology, grade, and lymphovascular space invasion, ITCs were not associated with an increased likelihood of adjuvant therapy receipt.

Conclusions

Although patients with ITCs were more likely to receive adjuvant treatment, this was accounted for by other clinical and histological factors. Clinicians were likely to make decisions based on established risk factors, and more data are needed on the role of ITCs in the landscape of molecularly based decision making.

Hysteroscopic endometrial laser ablation - A novel approach for palliative management of endometrial cancer in inoperable patients

Background

Endometrial cancer, the most common gynecologic malignancy in developed nations, poses substantial treatment challenges, particularly in patients with significant comorbidities or advanced obesity.

Purpose

This manuscript introduces an innovative method that employs awake hysteroscopic endometrial laser ablation (HEA) as a palliative treatment for patients with endometrial cancer who were either inoperable or medically unfit to undergo general or regional anaesthesia for conventional therapies.

Methods

A retrospective evaluation of patients diagnosed with endometrial cancer at a tertiary center from 2019 to 2024, focusing on those with symptomatic uterine bleeding, who failed previous treatment options and could not undergo surgical or standard palliative interventions due to high surgical risk.

Results

In our study, three patients (n = 3) with severe medical conditions-high BMI and poor performance status-underwent awake HEA using a vaginoscopic approach, treating symptomatic vaginal bleeding effectively. The procedure allowed for rapid treatment, minimal recovery time, and enhanced quality of life. Histological analyses post-ablation indicated satisfactory outcomes, contributing to symptom relief and stabilization of patients' conditions.

Conclusion

Our findings highlight the potential of conscious HEA as a palliative management strategy in high-risk patient populations, emphasizing its role when conventional therapies fail. This study underscores the importance of personalized treatment plans and multidisciplinary approaches in managing endometrial cancer, paving the way for further research into the safety and efficacy of HEA in similar cohorts.

The prognostic value of tumor microenvironment in endometrioid type endometrial cancer: Effect of CD44 on oncologic outcome

OBJECTIVES

The study aimed to evaluate the expression of CD44, CD47, interleukin-1 (IL-1), and tumor necrosis factor alpha (TNF-α) in immunohistochemically stained (IHS) samples from endometrioid endometrial cancer (EEC) and to examine their correlation with clinicopathologic parameters.

METHODS

IHS was used to assess CD44, CD47, IL-1, and TNF-α expression in 53 EEC samples. Immunostaining was scored as negative (-), slightly positive (+), moderately positive (++), or strongly/diffuse positive (+++). The prognostic value of these markers was analyzed in relation to clinicopathologic features, including survival.

RESULTS

In endometrial cancer tissues, positivity rates were CD44 (81%), CD47 (81%), TNF-α (40.5%), and IL-1 (42.9%). Strong and diffuse CD44 staining was associated with improved survival and linked to endocervical invasion and stage. Patients with slightly positive CD47 had significantly higher rates of pelvic and para-aortic lymph node metastases. Strong TNF-α staining correlated with grade 3 EEC, while slightly positive IL-1 staining was associated with increased endocervical invasion. No significant correlation was found between CD47, IL-1, and TNF-α expression and survival.

CONCLUSION

CD44 and CD47 were positive in most EEC specimens. CD44 expression was the only marker significantly correlated with overall survival and recurrence. TNF-α showed a positive correlation with high-grade tumors, and IL-1 staining was inversely associated with endocervical invasion. These findings suggest that CD44 is a prognostic marker for survival, while TNF-α and IL-1 may have indirect prognostic roles in EEC.

New FIGO 2023 Staging System of Endometrial Cancer: An Updated Review on a Current Hot Topic

The International Federation of Gynaecology and Obstetrics (FIGO) introduced a new staging system for endometrial carcinoma FIGO 2023 in June 2023. The new staging system differs significantly from previous versions by incorporating other non-anatomical parameters (histological type of tumour, tumour grade and the presence of massive lymphovascular space involvement as well as the molecular classification of the tumour). The FIGO 2023 staging system enhances the accuracy of prognostic assessments for patients at a specific stage with better options for targeted treatment. Another objective was to synchronise staging as much as possible with the European oncogynaecological ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma established in 2021. However, several changes are controversial. Routine molecular classification of endometrial carcinomas is not yet commonly available in most countries of the world. Another limitation of the FIGO 2023 staging system of endometrial cancer is the inclusion of variables whose definitions are still evolving, as well as variables that are subject to considerable interobserver variability in their assessment. Advantages, controversies, and limitations for clinical practice of the new FIGO 2023 endometrial cancer staging system are discussed.

Prognosis prediction and drug guidance of ovarian serous cystadenocarcinoma through mitochondria gene-based model

BACKGROUND

Mitochondrial dysregulation contributes to the chemoresistance of multiple cancer types. Yet, the functions of mitochondrial dysregulation in Ovarian serous cystadenocarcinoma (OSC) remain largely unknown.

AIM

We sought to investigate the function of mitochondrial dysregulation in OSC from the bioinformatics perspective. We aimed to establish a model for prognosis prediction and chemosensitivity evaluation of the OSC patients by targeting mitochondrial dysregulation.

