The association of polypoid growth pattern with lymph node involvement in endometrioid type endometrial adenocarcinoma

Background

Tumor size is an independent predictor of lymph node metastasis and survival in the endometrioid type endometrial adenocarcinoma (EC). However, some of the ECs tend to grow towards the cavity in the polypoid pattern, which can reach very large sizes. In this study, we aimed to analyze the association of growing in the polypoid pattern of the tumor with the proportion of lymph node metastasis and extrauterine tumor spread.

Methods

Four hundred seven patients were analyzed retrospectively. The effect of tumor size, tumor growing pattern, myometrial invasion, grade, and lymphovascular space invasion on the lymph node metastasis and extrauterine tumor spread were investigated. Statistical analysis consisted of unpaired t-tests for parametric data and Mann Whitney-U test for non-parametric data, whereas the Chi-square test for categorical variables. Logistic Regression, Cox Regression and multivariate analysis were used to estimate the risk predictors.

Results

No association was found between the growing in polypoid pattern and lymph node metastasis (P > 0.05). In the analysis of endometrioid type EC patients who had myometrial invasion less than ½ as a subgroup, no association was found between the growing pattern and lymph node metastasis and extrauterine disease. Tumor size was found to be a statistically significant predictor of lymph node metastasis and extrauterine disease (P < 0.05).

Conclusions

Lymphovascular space invasion, grade, and myometrial invasion are associated with a higher proportion of lymph node metastasis. The polypoid growth pattern of the tumor does not correlate with any histopathological parameters.

Ultrasound-based risk model for preoperative prediction of lymph-node metastases in women with endometrial cancer: model-development study

OBJECTIVE

To develop a preoperative risk model, using endometrial biopsy results and clinical and ultrasound variables, to predict the individual risk of lymph-node metastases in women with endometrial cancer.

METHODS

A mixed-effects logistic regression model for prediction of lymph-node metastases was developed in 1501 prospectively included women with endometrial cancer undergoing transvaginal ultrasound examination before surgery, from 16 European centers. Missing data, including missing lymph-node status, were imputed. Discrimination, calibration and clinical utility of the model were evaluated using leave-center-out cross validation. The predictive performance of the model was compared with that of risk classification from endometrial biopsy alone (high-risk defined as endometrioid cancer Grade 3/non-endometrioid cancer) or combined endometrial biopsy and ultrasound (high-risk defined as endometrioid cancer Grade 3/non-endometrioid cancer/deep myometrial invasion/cervical stromal invasion/extrauterine spread).

RESULTS

Lymphadenectomy was performed in 691 women, of whom 127 had lymph-node metastases. The model for prediction of lymph-node metastases included the predictors age, duration of abnormal bleeding, endometrial biopsy result, tumor extension and tumor size according to ultrasound and undefined tumor with an unmeasurable endometrium. The model's area under the curve was 0.73 (95% CI, 0.68-0.78), the calibration slope was 1.06 (95% CI, 0.79-1.34) and the calibration intercept was 0.06 (95% CI, -0.15 to 0.27). Using a risk threshold for lymph-node metastases of 5% compared with 20%, the model had, respectively, a sensitivity of 98% vs 48% and specificity of 11% vs 80%. The model had higher sensitivity and specificity than did classification as high-risk, according to endometrial biopsy alone (50% vs 35% and 80% vs 77%, respectively) or combined endometrial biopsy and ultrasound (80% vs 75% and 53% vs 52%, respectively). The model's clinical utility was higher than that of endometrial biopsy alone or combined endometrial biopsy and ultrasound at any given risk threshold.

CONCLUSIONS

Based on endometrial biopsy results and clinical and ultrasound characteristics, the individual risk of lymph-node metastases in women with endometrial cancer can be estimated reliably before surgery. The model is superior to risk classification by endometrial biopsy alone or in combination with ultrasound. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Synchronous primary cancers of endometrium and ovary vs endometrial cancer with ovarian metastasis: an observational study

OBJECTIVE

To compare the ultrasound characteristics of patients with synchronous primary cancers of the endometrium and ovary vs those of patients with endometrial cancer with ovarian metastasis.

METHODS

This was a single-institution retrospective observational study of patients with a histological diagnosis of endometrial cancer and an ovarian malignant mass, who had undergone preoperative ultrasound examination at our unit. Based on the histological diagnosis, patients were classified into two groups: those with synchronous primary cancers of the endometrium and ovary (synchronous group) and patients with endometrial cancer with ovarian metastasis (metastasis group). We compared the ultrasound features of ovarian malignant masses and of endometrial cancers between the two groups. Student's t-test, Mann-Whitney U-test, χ² test or Fisher's exact test were used for comparisons of variables between the two histological groups, as appropriate.

RESULTS

We identified 131 patients, of whom 51 had synchronous primary cancers of the endometrium and ovary (synchronous group) and 80 had endometrial cancer with ovarian metastasis (metastasis group). On ultrasound examination, ovarian masses in the synchronous group were more often multilocular-solid and less often bilateral than those in the metastasis group. With respect to the ultrasound features of the endometrial lesions, the median largest diameter was 29 (range, 11-118) mm in the synchronous group in comparison with 51.5 (range, 6-150) mm in the metastasis group (P < 0.0001). Endometrial lesions in the synchronous group presented more often with no myometrial infiltration and less often with a multiple-vessel pattern on color Doppler compared with the endometrial lesions in the metastasis group.

CONCLUSIONS

Synchronous primary cancers of the endometrium and ovary have significantly different sonomorphological patterns compared with endometrial cancer with ovarian metastasis. Ovarian masses in women with synchronous primary cancers of the endometrium and ovary appeared as unilateral multilocular-solid or solid masses, whereas ovarian masses in women with endometrial cancer with ovarian metastasis were mostly bilateral solid masses. The different sonomorphology of these two cancers may facilitate their preoperative identification, helping the surgeon to determine optimum management for the patient. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Treatment outcomes of patients with stage II pure endometrioid-type endometrial cancer: a Taiwanese Gynecologic Oncology Group (TGOG-2006) retrospective cohort study

OBJECTIVE

Choice of hysterectomy and adjuvant treatment for International Federation of Gynecology and Obstetrics (FIGO) 2009 stage II endometrioid endometrial cancer (EEC) is still controversial. Aims of this study were to evaluate survival benefits and adverse effects of different hysterectomies with or without adjuvant radiotherapy (RT), and to identify prognostic factors.

METHODS

The patients at 14 member hospitals of the Taiwanese Gynecologic Oncology Group from 1992 to 2013 were retrospectively investigated. Patients were divided into simple hysterectomy (SH) alone, SH with RT, radical hysterectomy (RH) alone, and RH with RT groups. Endpoints were recurrence-free survival (RFS), overall survival (OS), disease-specific survival (DSS), adverse effects and prognostic factors for survival.

RESULTS

Total of 246 patients were enrolled. The 5-year RFS, OS, DSS and recurrence rates for the entire cohort were 89.5%, 94.3%, 96.2% and 10.2%, respectively. Patients receiving RH had more adverse effects including blood loss (p<0.001), recurrent urinary tract infections (p=0.013), and leg lymphedema (p=0.038). Age over 50-year (HR=9.2; 95% confidence interval [CI]=1.2-70.9) and grade 3 histology (HR=7.28; 95% CI=1.45-36.6) were independent predictors of OS. Grade 3 histology was an independent predictor of RFS (HR=5.13; 95% CI=1.38-19.1) and DSS (HR=5.97; 95% CI=1.06-58.7). Patients receiving adjuvant RT had lower locoregional recurrence (p=0.046), but no impact on survival.

CONCLUSION

Different treatment modalities yield similar survival outcomes. Patients receiving SH with RT had lower locoregional recurrent with acceptable morbidity. Age and tumor grading remained significant predictors for survival among patients with FIGO 2009 stage II EEC.

Risk factors for ovarian involvement in young and premenopausal endometrioid endometrial cancer patients

OBJECTIVE

This study aimed to investigate the incidence of ovarian malignant involvement in young and premenopausal endometrioid endometrial cancer and study the possible risk factors.

