Evaluation of prognostic significance of lymphovascular space invasion in early stage endometrial cancer: a systematic review and meta-analysis

Background

Studies evaluating the prognostic significance of lymphovascular space invasion (LVSI) in early stage endometrial cancer (EC) are conflicting.

Objectives

To evaluate whether LVSI identified in stage I EC is associated with worse survival.

Search strategy

A comprehensive literature search of three databases (Embase, PubMed, and Cochrane) was performed up to April 30th 2023.

Selection criteria

Cohort studies that have evaluated the relationship between LVSI and prognosis in patients with stage I EC were included.

Data collection and analysis

Two authors independently assessed the studies for inclusion, extracted the data of recurrence and survival, and conducted meta-analysis using random effects model. Heterogeneity was evaluated by I2 test.

Main results

A total of 15 studies involving 6,705 patients were included in the meta-analysis. The overall pooled rate of LVSI was 14% [95% confidence interval (CI) CI 0.09-0.18] in stage I EC. LVSI was significantly associated with a higher risk of recurrence [odds ratio (OR) = 2.79, 95%CI 2.07-3.77], reduced overall survival (OS) [hazard ratio (HR)=5.19, 95%CI 3.33-8.07] and recurrence free survival (RFS) [HR = 5.26, 95%CI 3.45-8.02] in stage I EC patients. Similarly, LVSI was associated with an increased risk of recurrence [OR= 3.10, 95%CI 2.13-4.51], decreased OS [HR=5.52, 95%CI 2.16-14.09] and RFS [HR = 4.81, 95%CI 2.34-9.91] in stage IA grade 1 or 2 endometrioid carcinoma patients.

Conclusion

The presence of LVSI in stage I EC and in stage IA, grade 1 or 2 endometrioid carcinoma is associated with an increased risk of recurrence, lower OS and RFS.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier 42023425231.

Development and validation of MRI-based radiomics model to predict recurrence risk in patients with endometrial cancer: a multicenter study

OBJECTIVES

To develop a fusion model based on clinicopathological factors and MRI radiomics features for the prediction of recurrence risk in patients with endometrial cancer (EC).

METHODS

A total of 421 patients with histopathologically proved EC (101 recurrence vs. 320 non-recurrence EC) from four medical centers were included in this retrospective study, and were divided into the training (n = 235), internal validation (n = 102), and external validation (n = 84) cohorts. In total, 1702 radiomics features were respectively extracted from areas with different extensions for each patient. The extreme gradient boosting (XGBoost) classifier was applied to establish the clinicopathological model (CM), radiomics model (RM), and fusion model (FM). The performance of the established models was assessed by the discrimination, calibration, and clinical utility. Kaplan-Meier analysis was conducted to further determine the prognostic value of the models by evaluating the differences in recurrence-free survival (RFS) between the high- and low-risk patients of recurrence.

RESULTS

The FMs showed better performance compared with the models based on clinicopathological or radiomics features alone but with a reduced tendency when the peritumoral area (PA) was extended. The FM based on intratumoral area (IA) [FM (IA)] had the optimal performance in predicting the recurrence risk in terms of the ROC, calibration curve, and decision curve analysis. Kaplan-Meier survival curves showed that high-risk patients of recurrence defined by FM (IA) had a worse RFS than low-risk ones of recurrence.

CONCLUSIONS

The FM integrating intratumoral radiomics features and clinicopathological factors could be a valuable predictor for the recurrence risk of EC patients.

CLINICAL RELEVANCE STATEMENT

An accurate prediction based on our developed FM (IA) for the recurrence risk of EC could facilitate making an individualized therapeutic decision and help avoid under- or over-treatment, therefore improving the prognosis of patients.

KEY POINTS

• The fusion model combined clinicopathological factors and radiomics features exhibits the highest performance compared with the clinicopathological model and radiomics model. • Although higher values of area under the curve were observed for all fusion models, the performance tended to decrease with the extension of the peritumoral region. • Identifying patients with different risks of recurrence, the developed models can be used to facilitate individualized management.

The clinical significance of lymphovascular space invasion in patients with low-risk endometrial cancer

OBJECTIVE

The aim of this study was to assess the effect of lymphovascular space invasion on recurrence and disease-free survival in patients with low-risk endometrial cancer.

METHODS

The study included patients with stage 1A, grade 1-2 endometrioid endometrial cancer who underwent a total hysterectomy and bilateral salpingo-oophorectomy with pelvic lymphadenectomy. Independent prognostic predictors of endometrial cancer recurrence were assessed using the Cox regression model. Binary logistic regression analysis was used to identify the predictors of distant recurrence. Kaplan-Meier analysis was used to describe survival curves, and the log-rank test was used to compare the differences in survival curves.

RESULTS

A total of 189 patients met the inclusion criteria, of whom 24 (12.7%) had lymphovascular space invasion. The median follow-up time was 60 (3-137) months. Distant recurrence was present in 11 of 22 patients who developed recurrence. Kaplan-Meier survival analysis showed that the 5-year disease-free survival rates of patients with lymphovascular space invasion(+) and lymphovascular space invasion(-) were 62.5 and 91.9%, respectively, which were significantly lower (p<0.001). In multivariate Cox regression analysis, the presence of lymphovascular space invasion (p<0.001) and age ≥60 years (p=0.017) remained as prognostic factors for reduced disease-free survival. In binary logistic regression analysis, only lymphovascular space invasion (adjusted OR=13, 95%CI=1.456-116.092, p=0.022) was a prognostic factor for distant recurrence.

CONCLUSION

lymphovascular space invasion is a prognostic risk factor for recurrence and distant metastasis and also a predictor of poorer disease-free survival outcomes in low-risk endometrial cancer.

Postoperative Adjuvant Treatment in Women with Stage I Endometrial Cancer: A Retrospective Study

Objective. To evaluate whether postoperative adjuvant treatment is beneficial for patient survival after surgery for early stage endometrial cancer (EC). We analyzed the outcomes of patients treated with radiotherapy, chemotherapy, or progestagen combined with other adjuvant treatments. Methods. We analyzed the outcomes of patients treated with radiotherapy alone, chemotherapy alone, or progestagen treatment with other adjuvant treatments. Women without any adjuvant treatment after operation were used as controls. We retrospectively examined disease-free survival (DFS), overall survival (OS), and high-risk factors that affected the survival status of all patients who received different postoperative adjuvant therapies. Results. In all 192 patients, the total relapse and mortality rates were 5.57% and 1.68%, respectively. Fourteen patients (7.29%) developed isolated local recurrence, and 2 patients died (1.04%) of recurrence during the follow-up period. The 5-year DFS and OS rates of all patients were 95.83% and 93.75%, respectively. No significant differences were observed in the 5-year DFS, 5-year OS, OS, or DFS among the four groups of patients with FIGO stage I endometrial cancer ( $P=0.9849$ , 0.7430, 0.9754, and 0.4534, respectively). The differences in the log-rank test results of the estimates of the 5-year DFS, 5-year OS, DFS, and OS of patients with different disease stages and different ages were all significant, but no differences were observed in these parameters among patients with varying degrees of differentiation. Histologic grade, CA125 level, ER and PR status, and adjuvant therapy had no significant effect on the DFS and OS of all patients according to univariate and multivariate regression analyses, but a significant effect on DFS and OS was found when the patients were stratified by age. Conclusion. This retrospective study showed that adjuvant therapy after surgery was not significantly associated with improved DFS or OS in patients with early stage endometrial cancer. However, FIGO stage and age affected the survival of patients with stage I endometrial cancer.

Is Substantial Lymphovascular Space Invasion Prognostic for Clinical Outcomes in Type II Endometrial Cancer?

AIMS

Substantial lymphovascular space invasion (LVSI) compared with none or focal LVSI is predictive of lymph node involvement and worse clinical outcomes in endometrioid-type endometrial carcinoma. We aimed to quantify the incidence of substantial LVSI in type II (clear cell and serous) endometrial cancer and correlate the extent of LVSI with clinical outcomes.