METHODS

Differentially expressed genes (DEGs) were screened from the Cancer Genome Atlas (TCGA)-OV dataset and the mitochondrial-related DEGs were identified from the Human MitoCarta 3.0 database. Prognosis-related mitochondria-related genes (MRGs) were screened to establish the MRGs-based risk score model for prognosis prediction. To validate the risk score model, the risk score model was then evaluated by IHC staining intensity and survival curves from clinical specimens of OSC patients. Migration and proliferation assays were performed to elucidate the role of carcinogenic gene ACSS3 in serous ovarian cancer cell lines.

RESULTS

Using consensus clustering algorithm, we identified 341 MRGs and two subtypes of OSC patients. Moreover, we established a novel prognostic risk score model by combining the transcription level, intensity and extent scores of MRGs for prognosis prediction purpose. The model was established using 7 MRGs (ACOT13, ACSS3, COA6, HINT2, MRPL14, NDUFC2, and NDUFV2) significantly correlated to the prognosis of OSC. Importantly, by performing the drug sensitivity analysis, we found that the OSC patients in the low-risk group were more sensitive to cisplatin, paclitaxel and docetaxel than those in the high-risk group, while the latter ones were more sensitive to VEGFR inhibitor Axitinib and BRAF inhibitors Vemurafenib and SB590885. In addition, patients in the low-risk group were predicted to have better response in anti-PD-1 immunotherapy than those in the high-risk group. The risk score model was then validated by survival curves of high-risk and low-risk groups determined by IHC staining scores of OSC clinical samples. The carcinogenic effect of ACSS3 in OSC was confirmed through the knockdown of ACSS3 in SKOV3 and HO-8910 cells.

CONCLUSION

To summarize, we established a novel 7 MRGs - based risk score model that could be utilized for prognosis prediction and chemosensitivity assessment in OSC patients.

Clinical impact of surgical energy device (Caiman®) IN elderly patients with Endometrial Cancer (protocol ID: Cineca)

STUDY OBJECTIVE

To investigate the clinical performance of the Caiman® energy device in class A radical laparoscopic hysterectomy (RLH) according to Querleu-Morrow classification, combined with bilateral salpingo-oophorectomy (BSO) and pelvic lymph node assessment in elderly patients with early-stage endometrial cancer (EC), specifically focusing on hemostatic effectiveness and safety.

DESIGN

Single-institution, prospective observational study.

SETTING

Gynecologic Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.

PATIENTS

Forty-three women over 65 years with FIGO stage IA or IB endometrioid EC were enrolled from September 2021 to August 2023.

INTERVENTIONS

Use of Caiman® energy device in RLH combined with BSO and pelvic lymph node assessment in elderly patients.

MEASUREMENTS

The primary endpoint was operative time, with secondary endpoints including perioperative outcomes and postoperative complications.

MAIN RESULTS

Results demonstrated a median surgical time of 135 min, with no significant intraoperative complications attributed to the Caiman® device. Postoperative complications were minimal, with no severe complications (Grade 4 or 5) and a median hospital stay of two days.

CONCLUSION

The study highlights the advantages of the Caiman® in enhancing surgical efficiency while minimizing risks for elderly patients, suggesting its potential for improving resource allocation and patient outcomes in oncologic surgery. The findings of this study suggest the feasibility of using the Caiman® device for surgical procedures in elderly patients with early-stage endometrial cancer. Future prospective randomized trials are needed to establish its efficacy compared to traditional surgical methods.

Safety of minimally invasive surgery in early-stage endometrial cancer: A systematic Retrospective analysis based on 2023 FIGO staging system☆

OBJECTIVE

To evaluate the efficacy and safety of minimally invasive surgery in the management of early-stage endometrial cancer.

METHOD

This study involved a retrospective analysis of clinical data and prognosis for 382 patients diagnosed with early-stage endometrial cancer (stage I and II) who underwent either laparoscopy or laparotomy at Shanghai Sixth People's Hospital between June 2011 and November 2022. The postoperative pathological diagnoses were based on 2023 FIGO staging system.

RESULTS

A total of 189 patients underwent laparotomy and 193 patients underwent laparoscopic surgery. The intraoperative blood loss and postoperative complications (pulmonary embolism, pulmonary infection, intestinal obstruction, suboptimal healing or infection of surgical incision) rates in laparoscopy group was significantly lower than that in laparotomy group (P < 0.05). Regarding long-term prognosis (mean follow-up duration of 81.8 ± 41.1 months), there were no significant differences in DFS (Disease-Free Survival) and OS (Overall Survival) between two groups (P > 0.05). By integrating the new FIGO staging with risk factors for stratified analysis, the results still indicated that there were no significant differences in DFS or OS between laparoscopy group and laparotomy group across all risk stratification (P > 0.05).

CONCLUSIONS

In the management of early-stage EC, laparoscopy significantly reduces intraoperative blood loss and postoperative complication rates, which facilitate patient recovery without adversely affecting recurrence or survival outcomes.