METHODS

Premenopausal patients 45 years of age or younger with endometrioid endometrial cancer treated at the OB/GYN Hospital of Fudan University between 2009 and 2013 were identified. The incidence of ovarian malignant involvement in young and premenopausal endometrioid endometrial cancer patients were calculated and the possible risk factors were investigated.

RESULTS

A total of 144 younger (age ≤ 45, premenopausal) patients with endometrioid endometrial cancer were identified and coexisting malignant ovarian neoplasms were detected in 6 patients. Univariate analysis revealed that deeper myometrial invasion, positive lymphonode metastasis, positive LVSI, and high histologic grade (G2-G3) were associated with ovarian involvement in younger endometrial cancer patients. However, multivariate analysis revealed that only deep myometrial invasion was an independent risk factors for ovarian involvement (OR = 12.81, P = 0.046).

CONCLUSION

In conclusions, the incidence of coexisting ovarian malignant neoplasms in young and premenopausal patients with endometrioid endometrial cancer is low, and these findings may facilitate preoperative counseling of patients and decision making at the time of surgery.

[Curative Resection for Metastatic Lower Rectal Tumor from Ovarian Cancer - Report of a Case]

We here report the case of a 56-year-old female patient who underwent curative resection for right ovarian cancer with intraperitoneal dissemination and liver metastases. She received following adjuvant chemotherapy, and had been visited hospital for regular follow-up since then. One and half a year after surgery, blood examination showed increasing value of CA125. Contrast-enhanced CT scan revealed a tumor whose long diameter was 5 cm at front side of lower rectum. Following MRI and PET-CT examinations indicated the pelvic tumor as recurrence of ovarian cancer, so that laparotomy was carried out. As the tumor was palped through Douglas cavum, we performed low-anterior rectal resection for en bloc tumor extirpation. Tumor cells mainly developed at peri-rectal wall and proper muscle by HE staining of pathological findings, and ER(positive), vimentin(positive), CD56(positive), synaptophysin(negative)and chromogranin A(negative)by immunostaining indicated the tumor as metastasis of ovarian cancer. Though rectal metastasis from ovarian cancer is basically rare, it might be necessary to rule out possibility of metastatic colon tumor from ovarian cancer when treating patient with rectal tumor who had underwent surgery for ovarian cancer before.

An impressive response to pazopanib in a patient with metastatic endometrial carcinoma

The incidence of endometrial carcinoma is rising and the patients with distant metastases have a poor prognosis, especially when progression of disease occurs after systemic treatment with hormonal therapy or chemotherapy. Pazopanib, a multi-targeted inhibitor of several oncogenic receptor tyrosine kinases, has been investigated in patients with chemotherapy-resistant endometrial carcinoma or patients for whom chemotherapy is contraindicated. In this report we will describe a spectacular response to pazopanib in a patient with recurrent metastatic endometrial carcinoma.

Detection of circulating tumour cells may add value in endometrial cancer management

OBJECTIVE

To evaluate the role of circulating tumour cells (CTCs) in patients with endometrial cancer (EC).

STUDY DESIGN

This study included 40 patients with a pre-operative diagnosis of high-risk EC between April 2015 and May 2016. Patients were further divided into high-risk (grade 3, non-endometrioid, myometrial invasion ≥1/2 and stage III-IV) and high-intermediate-risk (grade 2-3, endometrioid, myometrial invasion <1/2 and stage I-II) groups according to postoperative pathological results. CTCs were detected using the CellSearch system, and CTC results were correlated with standard clinicopathological characteristics and serum tumour marker CA125/HE4 status using Chi-squared test, continuity correction or Fisher's exact test. The pharmacodynamic effect was detected after the first cycle of adjuvant therapy. Patients were followed up for 13 months to assess outcomes.

RESULTS

Fifteen percent of patients had one or more CTCs. The presence of CTCs was found to be significantly associated with cervical involvement (83.33% vs 11.76%, p=0.00). No significant difference in CTC-positive rates was detected between the high-risk and high-intermediate-risk groups, and no significant correlation was found between CTCs and serum CA125/HE4, either by positive rates or exact serum levels of the conventional tumour markers. No more CTCs were detected after the first cycle of standard chemotherapy in this study, and no distant metastases or recurrence were found in the CTC-positive patients during the follow-up period.

CONCLUSION

The presence of CTCs was correlated with cervical involvement. Early-stage EC patients with CTCs may benefit from additional adjuvant therapies. Assessment of CTCs may be useful in the management of high-risk EC patients.

Molecular Characterization of an Endometrial Endometrioid Adenocarcinoma Metastatic to a Thyroid Hürthle Cell Adenoma Showing Cancerization of Follicles

Tumor-to-tumor metastasis is rare. Herein, we present a unique case of endometrial endometrioid adenocarcinoma metastatic to a thyroid Hürthle cell adenoma 9 years after initial diagnosis. On histologic examination of the thyroid, the malignant endometrioid glands and single cells (donor tumor) were dispersed within the Hürthle cell adenoma (recipient tumor). In several sections of the adenoma with still preserved microfollicular architecture, malignant endometrial adenocarcinoma cells were admixed within oncocytic adenomatous epithelium (so-called "cancerization of the follicles"). This unusual phenomenon, to our knowledge, is a novel finding in the thyroid gland. Immunohistochemistry, subsequently elicited clinical history, and morphologic comparison of the tumor in the thyroid to the primary endometrial tumor confirmed the origin of the donor tumor cells. Molecular analysis of both the metastatic and primary endometrial tumors demonstrated PIK3CA and PTEN mutations in both tumors, as is characteristic of well-differentiated endometrioid tumors of the endometrium. Amplification of chromosome 1q was detected in both sites; however, only the metastatic tumor showed loss of chromosomes 2, 9, and 22. The morphologic differential diagnosis of metastatic endometrioid adenocarcinoma in the thyroid includes columnar cell variant of papillary thyroid carcinoma (CCVPTC) arising in a preexisting adenoma, endocrine glandular atypia within an adenoma, and metastasis from other anatomic sites. Histomorphologic differences among these entities may be subtle; therefore, knowledge of and morphologic comparison with prior malignancies and immunohistochemistry can be helpful in rendering the correct diagnosis.

Inguinal Node Metastasis of Low-Grade Endometrial Endometrioid Adenocarcinoma in a Morbidly Obese Patient

BACKGROUND

The accurate preoperative evaluation of endometrial cancer is needed to inform disease staging, but the evaluation may be more prone to error if the physical signs of advanced stage disease are difficult to appreciate in morbidly obese patients.

CASE

A morbidly obese (BMI = 56.9 kg/m2) 67-year-old woman with postmenopausal uterine bleeding was diagnosed with low-grade stage IB endometrial endometrioid adenocarcinoma after surgical staging. She received adjuvant vaginal brachytherapy. Fourteen months after surgery she presented with an ulcerating left inguinal mass. Fine-needle biopsy demonstrated adenocarcinoma consistent with her primary endometrioid adenocarcinoma. At the time of initial diagnosis, a preoperative physical examination was negative for inguinal lymphadenopathy and a computed tomography(CT) demonstrated inguinal lymphadenopathy that was not appreciated.

CONCLUSION

In morbidly obese patients, the sensitivity of a physical examination is limited by body habitus. Obese patients with limited physical examinations may benefit from imaging studies to aid early diagnosis of extraperitoneal disease.

Lymphovascular space invasion and positive pelvic lymph nodes are independent risk factors for para-aortic nodal metastasis in endometrioid endometrial cancer

OBJECTIVE

Para-aortic lymph node dissemination in endometrioid endometrial cancer is uncommon, and systematic para-aortic lymph node dissection increases morbidity. The purpose of this study was to identify a subgroup of endometrioid endometrial cancer patients who did not require para-aortic lymphadenectomy.

STUDY DESIGN

All patients who had undergone surgery for endometrioid endometrial cancer between 1 January 1995 and 31 December 2012 were retrospectively reviewed. Patients with higher risk factors for nodal metastasis and inadequate lymphadenectomy were excluded. Para-aortic lymph node dissemination was defined as nodal metastasis when pelvic and para-aortic lymph node dissection was performed, when para-aortic lymph node recurrence occurred after negative para-aortic lymph node dissection or when para-aortic lymph node dissection was not performed. Multivariate logistic regression models were used to identify the pathological features as predictors for para-aortic lymphatic dissemination.