MATERIALS AND METHODS

A retrospective review was conducted on type II endometrial cancer patients who underwent surgical management from July 2017 to December 2019 using the three-tier LVSI scoring system. Binary logistic regression and Cox regression were used to analyse predictors of lymph node involvement or survival outcomes, respectively. The Kaplan-Meier method and Log-rank test were used to analyse differences in locoregional disease-free survival (LR-DFS), distant metastasis disease-free survival (DM-DFS) and overall survival between patients with substantial versus none/focal LVSI.

RESULTS

In 79 patients with type II endometrial carcinoma, no LVSI, focal LVSI and substantial LVSI was present in 48.1%, 15.2% and 36.7% of patients, respectively. Lymph nodes were involved in 0.0% with no LVSI, 20.0% with focal LVSI and 60.0% with substantial LVSI (P < 0.001). The median follow-up was 22.2 months. In patients with none/focal versus substantial LVSI, the 2-year LR-DFS and DM-DFS rates were 91.5% versus 71.4% (P = 0.01) and 90.2% versus 63.8% (P = 0.005), respectively. On univariate analysis, myometrial invasion ≥50%, tumour size ≥3.6 cm, substantial versus none/focal LVSI, lymph node involvement and omission of adjuvant radiotherapy were significant predictors for worse LR-DFS and DM-DFS (P < 0.05).

DISCUSSION

Substantial LVSI has a high incidence in type II pathology at our institution and predicts for lymph node involvement and worse clinical outcomes.

Lymphovascular space invasion and Estrogen Receptor status in high-grade serous ovarian cancer-a multicenter study by the FRANCOGYN group

BACKGROUND

The aim of this study was to evaluate the impact of Lymphovascular Space Invasion (LVSI) on Overall Survival (OS) and Recurrence-Free Survival (RFS) in patients managed for high-grade serous epithelial ovarian cancer (HGSOC).

MATERIALS AND METHODS

Retrospective multicenter study by the FRANCOGYN research group between January 2001 and December 2018. All patients managed for HGSOC and for whom histological slides for the review of LVSI were available, were included. The characteristics of patients with LVSI (LVSI group) were compared to those without LVSI (No LVSI group). A Cox analysis for OS and RFS analysis was performed in all populations.

RESULTS

Over the study period, 410 patients were included in the thirteen institutions. Among them, 289 patients had LVSI (33.9%). LVSI was an independent predictive factor for poorer Overall and Recurrence-Free Survival. LVSI affected OS (p<0.001) and RFS (p<0.001), Association of LVSI status and estrogen receptor status (ER) also affected OS and RFS (p=0.04; p=0.04 respectively).

CONCLUSION

The presence of LVSI in HGSOC has an impact on OS and RFS and should be routinely included in the pathology examination along with ER status.

Lymphovascular invasion as a criterion for adjuvant chemotherapy for FIGO stage I-IIa clear cell carcinoma, mucinous, low grade serous and low grade endometrioid ovarian cancer

BACKGROUND

The aim of this study was to evaluate the impact of lymphovascular space invasion (LVSI) on overall survival (OS) and recurrence-free survival (RFS) in patients managed for stage I-IIa clear cell carcinoma, mucinous, low-grade serous and low-grade endometrioid ovarian cancer MATERIAL AND METHODS: Retrospective multicentre study of the research group FRANCOGYN between January 2001 and December 2018. All patients managed for stage I-IIa clear cell carcinoma, mucinous /low grade serous and endometrioid ovarian cancer and for whom the presence of histological slides for the review of LVSI was available, were included. Patient's characteristics with LVSI (LVSI group) were compared to those without LVSI (No LVSI group). A cox analysis for OS and RFS analysis were performed in all population.

RESULTS

Over the study period, 133 patients were included in the thirteen institutions. Among them, 12 patients had LVSI (9%). LVSI was an independent predictive factor for poorer Overall and recurrence free survivals. LVSI affected OS (p < 0.001) and RFS (p = 0.0007), CONCLUSION: The presence of LVSI in stage I-IIa clear cell carcinoma, mucinous /low grade serous and endometrioid ovarian cancer has an impact on OS and RFS and should put them at high risk and consider the option of adjuvant chemotherapy.

Absence of prognostic value of lymphovascular space invasion in patients with endometrial cancer and negative sentinel lymph nodes

OBJECTIVE

To evaluate if the prognostic value of lymphovascular space invasion (LVSI) is different in endometrial cancer patients with negative lymph nodes following sentinel lymph node (SLN) mapping or lymph node dissection (LND) as staging procedure.

MATERIAL AND METHODS

A retrospective study of 510 patients diagnosed with endometrial carcinoma in our institution between 2007 and 2014. We excluded patients that were diagnosed with positive nodes (Stage IIIc). We compared patients' characteristics and survival outcomes as function of their LVSI status (positive LVSI vs negative LVSI subgroups) in each cohort separately.

RESULTS

413 patients met the inclusion criteria, out of whom 239 underwent SLN and 174 patients underwent LND only. In the SLN group, life table analysis showed 5-year OS and PFS of 80% and 72% in patients with LVSI compared to 96%, and 93% without LVSI. Same trend was observed among patients with LND with 5-year OS and PFS of 74% and 64% in patients with LVSI compared to 97%, and 90% without LVSI. On multivariable analysis, adjusted for age, FIGO stage, grade and maximal tumor size, the favorable survival of negative LVSI remained only in the LND cohort (SLN cohort: HR 1.2, CI [0.3-4.0], P = 0.8 and HR 1.7, CI [0.7-4.3], p = 0.2 for OS and PFS, respectively; LND cohort: HR 3.1, CI [1.4-6.5], p < 0.001 and HR 2.5, CI [1.2-4.9], p = 0.01 for OS and PFS, respectively).

CONCLUSIONS

The prognostic value of LVSI disappears when patients undergo staging with SLN and are found to have negative nodes in contrast to those who have undergone LND. Future studies should confirm our observation on patients with negative sentinel nodes, and plan on tailoring adjuvant treatment to this specific subgroup.

Assessment of lymphovascular invasion in early stage endometrial carcinoma -a retrospective study

Introduction

Endometrial carcinoma is associated with several known prognostic factors. Recently, lymphovascular invasion (LVI) has gained a prominent position in the risk assessment of early endometrioid endometrial carcinoma, in identifying patients who can benefit from adjuvant radiation therapy. This study aims to assess LVI in early-stage endometrioid endometrial carcinoma accurately with emphasis on its extent /grading. We also propose a few local recommendations for improving LVI reproducibility in endometrial carcinoma to guide future studies.

Methods

The duration of this retrospective study was 2 years. Early-stage I (Ia and Ib), and grade 1 and 2 endometrioid endometrial carcinomas were included. 03 reviewers independently recorded their findings on H&E stained slides. LVI was graded as none, focal and substantial. In discordant cases, immunohistochemical stain CD 31 was used.

All the data was entered in the statistical software SPSS version 26 and analyzed for frequencies. The relationships between various histological parameters assessed and the degree of reproducibility for LVI amongst various observers were also determined.

Results

Out of a total of 70 cases of endometrioid carcinoma diagnosed on hysterectomy specimen, only 32 met our inclusion criteria. The rate of LVI positivity was 6.3 %, 34.4 %, and 37.5 % respectively for reviewers 1, 2, and 3. The degree of reproducibility in LVI assessment and LVI grading was significant amongst reviewers 2 and 3. Also, a significant association was drawn between tumor grade and LVI.

Conclusion

Despite limitations in our study we recommend including both LVI assessment and grading in routine reporting formats locally. By adding a second reviewer in LVI assessment and using CD31 in discrepant cases LVI positivity can be significantly increased.

Substantial lymphovascular space invasion predicts worse outcomes in early-stage endometrioid endometrial cancer

INTRODUCTION

Substantial as opposed to focal or no lymphovascular space invasion (LVSI) is proposed as an independent adverse prognostic factor in patients with early-stage endometrioid endometrial cancer (EEC). We reviewed outcomes of patients treated with adjuvant vaginal brachytherapy (VB) alone in a single institution, stratified by LVSI extent.