RESULTS

A total of 827 patients were assessed, 516 (62.4%) of whom underwent pelvic and para-aortic lymph node dissection. Sixty-seven (13%) patients (37 with only pelvic, 26 with pelvic and para-aortic, and 4 with only para-aortic metastasis) had positive lymph nodes in the pelvic and para-aortic lymph node dissection group. Multivariate analysis confirmed positive pelvic nodes (odds ratio 20.58; p<0.001) and lymphovascular space invasion (odds ratio 8.10; p=0.022) as independent predictors of para-aortic lymphatic dissemination. When these two factors were absent (in 83% of patients), the predicted probability of para-aortic lymph node metastasis was 0.1%.

CONCLUSION

Positive pelvic nodes and lymphovascular space invasion are highly associated with para-aortic lymph node metastasis. These markers may be useful for identifying those patients who require para-aortic lymph node dissection.

Evaluation of residual tumor locations in advanced ovarian cancer patients after incomplete primary cytoreduction

BACKGROUND

Nowadays complete primary cytoreduction can be achieved in a large number of patients suffering from advanced ovarian cancer. However, there is a group of patients in whom complete tumor resection remains impossible. The authors analyzed the intraoperative limiting factors in patients with residual tumor after primary surgery treated in the present institution.

MATERIALS AND METHODS

Patients with advanced epithelial ovarian cancer (FIGO Stage IIIB-IV), who underwent primary incomplete surgery in the present institution between 2006 and 2008 were included in this study. Patients' records were evaluated regarding to intraoperative findings and final surgical results.

RESULTS

The authors identified 39 eligible patients in their registry. Twenty-six (66.7%) patients underwent surgery with residual tumor < 1 cm and 13 (33.3%) ≥ 1 cm. The most frequent location of residual tumor limiting complete surgery was disseminated bowel carcinomatosis in 34 (87.2%) patients. Moreover significant differences in tumor residuals locations and operative time between patients with residuals < 1 cm and ≥ 1 cm were reported (p < 0.05).

CONCLUSIONS

The most frequent reason for incomplete primary cytoreduction remains disseminated carcinomatosis. However, in patients with residuals under one cm, its frequency is significantly higher. The complication rate is comparable in patients independently of residual tumor < 1 cm and ≥ 1 cm. Therefore the cytoreductive efforts should be made even in primarily not completely operated patients in order to achieve residuals under one cm.

Accuracy of robotic sentinel lymph node detection (RSLND) for patients with endometrial cancer (EC)

OBJECTIVES

Lymphadenectomy as a part of the staging for EC patients is controversial. Sentinel lymph node detection has been introduced to determine which patients would benefit from adjuvant therapy and to limit morbidities associated with a full pelvic nodal dissection. The purpose of this study is to evaluate diagnostic accuracy and detection rate of robotic sentinel lymph node detection (RSLND) as a part of the surgical staging for EC.

METHODS

A retrospective database of all patients who underwent intraoperative lymphatic mapping using cervical injection methylene blue followed by RSLND as a part of their procedure was reviewed. Sentinel lymph node (SLN) was initially examined by routine Hematoxylin and Eosin (H&E) and ultrastaging by immunohistochemistry (IHC).

RESULTS

Between 4/2011 and 6/2013, 120 patients with endometrial cancer underwent RSLND. The median age was 62years (25-87); median BMI was 32 (18-76). Out of 120 patients, only one patient underwent RSLND with fertility preservation; and 119 patients underwent robotic hysterectomy and surgical staging with RSLND. None of the cases was converted to an open procedure. At least 1 SLN was detected in 86% (103/120) of the patients. Bilateral SLNs were detected in 52% (62/120). Positive nodes were identified in 8% (10/120) of the patients. Of those with SLN (+), 50% (5/10) were by ultrastaging (IHC) alone. No patients had positive regional nodes without SLN (+).

CONCLUSIONS

RSLND using methylene blue cervical injection can identify SLN in most patients with EC. IHC ultrastaging improves the detection of node positive disease when compared to traditional pathological evaluation.

Estimated intermediate risk endometrial cancer: debate and new perspectives on therapy individualization and prognosis establishment starting from a peculiar case

The adequate treatment for stage IB endometrial cancer (EC) with G1-G2 grading (intermediate risk patients) is still debated. FIGO guidelines recommend adjuvant radio-therapy in order to avoid recurrences, despite it has been demonstrated that this does not improve the overall survival. Recently, other than the conventional risk-factor (histology, stage and grading), lymph-vascular involvement, tumor size and neoplasia molecular patterns has been proposed with intent to establish the most appropriated EC oncologic treatment and prognosis. We report an interesting case of a patient affected by an early stage EC (estimated intermediate low risk), treated by the adequate surgical staging and subsequent adjuvant radio-therapy that showed, in a follow up period, a very poor prognosis, similarly to patients affected by high risk cancer. Even if the classical validated risk factors remain the "cornerstone" in risk assessment, adjuvant treatments and follow up planning after surgery, the molecular investigation of estimated intermediate risk EC could represent a "keystone" to solve and avoid the "oncologic dilemma" of cases in which the observed prognosis results very different from the expected one. Only a detailed molecular evaluation of these cases could allow a more specific treatment targeting, leading to an individualized therapy and low recurrence-risk. The importance of recurrence-risk reduction is linked to difficulties in both their early detection and appropriate management. The delay in diagnosis as well as the performance of not adequate treatment can potentially make the prognosis of these cases worst that the one detected in case of uterine sarcoma or mixed müllerian tumors.

Appendectomy with cytoreductive surgery for ovarian and type 2 endometrial carcinoma

There is considerable variation within and between cancer centers in the practice of appendectomy as part of cytoreductive surgery for ovarian carcinoma and in the surgical staging of endometrial carcinoma. The purpose of this study was to determine the prevalence and the type of appendiceal pathology, the morbidity associated with appendectomy in gynaecologic cancer surgery.

MATERIALS AND METHODS

This is a retrospective review of all cytoreductive surgery for ovarian carcinoma and surgical staging for endometrial carcinoma with appendectomy over a four year period.

RESULTS

Two hundred and fifty-one patients (38 patients for endometrial carcinoma surgery and 213 patients for ovarian cytoreduction) had an appendectomy performed. Metastases to the appendix was present in 46 (23.2%) of primary ovarian carcinoma and one (2.6%) primary endometrial carcinosarcoma. The appendix was more likely to be involved in advanced stage ovarian cancer with positive peritoneal washings, omental deposits, grade 3 differentiation, and papillary serous histology. Sixteen (6.4%) co-incidental primary appendiceal tumours were detected. No postoperative morbidity specific to appendectomy was identified. One case of ovarian carcinoma was upstaged from IC to IIIA by the appendiceal metastases. There was no upstaging of disease in the endometrial carcinoma group.

DISCUSSION

Appendectomy is an integral part of ovarian cytoreductive surgery but the authors found it did not upstage the disease in a clinically significant manner. The incidence of co-incidental appendiceal primary tumours was high in this series and may add value to the procedure in preventing further surgeries. The absence of procedure related morbidity is reassuring. The authors recommend appendectomy for all ovarian staging surgery and its consideration in type 2 endometrial cancer.

Isolated sacral metastases as the initial presentation from an endometroid ovarian carcinoma: a case report

Bone metastases are rarely in ovarian carcainoma. It usually occurrs only when the cancer is advanced or recurrent. A case of endometrioid carcinoma in right ovary with intact capsule is reported. The isolated sacral metastasis was found as the initial presentation, and no distant metastases were reported.

Preoperative serum leptin levels in patients with endometrial cancer and its correlation with prognostic variables

PURPOSE OF INVESTIGATION

Since leptin is believed to be a key player in carcinogenesis, a study has been designed to investigate the relationship between leptin levels and endometrial cancer.

METHODS

A study including 30 patients with endometrial cancer and 30 healthy controls was carried out between November 2008 and July 2009 in Hacettepe University Hospital. All patients with endometrial cancer underwent a complete surgical staging procedure including lymphadenectomy. Preoperative leptin levels of endometrial cancer patients and healthy controls were compared. The relationships between leptin levels and stage, grade, histological type and lymph node status of endometrial cancer cases were evaluated.

RESULTS

The mean serum leptin levels were 16.9 ng/ml among endometrial cancer cases and 19.0 ng/ml among controls (p = 0.32). Of endometrial cancer cases, the mean leptin level was found to be 15.8 ng/ml for Stage I and 18.5 ng/ml for Stage II-IV disease (p = 0.34). The figure was 17.7 ng/ml for endometrioid and 13.2 ng/ml for non-endometrioid type of tumor (p = 0.24). The mean leptin levels of 16.3 ng/ml for grade 1 and 19.9 ng/ml for grade 2-3 tumors were observed (p = 0.07). The cases with positive and negative lymph nodes had leptin levels of 20.2 ng/ml and 16.1 ng/ml, respectively (p = 0.30).

CONCLUSIONS

Serum leptin levels in endometrial cancer patients were similar to healthy controls. Leptin did not show any significant correlation with stage, grade, histological type and node metastases in endometrial cancer.

Isolated splenic metastasis of endometrial adenocarcinoma--a case report

The spleen in rarely the place for solid, non-haematological tumors, isolated splenic metastases from adenocarcinomas being extremely rare findings, regardless of the origin and the histological type of the primary tumor. We present the case of a female patient with isolated splenic metastasis diagnosed by abdominal computer tomography at only 20 months after curative surgery for endometrial adenocarcinoma, in which the final diagnosis has been established by histological and immunohistochemical examination of the splenectomy piece. The haematogenous dissemination of the endometrial cancer occurs most commonly in the lungs, liver or bones, the spleen being rarely affected. In the medical literature there are cited up to date only 12 cases of solitary splenic metastasis from endometrial adenocarcinoma. The particularity of the case presented by us is the early appearance of an isolated splenic metastasis, at less than two years after curative surgery (compared to an average of 4-5 years cited in the literature), from an endometrial cancer which was classified histologicaly in the group with low-risk for relapse (well differentiated endometrioid adenocarcinoma). In conclusion, although solitary splenic secondary determinations are very rare, the incidence of the reported cases in the medical literature is increasing, their late appearance (a few years after the primary tumor's resection) and the lack of symptoms until the tumor reaches appreciable size or it complicates with necrosis, justifies the periodic abdominal imaging examination, on long-term, for postoperative monitorisation after the initial curative surgery. Their treatment of choice is open, classical splenectomy that must be followed by chemotherapy in order to prevent the development of other possible micrometastases.

Vaginal and pelvic recurrences in stage I and II endometrial carcinoma--survival and prognostic factors

AIM OF THE STUDY

The analysis of prognostic factors and treatment outcomes in 106 patients with Stage I and II endometrial carcinoma (EC) treated between 1980 and 2005 in the Center of Oncology, Maria Skłodowska-Curie Memorial Institute, Kracow, Poland, who developed vaginal or pelvic recurrences.

MATERIAL AND METHODS

The median age of patients was 61. Stage IB and IC of EC was diagnosed in 48 (45.3%) patients and Stage IIA and IIB in 58 (54.7%) patients. All patients were treated previously with surgery (TAH-BSO) and postoperative radiotherapy. There were 17 (16%) patients with vaginal vault recurrences, 30 (28.3%) with lower one-third vaginal recurrences, and 59 (55.7%) with pelvic recurrences. Palliative treatment (chemo- or hormonotherapy) or best supportive care only was undertaken in 53 (50.0%) patients. Radical treatment was conducted in 70.6% (12/17) of vault recurrences, 86.7% (26/30) of lower one-third vagina recurrences, and 25.4% (15/59) of pelvic recurrences, with surgery (4 patients), brachytherapy +/- chemotherapy (34 patients), and teleradiotherapy +/- chemotherapy (15 patients).

RESULTS

The 5-year overall survival rate in the observed group was 17%. Five-year survival was 23.3% (14/60) for patients with KPS 60-70 vs 8.7% (4/46) with KPS 40-50, 25% (12/48) patients with Stage I EC vs 10.3% (6/58) with Stage II EC, and 34% (16/47) patients with vaginal recurrence vs 3.4% (2/59) with pelvic recurrences.

CONCLUSIONS

In the analyzed group of 106 patients with Stage I and II EC, treated previously with surgery and postoperative radiotherapy, 5-year overall survival rate was low; in radically treated patients it was 42.1%, and 13.3% for vaginal and pelvis recurrences, respectively. Univariate analysis showed a statistically significant, unfavorable impact of KPS < 60, Stage II and recurrence pelvic. Cox multivariate analysis demonstrated that the only independent prognostic factor for 5-year overall survival was the site of recurrence.

Nodal metastasis in endometrial cancer

PURPOSE

Besides hysterectomy and bilateral salpingo-oophorectomy, the goal of surgery in early endometrial cancer is to identify extrauterine disease. The purpose of this study was to evaluate disease characteristics and survival of patients found to have nodal metastasis at staging for endometrial cancer.

METHODS

All patients presenting to our practice from January 1993 to July 2009 with a new diagnosis of early endometrial cancer underwent pelvic and paraaortic lymph node sampling at the time of surgery as permitted by the body mass index. Patient and disease characteristics of patients with nodal metastasis were abstracted by retrospective chart review. Factors contributing to disease-free and overall corrected survival were evaluated.

RESULTS

Forty-three patients with an early endometrial cancer were found to have pelvic and/or paraaortic nodal metastasis. Thirty-three percent of patients with nodal metastasis had papillary serous or clear cell cancers. Such tumors were often superficially invasive, yet were more likely to demonstrate lymphovascular space involvement as compared to endometrioid cancers. Furthermore, in a global model of disease-free and overall corrected survival, only tumor histology (endometrioid vs non-endometrioid) was a significant prognostic factor. Excluding clear cell and papillary serous tumors, only tumor grade was a significant prognostic factor in disease-free survival and overall corrected survival in patients with endometrioid adenocarcinomas and nodal involvement. Following adjuvant treatment after surgery, the recurrences were nearly evenly divided between pelvic, paraaortic nodal and distant sites. Only four of 33 (12%) patients treated with adjuvant pelvic radiation experienced a failure in the irradiated field. Furthermore, none of the patients experiencing a paraaortic nodal recurrence received adjuvant radiation to this site.

CONCLUSIONS

The data suggest a benefit to the use of adjuvant radiation for local control of disease. Furthermore, the use of paclitaxel and carboplatinum chemotherapy also appears a promising adjunct in patients with endometrioid histologies and nodal spread. Papillary serous and clear cell cancers contributed disproportionately to the incidence of nodal metastasis and an adverse prognosis following further adjuvant therapy of patients with nodal disease. Despite taxol/carboplatinum chemotherapy, over half of the patients with non-endometrioid cancers recurred, as opposed to one of 19 endometrioid cancers so treated. The ideal form of adjuvant treatment for such patients remains problematic.

Axillary metastasis in a patient with double neoplasia: a case report

BACKGROUND

Axillary lymph node metastases in women are most frequently associated with breast cancer. Few cases have been reported to be related to other primary tumors of the breast. Furthermore, emperipolesis, a phenomenon that occurs as a result of the phagocytosis of hematopoietic cells by neoplastic cells, is observed in few tumors.

CASE

A 72-year-old woman presenting endometrial and breast cancer developed axillary metastasis 2 months after diagnosis of breast cancer. A fine needle aspiration was performed. A diagnosis of metastasis from endometrial cancer was made on the basis of cytological characteristics.

CONCLUSION

The morphologic features in this case (emperipolesis) oriented as axillary metastases from primary endometrial cancer.

[Expression of EVEC in ovarian carcinoma and its biological significance]

OBJECTIVE

To investigate the expression of EVEC in ovarian carcinoma and explore its biological significance.

METHODS

The expression of EVEC in 22 specimens of normal ovarian tissues and 63 specimens of ovarian cancers was detected by RT-PCR and Western blotting analysis, respectively.