METHODS AND MATERIALS

Retrospective review identified Stage I-II EEC patients receiving VB alone from 2010 to 2017. Extent of LVSI was reported as none, focal, or substantial. Kaplan-Meier estimates and Log-Rank test were used to determine significance between variables. Cox proportional hazards model was used for multivariate analyses.

RESULTS

In total, 325 patients were identified with a median follow-up of 35 (23-48) months. LVSI was found in 112 patients with extent reported in 78, 45 (58%) had focal, and 33 (42%) substantial LVSI. Estimated disease-free survival for those with substantial LVSI was 73 (57-94)%, focal LVSI 89 (79-100)%, and no LVSI 94 (90-98)% at 48 months (p = 0.012). On multivariate analyses substantial LVSI was the only risk factor predictive of pelvic [HR substantial vs no: 7.2 (1.0-51.6); p = 0.048] and distant failure [HR substantial vs no: 4.4 (1.2-16.3); p = 0.027]. Both high-grade disease [HR 3 vs 1: 5.5 (1.2-25.6); p = 0.031] and extent of LVSI [HR substantial vs no: 4.4 (1.7-11.4); p = 0.002] predicted for worse disease-free survival.

DISCUSSION

Substantial LVSI was the strongest adverse prognostic factor for pelvic and distant failure in this cohort of EEC patients receiving adjuvant VB alone, suggesting this subset may benefit from additional adjuvant therapy. This study underscores the importance of quantifying LVSI extent in EEC.

Substantial lymph-vascular space invasion (LVSI) as predictor of distant relapse and poor prognosis in low-risk early-stage endometrial cancer

OBJECTIVE

The aim of this study is to analyze the prognostic role of lymph-vascular space invasion (LVSI), evaluated in a semi-quantitative fashion on prognosis of early stage, low risk endometrial cancer (EC).

METHODS

We enrolled patients who underwent surgery for endometrial cancer between 2003 and 2018 in two referral cancer center. All patients had endometrioid EC, G1-G2, with myometrial invasion <50%, and no lymph-node involvement. LVSI was analyzed in a semi-quantitative way, according to a 3-tiered scoring system in absent, focal and substantial.

RESULTS

Among 524 patients, any positive LVSI was found in 57 patients (10.9%) with focal LVSI (n=35, 6.7%) and substantial LVSI (n=22, 4.2%). Substantial LVSI was associated to higher rate of G2 (p<0.001), myometrial infiltration (p=0.002) and greater tumor dimensions (p=0.014). Patients with substantial LVSI were more likely to receive adjuvant treatment (6.6% vs. 52.6%, p<0.001). The 5-year OS was 99.5% in patients with absent LVSI and 70.6% in those with substantial LVSI (p<0.001). The 5-year disease free survival (DFS) was 93.6% in patients with absent LVSI and 56.5% in those with substantial LVSI (p<0.001). The rate of distant failures increased from 1.8% for absent LVSI to 22.7% for substantial LVSI (p=0.002). In univariate analysis substantial LVSI was the strongest predictor of poor overall survival (hazard ratio [HR]=11.9, p=0.001). Multivariate analysis showed that substantial LVSI was an independent predictive factor of both recurrence (HR=5.88, p=0.001) and distant failure (HR=10.6, p=0.006).

CONCLUSIONS

Substantial LVSI represents the strongest independent risk factor for decreased survival and distant relapse, indicating a role for potential hematogenous dissemination.

Semiquantitative evaluation of lymph-vascular space invasion in patients affected by endometrial cancer: Prognostic and clinical implications

OBJECTIVES

The interpretation of lymph-vascular space invasion (LVSI) is usually qualitative, as presence or absence. The aim of this study is to investigate the prognostic role of LVSI in patients affected by endometrial cancer, when evaluated with a semiquantitative analysis.

METHODS

This retrospective multicentre study enrolled patients who received a histologically confirmed diagnosis of endometrial cancer. The assessment of LVSI was semiquantitative in accordance with the three-tiered scoring system (absent, focal and diffuse).

RESULTS

Among 1258 patients with surgical-stage endometrial cancer, LVSI has been found in 32.8% of cases (n = 412), whose 12.7% (n = 160) were focal, and 20% (n = 252) diffuse. The rate of lymph node metastasis increased from the 5% in patients with no LVSI to 15% in patients with focal LVSI and 33% in those with diffuse LVSI (p < 0.001). Distant recurrences were more frequent in patients with diffuse LVSI than in focal or no LVSI (24.9% versus 14.7% and 6.6%, respectively, p < 0.001). Diffuse LVSI was found to significantly increase the risk of distant metastasis (adjusted odds ratio (A OR) 2.57, p < 0.001). Adjuvant radiation were associated with improved overall survival (OS) and disease-free survival (DFS) in patients with diffuse LVSI.

CONCLUSION

The presence of diffuse LVSI is an independent risk factor for both lymph node metastasis and distant recurrence in endometrial cancer patients, and it is associated with a significantly decreased OS and DFS. Adjuvant radiation improved survival regardless of grading, histotype and lymph nodal metastasis in women with diffuse LVSI.

Surgicopathological Outcomes and Survival in Carcinoma Body Uterus: A Retrospective Analysis of Cases Managed by Laparoscopic Staging Surgery in Indian Women

Objectives:

The context of this article is based on two main titles those being Gynecologic Oncology and Minimal invasive surgery. The aim of this study was to report the laparoscopic management of a series of cases of endometrial carcinoma managed by laparoscopic surgical staging in Indian women.

Materials and Methods:

This study was conducted in a private hospital (referral minimally invasive gynecological center).

This was a retrospective study (Canadian Task Force Classification II-3). Eighty-eight cases of clinically early-stage endometrial carcinoma staged by laparoscopic surgery and treated as per final surgicopathological staging. All patients underwent laparoscopic surgical staging of endometrial carcinoma, followed by adjuvant therapy when needed. Data were retrieved regarding surgical and pathological outcomes. Recurrence-free and overall survival durations were measured at follow-up. Survival analysis was calculated using Kaplan–Meier survival analysis.

Results:

The median age of presentation was 56 years, whereas the median body mass index was 28.3 kg/m². Endometroid variety was the most commonly diagnosed histopathology. There were no intraoperative complications reported. The median blood loss was 100 cc, and the median intraoperative time was 174 min. There were a total of 5 recurrences (5.6%). The outcome of this study was comparable to studies conducted in Caucasian population. The predicted 5-year survival rate according to Kaplan–Meier survival analysis is 95.45%, which is comparable to Caucasian studies.

Conclusion:

Laparoscopic management of early-stage endometrial carcinoma is a standard practice worldwide. However, there is still a paucity of data from the Indian subcontinent regarding the outcomes of laparoscopic surgery in endometrial carcinoma. The Asian perspective has been highlighted by a number of studies from China and Japan. To our knowledge, this study is the first from India to analyze the surgicopathological outcomes following laparoscopic surgery in endometrial carcinoma. The outcome of this study was comparable to studies conducted in Caucasian population.

Is the risk of substantial LVSI in stage I endometrial cancer similar to PORTEC in the North American population? - A single-institution study

OBJECTIVES

A pooled analysis of PORTEC-1 & 2 identified substantial lymphovascular space invasion (LVSI) in 4.8% of patients, which predicted for pelvic recurrence, distant metastasis, and overall survival. Our institution implemented the PORTEC three-tier system of LVSI reporting (absent, focal, or substantial). We aimed to quantify the incidence of substantial LVSI in a North American population and to correlate extent of LVSI with lymph node (LN) involvement.

METHODS

A retrospective review was conducted on patients with clinically uterine-confined, endometrioid type endometrial cancer who underwent surgical staging and were found to have pT1a-b disease. Binary logistic regression was used to assess predictors of LN involvement (defined as ITC, micrometastases, or macrometastases).

RESULTS

In total, 438 patients with pT1a-b disease were identified. In the overall cohort and in the subset meeting PORTEC-1 inclusion criteria (n = 195), no LVSI was present in 67.4% and 50.8%; focal LVSI was present in 16.7% and 24.1%; and substantial LVSI was present in 16.0% and 25.1%, respectively. Among patients who underwent surgical LN assessment (79.2%, n = 347), LNs were involved in 3.3% without LVSI, 7.5% with focal LVSI (OR 2.4), and 15.2% with substantial LVSI (OR 5.3) (p = .005), with a similar trend in the PORTEC-1 cohort. Extent of LVSI correlated with disease burden in LN metastases.

CONCLUSION

Our incidence of substantial LVSI was three to five times higher than reported by PORTEC and correlated with LN involvement. This questions the reproducibility of the three-tier LVSI reporting system and emphasizes the need for multi-institutional data outside PORTEC for confirmation of our findings.

Factors predicting recurrence in patients with stage IA endometrioid endometrial cancer: what is the importance of LVSI?

PURPOSE

The aim of this study is to define the clinical and pathological prognostic factors for recurrence and to evaluate the recurrence patterns and adjuvant therapies used in this group of patients with stage IA endometrioid type endometrial cancer (FIGO 2009-International Federation of Gynecology and Obstetrics).

METHODS

Among the patients with epithelial endometrial cancer operated between January 1993 and May 2013 in a single institution, 720 patients with stage IA endometrioid endometrial cancer were included. Patients with a tumor type of serous, clear cell, mucinous, undifferentiated, and mixed type and with a tumor containing sarcomatous component and the patients with a secondary primer cancer were excluded from the study.

RESULTS

Lympho-vascular space invasion (LVSI) was present in 60 (8.3%) patients. Pelvic and para-aortic lymphadenectomy was performed in 266 (36.9%) patients. Median follow-up time was 48 months (range 3-240). Recurrence occurred in 23 (3.4%) patients and 6 (0.9%) died of disease. The median time-to recurrence (TTR) was 24 months (range 4-52 months) in the patients with recurrence. LVSI was associated with recurrence in the univariate analysis. Five-year disease-free survival (DFS) decreased from 96.8 to 80.1% in the presence of LVSI (p < 0.001). This association could not be shown in patients who had had lymphadenectomy (p = 0.136). Extra-pelvic recurrence occurred in 6.7% and 1% of the patients with and without LVSI, respectively, (p = 0.001). Any independent prognostic factor could not be detected in the multivariate analysis.

CONCLUSIONS

Only LVSI and tumor grade were associated with DFS and disease-specific survival (DSS), respectively, in the 686 patients with stage IA endometrial cancer in the univariate analysis, since these associations could not be shown in multivariate analysis.

Pseudovascular Invasion: Minimally Invasive Surgery for Endometrial Cancer

Background and Objectives:

To determine if the use of an intrauterine manipulator is associated with an increased incidence of pseudovascular invasion on pathologic evaluation of hysterectomy specimens for endometrial cancer and to assess the possible implications of pseudovascular space invasion in the treatment of endometrial cancer.

Methods:

We performed a retrospective cohort study of patients with early stage (I/II) endometrial cancer who underwent minimally invasive surgical staging. The following data were abstracted: race, body mass index, grade, age, stage, histology, presence or absence of lymphovascular space invasion (LVSI), peritoneal cytology, and adjuvant treatment. Slides were blindly reviewed by a gynecologic pathologist.

Results:

Of the104 patients meeting eligibility criteria, 74 cases were reviewed in detail (the study was terminated early based on the results of an interim analysis). Patients in the no-manipulator group were older (P = .02) and had a higher stage 1B/II (P = .01) than patients in the manipulator group. No difference was found in the incidence of pseudovascular invasion between the manipulator and the no-manipulator groups (P = .86). Subgroup analysis showed no association of pseudovascular invasion with tumor grade (P = .79). Five patients were identified to have pseudovascular invasion misdiagnosed as true LVSI—4 had endometrioid and 1 had serous histology. Of these, 3 were in the manipulator group. Two received adjuvant radiotherapy which they not have gotten, absent reported lymphovascular invasion.

Conclusion:

The use of a uterine manipulator does not appear to increase the rate of pseudovascular invasion in our limited data set. Misdiagnosis of pseudovascular invasion as LVSI can result in risk migration of patients with potential for harm from unwarranted adjuvant therapy.

Lymphovascular space invasion as a predictive factor for lymph node metastases and survival in endometrioid endometrial cancer - a Swedish Gynecologic Cancer Group (SweGCG) study

Background: The aim of this study is to evaluate the impact of lymphovascular space invasion (LVSI) on the risk of lymph node metastases and survival in endometrioid endometrial adenocarcinoma.Material and methods: As regard the study design, this is a cohort study based on prospectively recorded data. Patients with endometrioid endometrial adenocarcinoma registered in the Swedish Quality Registry for Gynecologic Cancer 2010-2017 with FIGO stages I-III and verified nodal status were identified (n = 1587). LVSI together with established risk factors, namely DNA ploidy, FIGO grade, myometrial invasion and age, were included in multivariable regression analyses with lymph node metastases as the dependent variable. Associations between the risk factors and overall and relative survival were included in multivariable models. Estimates of risk ratios (RR), hazard ratios (HR), excess mortality rate ratios (EMR), and 95% confidence intervals (95% CI) were calculated.Results: The presence of LVSI presented the strongest association with lymph node metastases (RR = 5.46, CI 3.69-8.07, p < .001) followed by deep myometrial invasion (RR = 1.64, CI 1.13-2.37). In the multivariable survival analyses, LVSI (EMR = 7.69, CI 2.03-29.10,) and non-diploidy (EMR = 3.23, CI 1.25-8.41) were associated with decreased relative survival. In sub-analyses including only patients with complete para-aortic and pelvic lymphadenectomy and negative lymph nodes (n = 404), only LVSI (HR = 2.50, CI 1.05-5.98) was associated with a worsened overall survival.Conclusion: This large nationwide study identified LVSI as the strongest independent risk factor for lymph node metastases and decreased survival in patients with endometrioid adenocarcinomas. Moreover, decreased overall survival was also seen in patients with LVSI-positive tumors and negative lymph nodes, indicating that hematogenous dissemination might also be important.

Prognostic significance of lymphovascular space invasion in low-risk endometrial cancer

Objective

The purpose of this study was to assess the prognostic significance of lymphovascular space invasion in women with low-risk endometrial cancer.

Methods

A dual-institutional, retrospective department database review was performed to identify patients with ‘low-risk endometrial cancer’ (patients having <50% myometrial invasion with grade 1 or 2 endometrioid endometrial cancer according to their final pathology reports) at two gynecologic oncology centers in Ankara, Turkey. Demographic, clinicopathological and survival data were collected.

Results

We identified 912 women with low-risk endometrial cancer; 53 patients (5.8%) had lymphovascular space invasion. When compared with lymphovascular space invasion-negative patients, lymphovascular space invasion-positive patients were more likely to have post-operative grade 2 disease (p<0.001), deeper myometrial invasion (p=0.003), and larger tumor size (p=0.005). Patients with lymphovascular space invasion were more likely to receive adjuvant therapy when compared with lymphovascular space invasion-negative women (11/53 vs 12/859, respectively; p<0.001). The 5-year recurrence-free survival rate for lymphovascular space invasion-positive women was 85.5% compared with 97.0% for lymphovascular space invasion-negative women (p<0.001). The 5-year overall survival rate for lymphovascular space invasion-positive women was significantly lower than that of lymphovascular space invasion-negative women (88.2% vs 98.5%, respectively; p<0.001). Age ≥60 years (HR 3.13, 95% CI 1.13 to 8.63; p=0.02) and positive lymphovascular space invasion status (HR 6.68, 95% CI 1.60 to 27.88; p=0.009) were identified as independent prognostic factors for decreased overall survival.