RESULTS

RT-PCR showed that the expression level of EVEC in stage I-II ovarian cancer (0.199 ± 0.014) was significantly higher than that in stage III-IV ovarian cancer (0.155 ± 0.015, P < 0.05), and significantly lower than that in normal ovarian tissues (0.415 ± 0.055, P < 0.05). There was no significant difference between the expression levels of EVEC in primary sites and that in corresponding metastatic sites of ovarian cancer (P > 0.05). Furthermore, the results of Western blot also showed that the protein expression level of EVEC in stage I-II ovarian cancer was also significantly lower than that in normal ovarian tissues (0.179 ± 0.026 vs. 0.543 ± 0.032, P < 0.05), and higher than that in stage III-IV ovarian cancer (0.179 ± 0.026 vs. 0.115 ± 0.023, P < 0.05). The EVEC expression level in the epiploic metastasis of stage I-II ovarian cancer was significantly higher than that of stage III-IV ovarian cancer (0.201 ± 0.028 vs. 0.101 ± 0.037, P < 0.05). The expression of EVEC in ovarian carcinoma had no correlation with age, pathologic classification and histological grade (P > 0.05).

CONCLUSIONS

EVEC is closely related with carcinoma metastasis. The expression of EVEC in ovarian cancer and its metastatic sites was remarkably decreased. EVEC may play a negative role in the development and metastasis of ovarian cancer and may be a valuable marker in estimation of the prognosis for patients.

Muscle metastasis of low-grade endometrial carcinoma seven years after diagnosis: a case report

BACKGROUND

Early-stage low-grade endometrial carcinoma has an excellent prognosis. In few cases local relapse and/or distant metastases can occur. We report the muscle as an unusual site of metastasis.

CASE

A 69-year-old woman underwent surgery for FIGO Stage IA, grade 1 endometrioid adenocarcinoma of the endometrium. After four years she had local relapse without response to chemoradiation, requiring pelvic exanteration. Three years later she was diagnosed with a deltoid muscle metastasis confirmed histologically and bone metastases. After failing hormone therapy, chemotherapy was administered. She died eight months after diagnosis of the bone and muscle metastases.

CONCLUSION

Low-risk endometrial carcinoma can behave like a high-risk group. Furthermore, this report describes, to our knowledge, the first case of endometrial carcinoma muscle metastasis.

c-FLIPL expression defines two ovarian cancer patient subsets and is a prognostic factor of adverse outcome

The impairment of apoptotic pathways represents an efficient mechanism to promote chemoresistance in cancer cells. We previously showed that in epithelial ovarian cancer (EOC) cells, long isoform of cellular FLICE-inhibitory protein (c-FLIP(L)) accounts for apoptosis resistance in a context of functional p53 and resistance could be overcome by c-FLIP(L) downmodulation. Here, we studied the association between c-FLIP(L) and p53 expressions and their prognostic impact in EOC patients. Tumor tissue from 207 patients diagnosed with primary EOC was analyzed by immunohistochemistry (IHC) for c-FLIP(L) and p53 expressions, and multiple correspondence analysis (MCA) was used to evaluate the multivariable pattern of association among patients' clinical-pathological characteristics and biological determinants. IHC revealed c-FLIP(L) expression and p53 nuclear accumulation inversely related (P = 0.0001; odds ratio = 0.29, confidence interval (CI) = 0.15-0.055). MCA indicated that p53 accumulation was associated to clinical-pathological variables, while c-FLIP(L) expression contributed to the overall association pattern independently from other's clinical characteristics and complementary to p53. Kaplan-Meier curves showed a reduced survival time according to c-FLIP(L) expression in concert with p53 accumulation (median overall survival (OS): 35 months) compared with lack of expression of both markers (median OS: 110 months; log-rank test, P value = 0.024). The multivariable Cox regression model, adjusted for known prognostic factors, identified c-FLIP(L) expression, but not p53 nuclear accumulation, as an independent prognostic factor for adverse outcome (hazard ratio = 1.82, 95% CI = 1.17-2.82; P = 0.008). Altogether these data support the independent contribution of c-FLIP(L) in refining the prognostic information obtained from standard clinical-pathological indicators, confirming its pivotal role in promoting cell survival.

Bone metastasis from endometrioid ovarian carcinoma: a case study and literature review

INTRODUCTION

Bone metastases from epithelial ovarian carcinoma are rare, usually discovered postmortem. The survival of these patients is poor. Furthermore, only two cases of endometrioid ovarian carcinoma with metastasis to the skeletal structures have been described in the literature.

CASE REPORT

We present the case of a 58-year-old woman with a lytic metastasis in the left iliac ramus from endometrioid ovarian carcinoma that occurred seven years after the initial diagnosis.

DISCUSSION

A review of the literature since 1966 on bone metastasis of ovarian cancer is also presented. In patients suffering from a neoplasm that rarely metastasises to bone, histological proof should be obtained to diagnose uncommon sites of disease relapse.

A systematic review of tests for lymph node status in primary endometrial cancer

BACKGROUND

The lymph node status of a patient is a key determinate in staging, prognosis and adjuvant treatment of endometrial cancer. Despite this, the potential additional morbidity associated with lymphadenectomy makes its role controversial. This study systematically reviews the accuracy literature on sentinel node biopsy; ultra sound scanning, magnetic resonance imaging (MRI) and computer tomography (CT) for determining lymph node status in endometrial cancer.

METHODS

Relevant articles were identified form MEDLINE (1966-2006), EMBASE (1980-2006), MEDION, the Cochrane library, hand searching of reference lists from primary articles and reviews, conference abstracts and contact with experts in the field. The review included 18 relevant primary studies (693 women). Data was extracted for study characteristics and quality. Bivariate random-effect model meta-analysis was used to estimate diagnostic accuracy of the various index tests.

RESULTS

MRI (pooled positive LR 26.7, 95% CI 10.6 - 67.6 and negative LR 0.29 95% CI 0.17 - 0.49) and successful sentinel node biopsy (pooled positive LR 18.9 95% CI 6.7 - 53.2 and negative LR 0.22, 95% CI 0.1 - 0.48) were the most accurate tests. CT was not as accurate a test (pooled positive LR 3.8, 95% CI 2.0 - 7.3 and negative LR of 0.62, 95% CI 0.45 - 0.86. There was only one study that reported the use of ultrasound scanning.

CONCLUSION

MRI and sentinel node biopsy have shown similar diagnostic accuracy in confirming lymph node status among women with primary endometrial cancer than CT scanning, although the comparisons made are indirect and hence subject to bias. MRI should be used in preference, in light of the ASTEC trial, because of its non invasive nature.

Synchronous primary cancers of the endometrium and ovary

Simultaneous detection of malignancy in the endometrium and ovary represents an uncommon event. The objective of the study was to clarify the possible factors that influenced on the survival. From 1977 to 2005, totally 27 patients fulfilled the criteria and were included in the study. The medical records and the pathologic reports were reviewed. The histologic determination was followed by the World Health Organization Committee classification, and cancer stage was based on the staging system of the FIGO. The Kaplan-Meier survival analyses were generated and compared by the log-rank test. The incidence of synchronous primary endometrial and ovarian cancers was 3.3% in patients with endometrial cancer and 2.7% in patients with ovarian cancer. The mean survival in the group of similar histology (n= 15) was 63 months, and 48 months in the group of dissimilar histology (n= 12) (P= 0.63). The mean survival in the group of early stage (n= 21) was 68 months and 15 months in the group of advanced stage (n= 6) with statistic significance (P= 0.0003). However, the impact of adjuvant therapy on survival did not reach statistic significance (P= 0.15 for chemotherapy; P= 0.69 for radiotherapy). We conclude that the majority of the patients belonged to concordant endometrioid histology in endometrium and ovary, and it tends to be early stage and low grade with favorable prognosis. The stage had more significant influence on the survival than the histology. Adjuvant therapy should be given especially in patients with advanced stage although the optimal management remained to be determined.

Metastatic spread of gynaecological neoplasms to the adrenal gland: case reports with a review of the literature

Metastatic involvement of the adrenal glands due to gynaecological neoplasms is a relatively rare condition. The aim of our study was to present four cases of metastases to the adrenal gland due to endometrial adenocarcinoma, ovarian and cervical cancer. These cases are correlated with a review of the literature. CT scan and MRI have been previously used in an attempt to define the nature of the adrenal mass but this approach is of limited value in diagnosis. Image-guided pathological confirmation of an adrenal lesion may significantly change the staging or management of the primary neoplasm. The authors suggest that isolated adrenal metastasis should be routinely considered for surgical management.

Omental metastases in clinical stage I endometrioid adenocarcinoma

The clinical benefit of an omentectomy in endometrioid adenocarcinoma is unclear. The objective of this study was to clarify the significance of an omentectomy performed for clinical stage I endometrioid adenocarcinoma. A prospective study was performed on 134 patients with clinical stage I endometrioid adenocarcinoma who underwent omentectomy in addition to a staging laparotomy between 1998 and 2004: simple total hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, and peritoneal cytology. The frequency and prognosis of omental metastases and their relationships with extrauterine spread to other sites were investigated. Omental metastasis was noted in four patients (3.0%). As for extrauterine spread, the positivity rate of lymph node metastases was 13/128 (10.2%), peritoneal cytology was 13/133 (9.8%), and adnexal metastases was 10/134 (7.5%). Omental metastases correlated with peritoneal cytology and adnexal metastases (P < 0.05 for both); however, two of the omental metastases-positive patients were peritoneal cytology negative. All omental metastases-positive patients died shortly after surgery, showing that their prognosis was poor. The omental metastases rate for clinical stage I endometrioid adenocarcinoma was lower than the positive rates for extrauterine spread to other sites; thus, the routine application of omentectomy as a part of a staging laparotomy may not be efficacious. However, omental metastases are a significant poor prognostic factor, and intraoperative examination of the omentum by close inspection and palpation as well as pathologic examination, if possible, may be indicated.

Involvement of SDF-1alpha/CXCR4 axis in the enhanced peritoneal metastasis of epithelial ovarian carcinoma

Epithelial ovarian carcinoma (EOC) spreads by implantation of tumor cells onto the human peritoneal mesothelial cells (HPMCs) lining the peritoneal cavity. The aim of this study was to determine whether the stromal cell-derived factor-1alpha (SDF-1alpha)/CXCR4 axis is involved in the interaction of EOC cells with HPMCs in peritoneal metastasis. Clinically, we first evaluated CXCR4 expression in sections from 36 primary EOCs using immunohistochemistry. We next examined whether SDF-1alpha played roles in EOC progression, including in proliferation, cell motility, attachment to HPMCs, and the in vivo development of peritoneal metastasis through CXCR4. Of the 36 carcinomas, 16 cases (44.4%) were positive for CXCR4 immunoexpression. Positive CXCR4 expression significantly predicted poorer overall survival compared with negative expression (p = 0.0069). We found CXCR4 expression in both EOC cells and HPMCs. In contrast, the level of production of SDF-1alpha by HPMCs was higher than that by various EOC cells. Functionally, SDF-1alpha induced enhanced attachment between ES-2 cells and HPMCs or extracellular matrix components. The enhancement of adhesion potential by SDF-1alpha was inhibited by AMD3100, a CXCR4 antagonist, and by phosphatidylinositol 3 kinase and p44/42 inhibitors. Furthermore, intraperitoneal treatment with AMD3100 resulted in reduced dissemination in nude mice inoculated with ES-2 cells. The present results suggest that there may be a link between the SDF-1alpha/CXCR4 axis and enhanced intraperitoneal dissemination of EOC and that CXCR4 may be a novel target for the treatment of EOC.

Treatment of pulmonary recurrences in patients with endometrial cancer

OBJECTIVE

To assess the treatment and outcome of patients with endometrial cancer following isolated pulmonary relapse.

METHODS

Between 1984 and 1996, 82 of 1109 patients undergoing surgery for primary endometrial cancer experienced a primary pulmonary recurrence, 28 of which were solitary. Median follow up of censored patients after isolated pulmonary recurrence was 159 months.

RESULTS

Grade 1/2 disease, pulmonary nodule size <2 cm, and the presence of estrogen receptors (ER) were significant (p<0.05) predictors of improved disease specific survival (DSS) in the 28 patients with an isolated lung recurrence. Median DSS for the 11 patients with grade 1/2 tumors and pulmonary nodules measuring </=2 cm was 98 months. Treatment with hormonal therapy, surgery, or combination therapy was not predictive of survival after recurrence. In contrast, median DSS for patients treated with chemotherapy was 14 months vs. 28 months for those treated with other modalities (p=0.04). Median DSS was 28 months for patients treated with hormonal therapy compared to 18 months for those who underwent surgical resection (p=NS).

CONCLUSION

Patients with grade 1/2 endometrial cancer and isolated pulmonary recurrences measuring less than 2 cm have appreciable median DSS, 98 months in this series. Treatment with chemotherapy appears to be associated with poor outcomes, but this finding was likely to be confounded by indication. Compared to treatment with hormonal therapy, thoracotomy was not associated with a survival advantage. Although potentially confounded by selection bias, these data suggest that initial hormonal therapy may offer the greatest risk/benefit ratio for patients with low grade isolated pulmonary failures.

Lack of prognostic significance of HER-2/neu in early epithelial ovarian cancer

A total of 74 patients with apparent early stage epithelial ovarian cancer who underwent exploratory laparotomy at King Chulalongkorn Memorial Hospital or other hospitals and were referred for further treatment, were evaluated. Formalin fixed paraffin-embedded ovarian tissue specimens were collected and immuno-stained with HER-2/neu antibodies for comparison with clinicopathologic data after median follow up of 46 months (range 3 - 83 months). The prevalence of HER-2/neu overexpression in these patients was 10.2%. No significant correlation between HER-2/neu overexpression and clinicopathological parameters (stage, ascites, capsular rupture, capsular adherence, histological subtype and histological grade) was found. Disease free survival and overall survival did not statistically differ between those with lesions positive or negative for HER-2/neu overexpression.

The efficacy of tamoxifen in patients with advanced epithelial ovarian cancer

BACKGROUND

Activity of tamoxifen as a salvage therapy in patients with advanced epithelial ovarian cancer was evaluated by a number of studies. In this study, we evaluated efficacy of tamoxifen in our patients with platinum-resistant epithelial ovarian carcinoma.

PATIENTS AND METHODS

A retrospective analysis was conducted of patients who received tamoxifen at a dose 20 mg twice daily for the treatment of advanced epithelial ovarian cancer.

RESULTS

Twenty-nine eligible patients were included to the study. There were 1 (3%) complete response, 2 (7%) partial response, 6 (21%) stable disease, and 20 (69%) progressive disease. All patients were progressed after initiation of tamoxifen. Median progression-free survival was 4 mo (95% CI: 2.98-5.02). Disease progression of 19 (65%) patients were shown within the first 6 mo after initiation of tamoxifen. Progression-free survival was between 6 and 12 mo for 7 (24%) patients and > or =12 mo for 3 (10%) patients. The median survival after initiation of tamoxifen was 15 mo (95% CI: 7.2-22.8). No toxicity attributable to tamoxifen was seen in any of the patients. The only independent prognostic factor that had a significant predictive value for progression- free survival was the response to tamoxifen treatment (p = 0.043, hazard ratio: 0.12, 95% CI: 0.01-0.94).

CONCLUSION

Considering minimal side effects and ability to cause objective responses, there is a place for tamoxifen in treatment of patients with platinum-resistant ovarian cancer. A phase III trial is required to con- firm the value of the drug in patients presenting these clinical settings.

Endometrial carcinoma recurring as carcinosarcoma: Report of two cases

Endometrial carcinosarcoma is a rare, aggressive disease, accounting for approximately 3% of all uterine neoplasms. The emergence of sarcomatous elements is considered the evolution of subclones arising from high grade endometrial carcinomas. Here, we report two cases of primary endometrial carcinomas recurring as carcinosarcoma. Case 1. a 58-year-old postmenopausal woman diagnosed to have a poorly differentiated endometrial endometrioid adenocarcinoma (FIGO stage IB) developed an intra-abdominal recurrence of disease after 17 months from diagnosis. Histopathological analysis documented a biphasic neoplasia consisting of an epithelial (grade 3 endometrial endometrioid adenocarcinoma) and a sarcomatous component. Salvage chemotherapy with cisplatin, ifosfamide, epirubicin, and then with taxotere was attempted. The patient died after 2 months. Case 2. A 56-year-old woman with a diagnosis of grade 3 endometrial adenosquamous carcinoma of the endometrium (FIGO stage IIIA) experienced pelvic recurrence after five months from completion of chemotherapy. Definitive histology was malignant mixed mesodermal tumor with focal areas of chondrosarcomatous elements. The patient was triaged to exclusive concomitant chemoradiotherapy and salvage chemotherapy. The patient died after 3 months. We describe two cases of high grade endometrial carcinomas recurring as carcinosarcoma, thus providing evidence that the metaplastic sarcomatous evolution is a very rare event which can occur in patients with anaplastic endometrial cancer.