Conclusions

Age ≥60 years and positive lymphovascular space invasion status appear to be important prognostic parameters in patients with low-risk endometrial cancer who have undergone complete surgical staging procedures including pelvic and para-aortic lymphadenectomy. Lymphovascular space invasion seems to be associated with an adverse prognosis in women with low-risk endometrial cancer; this merits further assessment on a larger scale with standardization of the lymphovascular space invasion in terms of presence/absence and quantity.

Lymphovascular Space Invasion for Endometrial Cancer: Undertreatment and Overtreatment Risks: A Survey of the Spanish Gynecologic Oncology Group

OBJECTIVE

The purpose of this study is to asses the impact of lymphovascular space invasion (LVSI) present in early-stage endometrial cancer, regarding its therapeutic management and prognosis knowledge, based on a survey among Spanish oncologic gynecologist.

METHODS/MATERIALS

Between October and November 2014, the Young Spanish Onco-gynecologist Group carried out a survey to perform a cross-sectional study about the management of LVSI. All active members in the oncology field of the Spanish Society of Gynecology and Obstetrics were invited to participate in the survey.

RESULTS

Most respondents consider LVSI a bad prognosis factor for endometrial cancer (66%) and also consider that it should be included in the International Federation of Gynecology and Obstetrics classification (56%). Seventy-five percent of all gynecologists did not modify their surgical treatment. Regarding follow-up, 38% of the respondents do not change their surveillance, 28% modify it, and 31% reported any change only with additional factors. Forty-seven percent of respondents advise systemic treatment with chemotherapy.Data were dichotomized between less than or equal to 20 versus greater than 20 years of OB-GYN specialist and less than or equal to 5 versus greater than 5 years of main dedication to gynecology oncology, but it was not possible to show any significant differences among the groups. The response rate (34 individuals) was too low to expect any significant differences.

CONCLUSIONS

Results suggest that LVSI remains a controversial issue in the management of patients with endometrial cancer. Acquiring a deeper knowledge and uniform criteria could avoid the risk of undertreatment and overtreatment in this group of patients with early-stage endometrial cancer. The identification of vascular pseudoinvasion is recommended, although the clinical and prognostic implications still need to be determined.

Comparison of three different risk-stratification models for predicting lymph node involvement in endometrioid endometrial cancer clinically confined to the uterus

OBJECTIVE

To compare the clinical validity of the Gynecologic Oncology Group-99 (GOG-99), the Mayo-modified and the European Society for Medical Oncology (ESMO)-modified criteria for predicting lymph node (LN) involvement in women with endometrioid endometrial cancer (EC) clinically confined to the uterus.

METHODS

A total of 625 consecutive women who underwent comprehensive surgical staging for endometrioid EC clinically confined to the uterus were divided into low- and high-risk groups according to the GOG-99, the Mayo-modified, and the ESMO-modified criteria. Lymphovascular space invasion is the cornerstone of risk stratification according to the ESMO-modified criteria. These 3 risk stratification models were compared in terms of predicting LN positivity.

RESULTS

Systematic LN dissection was achieved in all patients included in the study. LN involvement was detected in 70 (11.2%) patients. LN involvement was correctly estimated in 51 of 70 LN-positive patients according to the GOG-99 criteria (positive likelihood ratio [LR+], 3.3; negative likelihood ratio [LR-], 0.4), 64 of 70 LN-positive patients according to the ESMO-modified criteria (LR+, 2.5; LR-, 0.13) and 69 of the 70 LN-positive patients according to the Mayo-modified criteria (LR+, 2.2; LR-, 0.03). The area under curve of the Mayo-modified, the GOG-99 and the ESMO-modified criteria was 0.763, 0.753, and 0.780, respectively.

CONCLUSION

The ESMO-modified classification seems to be the risk-stratification model that most accurately predicts LN involvement in endometrioid EC clinically confined to the uterus. However, the Mayo-modified classification may be an alternative model to achieve a precise balance between the desire to prevent over-treatment and the ability to diagnose LN involvement.

Impact of lympho-vascular space invasion on tumor characteristics and survival outcome of women with low-grade serous ovarian carcinoma

BACKGROUND AND OBJECTIVES

To examine association of lympho-vascular space invasion (LVSI) with clinico-pathological factors and to evaluate survival of women with low-grade serous ovarian carcinoma containing areas of LVSI.

METHODS

This is a multicenter retrospective study examining consecutive cases of surgically treated stage I-IV low-grade serous ovarian carcinoma (n = 178). Archived histopathology slides for the ovarian tumors were reviewed, and LVSI was scored as present or absent. LVSI status was correlated to clinico-pathological findings and survival outcome.

RESULTS

LVSI was seen in 79 cases (44.4%, 95% confidence interval [CI] 37.1-51.7). LVSI was associated with increased risk of omental metastasis (87.0% vs 64.9%, odds ratio [OR] 3.62, P = 0.001), high pelvic lymph node ratio (median 12.9% vs 0%, P = 0.012), and malignant ascites (49.3% vs 32.6%, OR 2.01, P = 0.035). On multivariable analysis, controlling for age, stage, and cytoreductive status, presence of LVSI in the ovarian tumor remained an independent predictor for decreased progression-free survival (5-year rates 21.0% vs 35.7%, adjusted-hazard ratio 1.57, 95%CI 1.06-2.34, P = 0.026). LVSI was significantly associated with increased risk of recurrence in lymph nodes (OR 2.62, 95%CI 1.08-6.35, P = 0.047).

CONCLUSION

LVSI in the ovarian tumor is associated with adverse clinico-pathological characteristics and decreased progression-free survival in women with low-grade serous ovarian carcinoma.

Extent of lymphovascular space invasion may predict lymph node metastasis in uterine serous carcinoma

OBJECTIVES

Emerging evidence suggests that extent of lymphovascular space invasion (LVSI) predicts for risk of lymph node metastasis in endometrioid uterine cancers. However, this correlation remains unknown in the setting of uterine serous carcinoma (USC). We sought to examine the association between extent of LVSI and other histopathologic characteristics with risk of nodal metastasis for women with USC.

MATERIALS/METHODS

Pathological data from all cases of uterine serous carcinoma between July 1998 to July 2015 at our institution were reviewed. Descriptive, univariate, and multivariate logistic regression analysis of selected pathologic features were performed.

RESULTS

88 patients with USC underwent total abdominal or laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and selective lymphadenectomy. Surgical staging revealed the following FIGO stage distributions: I (41%), II (8%), III (32%), IV (19%). LVSI was present in 44 (50%) patients. 36 patients (41%) had LN metastases with median number of total nodes removed of 17 (range, 1-49). On univariate analysis, depth of myometrial invasion, LVSI, tumor size, and cervical stromal involvement were significantly associated with nodal involvement. In a multivariate model, LVSI (OR 6.25, 95% CI 2.2-18.0, p<0.01) and cervical stromal involvement (OR 3.33, 95% CI 1.10-10.0, p=0.03) were the only factors that remained significant. Among patients with LVSI-positive disease, extensive LVSI was associated with increased risk of nodal involvement compared to focal LVSI (90% vs 29%, p=0.04).

CONCLUSIONS

Presence and extent of LVSI, and cervical stromal invasion are important predictors for lymph node metastasis in uterine serous carcinoma.

Factors associated with survival after relapse in patients with low-risk endometrial cancer treated with surgery alone

Objective

To determine factors influencing overall survival following recurrence (OSFR) in women with low-risk endometrial cancer (EC) treated with surgery alone.

Methods

A multicenter, retrospective department database review was performed to identify patients with recurrent “low-risk EC” (patients having less than 50% myometrial invasion [MMI] with grade 1 or 2 endometrioid EC) at 10 gynecologic oncology centers in Turkey. Demographic, clinicopathological, and survival data were collected.