Clinicopathologic Analysis of 187 High-grade Endometrial Carcinomas of Different Histologic Subtypes: Similar Outcomes Belie Distinctive Biologic Differences

The clinical and histopathologic features of 187 high-grade endometrial cancers [FIGO grade 3 endometrioid (EC-3), serous (SC), and clear cell (CC)] were studied to determine whether clinicopathologic differences between these various histologic subtypes existed. The study group consisted of 89 EC-3s, 61 SCs, and 37 CCs. Treatment regimens were individualized. SCs and CCs were significantly more likely than EC-3s to occur in patients older than 65 years (P=0.03), and SCs tended to occur more frequently in patients of African descent than EC-3s and CCs (P=0.07), although this was not statistically significant. EC-3s had the highest rate of associated endometrial hyperplasia (P=0.05). SCs were most likely to have high-stage disease at presentation (>or=stage IIB; P=0.01), with peritoneal dissemination at diagnosis being much more common compared with EC-3s and CCs (P=0.004). Median follow-up was 39 months, and median overall survival was 47 months. Five-year survivals were 45% (EC-3), 36% (SC), and 50% (CC)-differences that were not statistically significant. In contrast, the impact of stage on survival was significant (P<0.001). Among all other factors evaluated, only age greater than 65 years was a negative predictor (risk ratio, 2.23; P<0.001), whereas a family history of cancer reduced the risk of death when controlling for stage (risk ratio, 0.54; P=0.005). When controlling for stage, race, reproductive history, personal history of cancer, histologic subtype, depth of myometrial invasion, lymphovascular invasion, presence of an endometrial polyp, presence of hyperplasia, or staging adequacy did not affect prognosis. High-grade endometrial cancers of different histologic subtypes treated in an individualized manner are associated with similar clinical outcomes, but differences in age at presentation, race distribution, association with hyperplasia, stage, and sites of tumor dissemination support the idea that these represent distinct disease entities as defined by traditional histopathologic classification of endometrial cancers.

Yolk sac tumor of the ovary associated with endometrioid carcinoma with metastasis to the vagina: A case report

BACKGROUND

Mixed yolk sac tumors of the ovary are biologically aggressive even in early stage disease.

CASE

A 41-year-old woman presented with a large pelvic mass and anterior vaginal wall tumor. At surgery vaginal biopsies were performed followed by an exploratory laparotomy with resection of the mass. Pathology of the ovary revealed a primary yolk sac tumor associated with poorly differentiated endometrioid and undifferentiated carcinoma with vaginal metastasis only. She was initiated on bleomycin, etoposide, and cisplatin, with three additional cycles of etoposide and cisplatin. Initially the patient experienced a complete response, however her disease recurred and she currently is dead of her disease.

CONCLUSION

To our knowledge this is the first case of a mixed ovarian germ cell tumor with vaginal metastasis.

Use of preoperative serum CA-125 levels for prediction of lymph node metastasis and prognosis in endometrial cancer

BACKGROUND

The purpose of this study was to evaluate the predictive value of preoperative serum CA-125 levels in the assessment of disease extent and clinical outcome of endometrial cancer.

METHOD

This retrospective study evaluated 92 women with pathologically proven endometrial carcinoma scheduled for treatment that had preoperative serum CA-125 levels between January 1999 and February 2006. The association of preoperative serum CA-125 with a variety of histopathologic factors was evaluated. Statistical analysis was performed using chi2/Fisher's exact test and a logistic regression. Survival was studied with the Kaplan-Meier method and Cox regression models.

RESULTS

Elevated serum CA-125 levels were significantly correlated with advanced-stage disease (p<0.001), lymph node metastases (p<0.001), increased depth of myometrial invasion (p=0.001), and positive peritoneal cytology (p=0.026). Multivariate analyses using logistic regression showed that lymph node metastases had the most significant effect on the elevation of preoperative serum CA-125 levels (p=0.004). Patients with a serum CA-125 < or =28.5 U/ml had a significantly better five-year disease-free survival than those with an elevated level in this study: 85.6% versus 60.0% (p=0.004).

CONCLUSIONS

The preoperative serum CA-125 level appears to be a significant independent predictor of lymph node metastasis and prognosis after surgical intervention. Therefore, preoperative serum CA-125 may be a useful tool, in the clinical setting, for optimal individualized patient management.

A pilot study of sentinel lymph nodes identification in patients with endometrial cancer

PURPOSE

The purpose of this study was to investigate the feasibility of sentinel lymph node (SLN) identification in patients with endometrial cancer.

METHODS

Twenty patients with endometrial cancer undergoing hysterectomy and lymphadenectomy were included in the study. At laparotomy, methylene blue dye was injected into the subserosal myometrium of corpus uteri at multiple sites. Dye uptake into lymphatic channels was observed and blue nodes were identified as SLNs. The SLNs were biopsied before lymphadenectomy performed. The samples of SLNs and non-SLNs were recorded separately and correlated with the final pathological results.

RESULTS

Dye uptake into lymphatic channels was seen in all 20 cases. Among them, SLN was identified in 15 (75%) cases. A total of 71 SLNs with a mean number of 4.7 SLN (range, 1-10) were identified from all pelvic sites. The most frequent locations of SLNs included obturator in 29 (41%), interiliac in 16 (26%). No dye-containing paraaortic nodes were found. Two patients (10%) had nodal metastases, and they all had at least one SLN found to be positive. No adverse reactions or injures were attributed to the study.

CONCLUSIONS

This study shows the feasibility and safety of SLN identification with blue dye in patients with endometrial cancer undergoing staging surgery. The approach might provide an alternative to limit the extent of nodal sampling.

[Advanced ovarian cancer with Sister Mary Joseph's nodule--a case report]

A metastatic umbilical tumor,which we call Sister Mary Joseph's nodule (SMJN), is a sign of poor prognosis despite the primary site of malignant tumor. We describe here a patient with an advanced ovarian cancer and SMJN. A 51-year-old woman was referred to our department for evaluation of an umbilical tumor. As a result of systemic examination, the patient was diagnosed as stage IV ovarian cancer and rapidly underwent an optimal operation. Postoperatively, the chemotherapy for advanced ovarian tumors was begun (paclitaxel 180 mg/m(2) and carboplatin AUC 5, 10 courses every 3 weeks). The patient is well without signs of tumor recurrence or metastasis 10 months after the operation. Forty percent of all navel neoplasms are malignant tumors. It is important to perform a pathological examination of a navel neoplasm or a systemic examination as fast as possible.

Endometrioid Carcinoma Simultaneously Involving the Uterus and the Fallopian Tube

Although the simultaneous presentation of endometrial and ovarian carcinomas of the endometrioid type is well described, little is known about a similar phenomenon involving the endometrium and fallopian tube (FT). We present the clinicopathologic features of 13 such cases seen in the Department of Pathology at The University of Texas M.D. Anderson Cancer Center over an 8 year period (1995 to 2002). FT tumors that could have represented luminal extension of the endometrial carcinoma or that represented an unequivocal metastasis to the FT were excluded. The patients' ages ranged from 34 to 77 years (median 54). The most common symptom was abnormal uterine/vaginal bleeding (11) and all of the patients were considered overweight or obese (mean body mass index was 41). The size of the endometrial carcinomas ranged from 0.3 to 8 cm. According to the FIGO grading of the endometrial endometrioid carcinomas, the cases were distributed as follows: Grade 1 (3) and Grade 2 (10). In 2 cases, there were also small areas of other histologic types, papillary serous carcinoma (1 case), and papillary endometrial carcinoma of intermediate grade (another case). The size of the fallopian tube carcinomas ranged from 0.2 to 17.5 cm. Seven of these tumors were located in the distal/fimbriated end of the FT. There was bilateral involvement in 2 cases. Three of the FT tumors were in situ. The grades of the fallopian tube carcinomas were as follows: Grade 1 (2), Grade 2 (6), and Grade 3 (2). In situ components were seen in all cases. One fallopian tube carcinoma was mixed with serous carcinoma. In 4 cases, there was also an endometrioid carcinoma involving the ovary, all of them with an intact ovarian capsule. Patients were treated as follows: total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH/BSO) (4), TAH/BSO/chemotherapy (chemo) (4), TAH/BSO/radiation (3), and TAH/BSO/chemo/radiation (2). Follow-up ranging from 6 to 54 months was available in 10 patients: 1 patient died of disease (at 38 mo), 1 patient is alive with disease (at 9 mo), 7 patients have no evidence of disease (6 to 54 mo), and 1 patient died of metastatic endometrial carcinoma (at 9 mo). Simultaneous endometrioid carcinomas of the uterus and FT are unusual and occur primarily in obese perimenopausal women. The tumors are predominantly well or moderately differentiated with dissimilar endometrial and FT grades. The FT carcinoma is usually unilateral and located at the distal end of the tube.