Results

We identified 67 patients who developed recurrence of their EC after initially being diagnosed and treated for low-risk EC. For the entire study cohort, the median time to recurrence (TTR) was 23 months (95% confidence interval [CI]=11.5–34.5; standard error [SE]=5.8) and the median OSFR was 59 months (95% CI=12.7–105.2; SE=23.5). We observed 32 (47.8%) isolated vaginal recurrences, 6 (9%) nodal failures, 19 (28.4%) peritoneal failures, and 10 (14.9%) hematogenous disseminations. Overall, 45 relapses (67.2%) were loco-regional whereas 22 (32.8%) were extrapelvic. According to the Gynecologic Oncology Group (GOG) Trial-99, 7 (10.4%) out of 67 women with recurrent low-risk EC were qualified as high-intermediate risk (HIR). The 5-year OSFR rate was significantly higher for patients with TTR ≥36 months compared to those with TTR <36 months (74.3% compared to 33%, p=0.001). On multivariate analysis for OSFR, TTR <36 months (hazard ratio [HR]=8.46; 95% CI=1.65–43.36; p=0.010) and presence of HIR criteria (HR=4.62; 95% CI=1.69–12.58; p=0.003) were significant predictors.

Conclusion

Low-risk EC patients recurring earlier than 36 months and those carrying HIR criteria seem more likely to succumb to their tumors after recurrence.

Lymphovascular Space Invasion Portends Poor Prognosis in Low-Risk Endometrial Cancer

OBJECTIVE

The prognostic significance of lymphovascular space invasion (LVSI) in patients with early-stage endometrial cancer is not established. We sought to determine if LVSI status in patients with early-stage low-risk endometrial cancer correlates with recurrence and survival.

METHODS

The records of all women who underwent hysterectomy for primary treatment of endometrial cancer from January 2006 through January 2011 at 1 academic institution were reviewed. Patients with grade 1 or 2 endometrioid histology, myometrial invasion less than 50%, and disease confined to the uterus (clinical International Federation of Obstetrics and Gynecology stage IA) were analyzed. Fisher exact test and the Wilcoxon rank-sum test were applied to compare patients with and without LVSI. Recurrence-free survival (RFS) and overall survival (OS) were calculated using the Kaplan-Meier method.

RESULTS

Two hundred forty patients met the inclusion criteria. Forty (16.7%) had LVSI. Ninety-one patients (37.9%) underwent lymphadenectomy. Median tumor size was 30 mm in patients with and 26 mm in patients without LVSI (P = 0.150). Thirty patients (12.5%) received adjuvant therapy. Site of recurrence did not differ between patients with and without LVSI. Patients with LVSI were more likely to have myometrial invasion (P < 0.001), postoperative pathologic grade 2 disease (P < 0.001), to undergo lymphadenectomy (P = 0.049) and receive adjuvant therapy (P < 0.001). The 5-year cumulative incidence of recurrence was 3.8% in the no-LVSI group and 14.2% in the LVSI group (P = 0.053). The presence of LVSI was significantly associated with worse RFS (P = 0.002) and OS (P = 0.013).

CONCLUSIONS

Patients with low-risk endometrial cancer and LVSI have worse RFS and OS despite being more likely to undergo lymphadenectomy and adjuvant therapy.

Impact of depth and extent of lymphovascular space invasion on lymph node metastasis and recurrence patterns in endometrial cancer

BACKGROUND AND OBJECTIVES

To determine the significance of depth and extent of lymphovascular space invasion (LVSI) on lymph node metastasis and recurrence in endometrial cancer.

METHODS

A case-control study was conducted to examine LVSI-positive (n = 70) and LVSI-negative (n = 641) stage I-III endometrial cancer cases that underwent hysterectomy-based surgical staging. The risk of lymph node metastasis and distant recurrence was estimated based on LVSI patterns.

RESULTS

In multivariate analysis, deep (>50% invasion), and extensive (≥7 foci/slide) LVSI patterns had a significantly increased risk of lymph node metastasis (incidence 57.6% and 72.7%, odds ratio 33.8 and 49.9, respectively, P < 0.001) as compared to other traditional uterine factors (>50% myometrial tumor invasion, cervical stromal invasion, and adnexal involvement: incidence range 30.4-37.9%, odds ratio range 3.80-7.03). Deep and extensive of LVSI patterns were both significantly correlated to distant recurrence (P < 0.001). Among women who received postoperative chemotherapy, deep and extensive LVSI patterns did not have increased risks for distant recurrence compared to no LVSI (P = 0.47 and 0.32, respectively). Among women who received postoperative radiotherapy, the depth of LVSI was significantly associated with recurrence outside the radiated field (P = 0.02).

CONCLUSIONS

Depth and extent of LVSI are important predictors for lymph node metastasis and distant recurrence in endometrial cancer.

Lymphovascular space invasion and the treatment of stage I endometrioid endometrial cancer

OBJECTIVES

Treatment of clinical early-stage endometrioid endometrial cancer (EEC) in The Netherlands consists of primary hysterectomy and bilateral salpingo-oophorectomy. Adjuvant radiotherapy is given when 2 or more the following risk factors are present: 60 years or older, grade 3 histology, and 50% or more myometrial invasion. Lymphovascular space invasion (LVSI) is a predictor of poor prognosis and early distant spread. It is unclear whether adjuvant radiotherapy is sufficient in patients with LVSI-positive EEC.

METHODS/MATERIALS

Eighty-one patients treated from 1999 until 2011 for stage I LVSI-positive EEC in 11 Dutch hospitals were included. The outcomes of patients with 0 to 1 risk factors were compared with those with 2 to 3 risk factors, and both were compared with the known literature.

RESULTS

Eighteen patients presented with recurrent disease, and 12 of those recurrences had a distant component. Overall and distant recurrence rates were 19.2% and 11.5% in patients with 0 to 1 risk factors followed by observation and 25.5% and 17% in patients with 2 to 3 risk factors who received adjuvant radiotherapy. Only 1 patient with grade 1 disease had a recurrence.

CONCLUSIONS

In stage I LVSI-positive EEC with 0 to 1 risk factors, observation might not be adequate. Moreover, despite adjuvant radiotherapy, a high overall and distant recurrence rate was observed in patients with 2 to 3 risk factors. The use of systemic treatment in these patients, with the exception of patients with grade 1 disease, should be investigated.

Long-term survival outcome of laparoscopic staging surgery for endometrial cancer in Taiwanese experience

OBJECTIVE

This study aims to evaluate the long-term safety and efficacy of laparoscopic staging surgery (LSS) for endometrial cancer in Taiwanese women.

MATERIALS AND METHODS

This is a longitudinal study of prospectively registered 105 patients who underwent LSS for endometrial cancer between June 1995 and June 2008.

RESULTS

The mean duration of surgery was 186.8 minutes, and the mean intraoperative blood loss was 220.38 mL. The median number of retrieved pelvic lymph nodes was 18. The intraoperative complication rate was 4.8%, including two cases of ureteral injury and one case each of bladder injury, bowel injury, and vascular injury. No patient required conversion to laparotomy. During the median follow-up of 55.3 months, six cases of recurrence (5.7%) and three tumor-related deaths (2.9%) were recorded. The 5-year disease-free survival and the overall survival were 93.39% and 98.05%, respectively.

CONCLUSION

The study revealed favorable perioperative outcomes and better long-term survival than reported in the Taiwan Cancer Registry, and similar good surgical results to those reported in the Western studies. Therefore, LSS by experienced surgeons for endometrial cancer is a feasible and efficacious alternative to laparotomy.

Risk group criteria for tailoring adjuvant treatment in patients with endometrial cancer: a validation study of the Gynecologic Oncology Group criteria

OBJECTIVE

The purpose of this study is to validate the Gynecologic Oncology Group (GOG) criteria for adjuvant treatment in a different cohort of patients and to evaluate the simplified risk criteria predicting the prognosis and tailoring adjuvant treatment in patients with surgically staged endometrial cancer.

METHODS

We performed a retrospective analysis of 261 consecutive patients with surgically staged endometrial cancer between January 2000 and February 2013. All patients had complete staging procedures and were surgically staged according to the 2009 International Federation of Gynecology and Obstetrics staging system. Clinical and pathologic data were obtained from medical records. We designed the simplified risk criteria for adjuvant treatment according to the risk factors associated with survival. The patients were divided into low and low-intermediate, high-intermediate, and high-risk groups according to the GOG criteria and simplified criteria and their survivals were compared. Receiver-operating characteristic curve analysis was used to evaluate the prognostic significance of both criteria.

RESULTS

Median follow-up time was 48 months (range, 10 to 122 months). According to the GOG criteria, we identified 197 low and low-intermediate risk patients, 20 high-intermediate risk patients, and 44 high-risk patients. There were significant differences in disease-free (p<0.001) and overall survival (p<0.001) among the three groups. Using the simplified risk criteria, we identified 189 low and low-intermediate risk patients, 28 high-intermediate risk patients, and 44 high-risk patients. There were significant differences in disease-free (p<0.001) and overall survival (p<0.001) among the three groups. The performance of the simplified criteria (area under the curve [AUC]=0.829 and 0.916 for disease recurrences and deaths, respectively) was as good as the GOG criteria (AUC=0.836 and 0.921 for disease recurrences and deaths, respectively).

CONCLUSION

The simplified criteria may be easily applicable and offer useful information for planning strategy of adjuvant treatment in patients with surgically staged endometrial cancer as the GOG criteria.

Lymphovascular space invasion in robotic surgery for endometrial cancer

BACKGROUND

Minimally invasive surgery has become a standard treatment for endometrial cancer and offers significant benefits over abdominal approaches. There are discrepant data regarding lymphovascular space invasion (LVSI) and positive peritoneal cytology with the use of a uterine manipulator, with previous small-scale studies demonstrating an increased incidence of these prognostically important events. We sought to determine if there was a higher incidence of LVSI in patients who underwent robot-assisted surgery for endometrial cancer.

METHODS

We performed a single-institution review of medical records for patients who underwent open abdominal or robot-assisted hysterectomy for endometrial cancer over a 24-month period. The following data were abstracted: age, tumor grade and stage, size, depth of invasion, LVSI, and peritoneal cytology. For patients with LVSI, slides were reviewed by 2 pathologists for confirmation of LVSI.

RESULTS

Of 104 patients identified, LVSI was reported in 39 (37.5%) and positive peritoneal cytology in 6 (4.8%). Rates of peritoneal cytology were not significantly different between the 2 groups (odds ratio, 0.55; 95% confidence interval, 0.10-3.17; P=.50). LVSI was reported in significantly fewer robot-assisted hysterectomies than open procedures (odds ratio, 0.39; 95% confidence interval, 0.17-0.92; P=.03). In subgroup analyses restricted to early-stage disease (stage≤II), there was no significant difference in LVSI between open and robot-assisted hysterectomies (odds ratio, 0.64; 95% confidence interval, 0.22-1.85; P=.43).

CONCLUSION

In this retrospective study, we found that use of a uterine manipulator in robot-assisted surgery did not increase the incidence of LVSI.

A clue towards improving the European Society of Medical Oncology risk group classification in apparent early stage endometrial cancer? Impact of lymphovascular space invasion

Background:

Lymphovascular space invasion (LVSI) is one of the most important predictors of nodal involvement and recurrence in early stage endometrial cancer (EC). Despite its demonstrated prognostic value, LVSI has not been incorporated into the European Society of Medical Oncology (ESMO) classification. The aim of this prospective multicentre database study is to investigate whether it may improve the accuracy of the ESMO classification in predicting the recurrence risk.

Methods:

Data of 496 patients with apparent early-stage EC who received primary surgical treatment between January 2001 and December 2012 were abstracted from prospective multicentre database. A modified ESMO classification including six risk groups was created after inclusion of the LVSI status in the ESMO classification. The primary end point was the recurrence accuracy comparison between the ESMO and the modified ESMO classifications with respect to the area under the receiver operating characteristic curve (AUC).

Results:

The recurrence rate in the whole population was 16.1%. The median follow-up and recurrence time were 31 (range: 1–152) and 27 (range: 1–134) months, respectively. Considering the ESMO modified classification, the recurrence rates were 8.2% (8 out of 98), 23.1% (15 out of 65), 25.9% (15 out of 58), and 45.1% (28 out of 62) for intermediate risk/LVSI−, intermediate risk/LVSI+, high risk/LVSI−, and high risk/LVSI+, respectively (P<0.001). In the low risk group, LVSI status was not discriminant as only 7.0% (14 out of 213) had LVSI+. The staging accuracy according to AUC criteria for ESMO and ESMO modified classifications were of 0.71 (95% CI: 0.68–0.74) and 0.74 (95% CI: 0.71–0.77), respectively.

Conclusions:

The current modified classification could be helpful to better define indications for nodal staging and adjuvant therapy, especially for patients with intermediate risk EC.

Early recurrence of early stage endometrioid endometrial carcinoma: possible etiologic pathways and management options

The majority of endometrial cancers is early stage and of the endometrioid histological type, as the symptoms (mainly vaginal bleeding) of the disease lead to an early diagnosis. Close follow-up is nevertheless essential in such cancers staged early on, in which the rate of recurrence is relatively low. We retrieved the studies included in our narrative review after performing a systematic electronic search in the PubMed, Scopus and Cochrane databases. The incidence or recurrence of disease in such patients could be up to 2.6%, with the main sites of recurrence being the vaginal vault or metastases in distant parts of the body. Genetic factors such as p53 overexpression, inactivation of 14-3-3-sigma, KRAS amplification and KRAS mRNA expression, microsatellite instability and Lynch syndrome genes could be associated with such a recurrence. Black race is also correlated, as well as lymphovascular space involvement, lower uterine segment involvement and DNA aneuploidy. Longer hysteroscopy duration was not found to be associated. Close follow-up is suggested for early detection of recurrences, while surgical excision of isolated disease or exenteration of local disease as well as radiotherapy and chemotherapy are the main treatment options. This narrative review investigated the possible mechanisms of early recurrence in patients with endometrioid endometrial cancer as well as the further management of them.

The impact of lymph vascular space invasion on recurrence and survival in patients with early stage endometrial cancer

The aim of this study was to determine impact of lymph vascular space involvement (LVSI) on recurrence and survival in early stage of endometrial cancer. From 1991 through 2010, all endometrial cancer patients at University Hospital of Bari, Italy were identified. The Log-rank test and Kaplan-Meyer methods were used for time-to-event analysis to evaluate the effects of on lymph vascular space involvement recurrence rate and survival time. Of the 560 endometrial cancer patients, 525 underwent primary surgery. Of those, 399 had early stage disease. Three hundred and forty women were not found to have LVSI, whereas 59 were found to have lymph vascular space involvement. Forty-nine (12%) patients developed a recurrence and 20 of them showed lymph vascular space involvement. The statistical analysis demonstrated that LVSI was strongly associated with a poor survival (P < 0.0001). Lymph vascular space involvement is associated with a high risk of recurrence and poor overall survival in early stage of endometrial cancer; therefore, the clinical decision to decide whether or not a patient with early stage endometrial cancer should receive adjuvant therapy should be included the evaluation of lymph vascular space involvement.

Does the type of surgery for early-stage endometrial cancer affect the rate of reported lymphovascular space invasion in final pathology specimens?

OBJECTIVE

Laparoscopically assisted vaginal hysterectomy (LAVH), which usually involves the use of an intrauterine manipulator for optimal surgical control, has been shown to be as effective and safe as conventional total abdominal hysterectomy (TAH) for the staging of endometrial carcinoma. The purpose of this study was to determine whether the use of an intrauterine manipulator was associated with an increase in the pathologic reporting of lymphovascular space invasion (LVSI), which is an important determinant in choosing adjuvant therapy. We hypothesized that intracavitary manipulation and an increase of the intrauterine pressure could cause pseudolymphovascular invasion.