Prediction of lymph node metastasis in patients with endometrioid endometrial cancer using expression microarray

PURPOSE

To characterize the gene expression profiles of endometrioid endometrial cancers associated with lymph node metastasis in an effort to identify genes associated with metastatic spread.

EXPERIMENTAL DESIGN

Tumors from 41 patients with endometrioid endometrial cancer grossly confined to the uterine cavity were evaluated. Positive lymph nodes were noted in 12 of 41 patients. RNA was analyzed for gene expression using the Affymetrix HG133A and HG133B GeneChip set, representing 45,000 array features covering >28,000 UniGene clusters. Data analysis was done using multidimensional scaling, binary comparison, and hierarchical clustering. Gene expression for several differentially expressed genes was examined using quantitative PCR.

RESULTS

Gene expression data was obtained from 30,964 genes that were detected in at least 5% of the cases. Supervised analysis of node-positive versus node-negative cases indicated that 450 genes were significantly differentially expressed between the two classes at P < 0.005, 81 of which were differentially expressed by at least 2-fold at P < 0.005. Overexpressed genes included two cell cycle checkpoint genes, CDC2 and MAD2L1, which have previously been described in association with lymph node metastasis in other cancer types. The ZIC2 zinc finger gene was overexpressed in endometrial cancers with positive nodes versus those with negative nodes.

CONCLUSION

Gene expression profiling of the primary tumors in patients with endometrioid endometrial cancers seems promising for identifying genes associated with lymph node metastasis. Future studies should address whether the status of nodal metastasis can be determined from the expression profiles of preoperative tissue specimens.

Laparoscopic surgery does not increase the positive peritoneal cytology among women with endometrial carcinoma

OBJECTIVE

The purpose of our study was to find if uterine manipulation at the time of laparoscopic hysterectomy among women with endometrial carcinoma increases the incidence of malignant cells in the peritoneal washings.

MATERIAL AND METHODS

We conducted a prospective study including women with clinical stage I endometrioid endometrial carcinoma undergoing laparoscopic surgery between 07/01/2000 and 07/01/2004. Surgery on all patients was conducted by the same surgeon using the same technique and instruments. Two sets of peritoneal washings were obtained, one before and one after the insertion of the Pelosi uterine manipulator. The two sets of washings were blindly reviewed by the same cytopathologist for the presence of malignant cells. Correlation was made between the two sets of washings.

RESULTS

Forty-two consecutive women (age 46-90, median: 58) were enrolled in the study. The procedure was converted to laparotomy in 3 (7.6%) patients after obtaining the two sets of washings. The preoperative tumor grades were: G1: 22 (52.4%), G2: 12 (28.6%), and G3: 8 (19.0). The incidence of positive peritoneal washings was 14.3%. All patients underwent laparoscopically assisted vaginal hysterectomy with bilateral salpingo-oophorectomy, 30 patients had bilateral pelvic lymphadenectomy, and 5 patients had bilateral pelvic and para-aortic lymphadenectomy. There was perfect agreement between the two sets of washings in all patients (100%, P < .001). No patients had positive washings after the insertion of the uterine manipulator if the washings were negative before the insertion. The surgical stages were: IA: 14 (33.3%), IB: 12 (28.6%), IC: 7 (16.7%), IIA: 1 (2.4%), IIB: 1 (2.4%), IIIA: 4 (9.5%), IIIB: 1 (2.4%), IIIC: 1 (2.4%), and IV: 1 (2.4%). Twenty-nine patients received no postoperative treatment, 2 received chemotherapy, 3 received Megace, and 9 received radiation therapy. Patients were followed-up for 7-56 months (median: 28). Two patients had tumor recurrence, and one patient died secondary to her disease. Two other patients died secondary to other causes.

CONCLUSIONS

We conclude that uterine manipulation at the time of laparoscopic hysterectomy does not increase the incidence of positive peritoneal cytology among women with endometrial carcinoma.

Histopatological aspects of endometroid carcinoma in correlation to the state of tumoral progression in women patients during their premenopausal period

The performed study has comprised a number of 60 endometrial carcinomas, prevailed from women aged in the premenstrual period, in whose cases we have followed also the appreciation of the differentiating grading as well as the various aspects in neoplasies progression. The appreciation of the differentiating grading has allowed their placing as it follows: 39 cases of endometroid carcinoma well differentiated, seven cases of endometroid carcinoma mildly differentiated and five cases of endometroid carcinoma poorly differentiated. The correlation of the differentiating grading with the stage of tumoral progression has allowed the observation of the fact that while well invasive differentiated endometroid adenocarcinoma have been limited to the level of the uterine body, mildly and poorly differentiated invasive endometroid carcinoma besides profound myometrial invasion have associated cervical invasion and metastasis in structures situated at a real distance.

Third stage ovarian carcinoma--case report: the necessity of a multidisciplinary approach to treatment

Ovarian carcinoma, part of a heterogeneous group of tumours, is the main cause of death by gynaecological neoplasms. The diagnosis, in general, is delayed. Multiorgan diffusion, the necessity of a surgical operation and strong chemotherapy, and the eventual pathology due to patient age are all factors that require a multidisciplinary approach. In fact the case, here reported, refers to a patient who came under our observation for a bilateral ovarian mass discovered casually during an abdominal ultrasound exam carried out for renal colic. Excellent cytoreduction with peritoneal cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy (Figure 2), bilateral pelvic lymphadenectomy, total omentectomy, removal of nodules from the mesentery, the colon and three nodules in the abdominal wall thickness was executed. The histological report was G3, angioinvasive bilateral ovarian endometrioid adenocarcinoma. Metastasis was found only in one left obturator lymph node out of 17 lymph nodes removed. All of the removed abdominal, mesenteric and intestinal nodules were neoplastic. It is concluded that the complexity of similar cases always requires a multidisciplinary approach as in our case, involving an oncologist, hematologist, surgeon, gynaecologist, radiologist, anaesthesiologist, and nursing staff in the management of third stage ovarian cancer patients to obtain the best treatment thus guaranteeing a higher survival rate and better quality of life.

Ovarian endometrioid carcinoma with diffuse pigmented peritoneal keratin granulomas: a case report and review of the literature

The presence of keratin granulomas in peritoneal cavity associated with ovarian endometrioid carcinoma, which might be related to leakage from the ovarian tumor, is rarely reported. Its clinical significance has not yet been well investigated. We report a case presenting with intermittent abdominal pain after an acute episode 1 month before a complex adnexal tumor was noted. Comprehensive cytoreductive surgery was performed. The ovarian tumor was an endometrioid adenocarcinoma with squamous differentiation. There were diffuse brownish flecks over the omental surface and pelvic peritoneum, which contained fragments of degenerated squamous cells, keratin, and numerous foreign body giant cells. Extensive multiple sections were examined for these implants. DNA flow cytometry and various immunostaining studies (HER-2/neu, p53, CK-7, and cytokeratin [AE1/AE3]) were performed. Since viable epithelial cells in the implants could be differentially identified against mesothelial or granulomatous components by CK-7 staining and DNA aneuploidy was demonstrated on primary ovarian tumor, four courses of chemotherapy were administered. The patient has been free of disease for 18 months since diagnosis.