STUDY DESIGN

We performed a retrospective chart review of endometrial cancer patients treated at our institution from January 1996 through January 2006. Records were reviewed for patient's age, preoperative diagnosis, procedure type, final surgical staging, and final pathology report. Using the 2009 International Federation of Gynecology and Obstetrics staging, we included all patients having stage IA or IB endometrioid-type endometrial cancer who had undergone either a TAH or LAVH with or without pelvic and paraaortic lymph node dissection. The χ2 and Fisher exact tests were used to measure the association between risk of positive lymphovascular invasion and surgical groups.

RESULTS

Of 568 women identified as having endometrioid-type endometrial cancer, 486 (85.6%) met criteria for stage IA-IB endometrioid histology, grade 1, 2, or 3. LVSI was reported in 553/568 cases, with LVSI positivity in 16.9% (n = 96/568). The mean ages of the LAVH and TAH groups were significantly different (59.4 vs 62.4 years, respectively, P = .0050). Also, mean estimated blood loss and uterine weight significantly varied between TAH and LAVH groups (P = .0001 and .008, respectively). For stage IA, 17/220 (7.7%) who had been treated with LAVH had positive LVSI compared with 20/199 (10.1%) of patients receiving TAH (P = .73). For stage IB, 11/25 (44.0%) of patients treated with LAVH had positive LVSI compared with 10/31 (32.3%) of patients receiving TAH (P = .53). The stage I cancer patients were further subdivided into histological grades 1, 2, and 3, and LVSI was not significantly different between TAH and LAVH groups per grade of cancer. We found no differences between TAH and LAVH in early-stage endometrial cancer (stage IA and IB), with respect to the presence of positive peritoneal washings.

CONCLUSION

In early-stage endometrial cancer (stage IA and IB), there were no differences between TAH and LAVH in the final pathologic report of LVSI. The use of an intrauterine manipulator for LAVH was not associated with an increased detection of LVSI.

The endometrial lymphatic vasculature: function and dysfunction

The endometrium has a complex and dynamic blood and lymphatic vasculature which undergoes regular cycles of growth and breakdown. While we now have a detailed picture of the endometrial blood vasculature, our understanding of the lymphatic vasculature in the endometrium is limited. Recent studies have illustrated that the endometrium contains a population of lymphatic vessels with restricted distribution in the functional layer relative to the basal layer. The mechanisms responsible for this restricted distribution and the consequences for endometrial function are not known. This review will summarise our current understanding of endometrial lymphatics, including the mechanisms regulating their growth and function. The potential contribution of lymphatic vessels and lymphangiogenic growth factors to various endometrial disorders will be discussed.

Significance of lymphovascular space invasion in epithelial ovarian cancer

While the prognostic significance of lymphovascular space invasion (LVSI) is well established in endometrial and cervical cancer, its role in ovarian cancer is not fully understood. First, a training cohort was conducted to explore whether the presence and quantity of LVSI within the ovarian tumor correlated with nodal metastasis and survival (n = 127). Next, the results of the training cohort were applied to a different study population (validation cohort, n = 93). In both cohorts, histopathology slides of epithelial ovarian cancer cases that underwent primary cytoreductive surgery including pelvic and/or aortic lymphadenectomy were examined. In a post hoc analysis, the significance of LVSI was evaluated in apparent stage I cases (n = 53). In the training cohort, the majority of patients had advanced-stage disease (82.7%). LVSI was observed in 79.5% of cases, and nodal metastasis was the strongest variable associated with the presence of LVSI (odds ratio [OR]: 7.99, 95% confidence interval [CI]: 1.98–32.1, P = 0.003) in multivariate analysis. The presence of LVSI correlated with a worsened progression-free survival on multivariate analysis (hazard ratio [HR]: 2.06, 95% CI: 1.01–4.24, P = 0.048). The significance of the presence of LVSI was reproduced in the validation cohort (majority, early stage 61.3%). In apparent stage I cases, the presence of LVSI was associated with a high negative predictive value for nodal metastasis (100%, likelihood ratio, P = 0.034) and with worsened progression-free survival (HR: 5.16, 95% CI: 1.00–26.6, P = 0.028). The presence of LVSI is an independent predictive indicator of nodal metastasis and is associated with worse clinical outcome of patients with epithelial ovarian cancer.

Vascular endothelial growth factor-D over-expressing tumor cells induce differential effects on uterine vasculature in a mouse model of endometrial cancer

BACKGROUND

It has been hypothesised that increased VEGF-D expression may be an independent prognostic factor for endometrial cancer progression and lymph node metastasis; however, the mechanism by which VEGF-D may promote disease progression in women with endometrial cancer has not been investigated. Our aim was to describe the distribution of lymphatic vessels in mouse uterus and to examine the effect of VEGF-D over-expression on these vessels in a model of endometrial cancer. We hypothesised that VEGF-D over-expression would stimulate growth of new lymphatic vessels into the endometrium, thereby contributing to cancer progression.

METHODS

We initially described the distribution of lymphatic vessels (Lyve-1, podoplanin, VEGFR-3) and VEGF-D expression in the mouse uterus during the estrous cycle, early pregnancy and in response to estradiol-17beta and progesterone using immunohistochemistry. We also examined the effects of VEGF-D over-expression on uterine vasculature by inoculating uterine horns in NOD SCID mice with control or VEGF-D-expressing 293EBNA tumor cells.

RESULTS

Lymphatic vessels positive for the lymphatic endothelial cell markers Lyve-1, podoplanin and VEGFR-3 profiles were largely restricted to the connective tissue between the myometrial circular and longitudinal muscle layers; very few lymphatic vessel profiles were observed in the endometrium. VEGF-D immunostaining was present in all uterine compartments (epithelium, stroma, myometrium), although expression was generally low. VEGF-D immunoexpression was slightly but significantly higher in estrus relative to diestrus; and in estradiol-17beta treated mice relative to vehicle or progesterone treated mice. The presence of VEGF-D over-expressing tumor cells did not induce endometrial lymphangiogenesis, although changes were observed in existing vessel profiles. For myometrial lymphatic and endometrial blood vessels, the percentage of profiles containing proliferating endothelial cells, and the cross sectional area of vessel profiles were significantly increased in response to VEGF-D in comparison to control tumor cells. In contrast, no significant changes were noted in myometrial blood vessels. In addition, examples of invading cells or tumor emboli were observed in mice receiving VEGF-D expressing 293EBNA cells.

CONCLUSIONS

These results illustrate that VEGF-D over-expression has differential effects on the uterine vasculature. These effects may facilitate VEGF-D's ability to promote endometrial cancer metastasis and disease progression.

The Grading of Lymphovascular Space Invasion in Epithelial Ovarian Carcinoma

Introduction:

To assess the prognostic value of lymphovascular space invasion (LVSI) in epithelial ovarian carcinoma.

Methods:

We reexamined single representative hematoxylin and eosin-stained sections of 66 patients with epithelial ovarian carcinoma to identify LVSI. A 4-grade system was used to classify LVSI: absent (no LVSI), mild (1-2 foci of LVSI), moderate (3-8 foci of LVSI), and severe (≥9 foci of LVSI). We investigated the possible associations between the grade of LVSI and clinicopathologic factors.

Results:

Lymphovascular space invasion was present in 36 patients (54.5%) and absent in 30 (45.5%). Statistical analysis indicated that LVSI was significantly associated with advanced clinical stage, poor histological grade, and lymph node metastasis. Follow-up studies indicated that the disease-free survival time for patients without LVSI was significantly longer than that for patients with moderate LVSI (P = 0.01) and severe LVSI (P = 0.001). The overall survival (OS) time for patients with moderate or severe LVSI was significantly shorter than that for patients with mild or no LVSI. The grade of LVSI was found to be significantly associated with OS (P = 0.004). The grade of LVSI showed poor correlation with disease-free survival and OS.

Conclusions:

The grade of LVSI is an important predictive factor for disease recurrence and poor survival of patients with epithelial ovarian carcinoma.