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Shiwani H, Clement NS, Daniels JP, Atiomo W. Metformin for endometrial hyperplasia. Cochrane Database Syst Rev 2024; 5:CD012214. [PMID: 38695827 PMCID: PMC11064888 DOI: 10.1002/14651858.cd012214.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
BACKGROUND Endometrial cancer is one of the most common gynaecological cancers in the world. Rates of endometrial cancer are rising, in part because of rising obesity rates. Endometrial hyperplasia is a precancerous condition in women that can lead to endometrial cancer if left untreated. Endometrial hyperplasia occurs more commonly than endometrial cancer. Progesterone tablets that are currently used to treat women with endometrial hyperplasia are associated with adverse effects in up to 84% of women. A levonorgestrel intrauterine device may improve compliance, but it is invasive, is not acceptable to all women, and is associated with irregular vaginal bleeding in 82% of cases. Therefore, an alternative treatment for women with endometrial hyperplasia is needed. Metformin, a drug that is often used to treat people with diabetes, has been shown, in some human studies, to reverse endometrial hyperplasia. However, the effectiveness and safety of metformin for treatment of endometrial hyperplasia remain uncertain. This is an update of a review first published in 2017. OBJECTIVES To determine the effectiveness and safety of metformin in treating women with endometrial hyperplasia. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility Specialised Register, CENTRAL, MEDLINE, PubMed, Embase, Google Scholar, OpenGrey, LILACS, and two trials registers from inception to 5 September 2022. We searched the bibliographies of all relevant studies, and contacted experts in the field for any additional trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) and cross-over trials comparing metformin (used alone or in combination with other medical therapies) versus placebo, no treatment, any conventional medical treatment, or any other active intervention for women with histologically confirmed endometrial hyperplasia of any type. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for eligibility, extracted data from included studies, assessed the risk of bias in the included studies, and assessed the certainty of the evidence for each outcome. We resolved disagreements by discussion or by deferring to a third review author. When study details were missing, review authors contacted the study authors. The primary outcome of this review was regression of endometrial hyperplasia histology (with or without atypia) towards normal histology. MAIN RESULTS We included seven RCTs, in which a total of 387 women took part. In the comparison, Metformin plus megestrol versus megestrol alone, we rated the certainty of the evidence as low for the outcome, regression of endometrial hyperplasia. We rated the quality of the evidence as very low for the rest of the outcomes, in all three comparisons. Although there was a low risk of selection bias, there was a high risk of bias in the blinding of personnel and outcome assessment (performance bias and detection bias) in many studies. This update identified four new RCTs and six ongoing RCTs. Metformin versus megestrol We are uncertain whether metformin increases the regression of endometrial hyperplasia towards normal histology over megestrol (odds ratio (OR) 4.89, 95% confidence interval (CI) 1.56 to 15.32; P = 0.006; 2 RCTs, 83 participants; I² = 7%; very low-certainty evidence). This evidence suggests that if the rate of regression with megestrol is 61%, the rate of regression with metformin would be between 71% and 96%. It is unresolved whether metformin results in different rates of abnormal uterine bleeding or hysterectomy compared to megestrol. No study in this comparison reported progression of hyperplasia to endometrial cancer, recurrence of endometrial hyperplasia, health-related quality of life, or adverse effects during treatment. Metformin plus megestrol versus megestrol monotherapy The combination of metformin and megestrol may enhance the regression of endometrial hyperplasia towards normal histology more than megestrol alone (OR 3.27, 95% CI 1.65 to 6.51; P = 0.0007; 4 RCTs, 258 participants; I² = 0%, low-certainty evidence). This suggests that if the rate of regression with megestrol monotherapy is 54%, the rate of regression with the addition of metformin would be between 66% and 84%. In one study, 3/8 (37.5%) of participants who took metformin had nausea that settled without further treatment. It is unresolved whether the combination of metformin and megestrol results in different rates of recurrence of endometrial hyperplasia, progression of endometrial hyperplasia to endometrial cancer, or hysterectomy compared to megestrol monotherapy. No study in this comparison reported abnormal uterine bleeding, or health-related quality of life. Metformin plus levonorgestrel (intrauterine system) versus levonorgestrel (intrauterine system) monotherapy We are uncertain whether there is a difference between groups in the regression of endometrial hyperplasia towards normal histology (OR 0.29, 95% CI 0.01 to 7.56; 1 RCT, 46 participants; very low-certainty evidence). This evidence suggests that if the rate of regression with levonorgestrel monotherapy is 96%, the rate of regression with the addition of metformin would be between 73% and 100%. It is unresolved whether the combination of metformin and levonorgestrel results in different rates of abnormal uterine bleeding, hysterectomy, or the development of adverse effects during treatment compared to levonorgestrel monotherapy. No study in this comparison reported recurrence of endometrial hyperplasia, progression of hyperplasia to endometrial cancer, or health-related quality of life. AUTHORS' CONCLUSIONS Review authors found insufficient evidence to either support or refute the use of metformin, specifically megestrol acetate, given alone or in combination with standard therapy, for the treatment of women with endometrial hyperplasia. Robustly designed and adequately powered randomised controlled trials, yielding long-term outcome data are still needed to address this clinical question.
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Affiliation(s)
- Hunain Shiwani
- Faculty of Population Health Sciences, University College London, London, UK
| | - Naomi S Clement
- Department of Obstetrics & Gynaecology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jane P Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - William Atiomo
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
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Zheng C, Wang Y, Bi B, Zhou W, Cao X, Zhang C, Lu W, Sun Y, Qu J, Lv W. Gallic acid ameliorates endometrial hyperplasia through the inhibition of the PI3K/AKT pathway and the down-regulation of cyclin D1 expression. J Pharmacol Sci 2024; 155:1-13. [PMID: 38553133 DOI: 10.1016/j.jphs.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 02/07/2024] [Accepted: 02/27/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Gallic acid (GA) is an organic compound with phenolic properties that occurs naturally and can be found in Guizhi Fuling capsules, showcasing a wide range of biological functionalities. PURPOSE The objective of this study was to examine the influence of GA on endometrial hyperplasia (EH) and elucidate its underlying mechanism. METHODS Initially, the induction of EH was achieved by administering estradiol to mice via continuous subcutaneous injection for a duration of 21 days. Concurrently, GA treatment was administered, and subsequently, the uterine tissue structure was assessed using hematoxylin and eosin (H&E) staining. Following this, the proliferation of human endometrial cells treated by GA was determined utilizing the CCK-8 method. Furthermore, network pharmacology and single-cell-RNA-seq data were employed to identify the target of GA action. In addition, we will employ immunofluorescence (IF), immunohistochemistry (IHC), flow cytometry, western blot and RT-qPCR methodologies to investigate the impact of GA on the expression level of cyclin D1, PI3K, p-PI3K, AKT, p-AKT. RESULTS GA treatment ameliorated histopathological alterations in the uterus and suppress proliferation. Estradiol stimulation can activate the PI3K/AKT pathway, leading to up-regulation of cyclin D1 expression, whereas GA treatment results in down-regulation of its expression. CONCLUSIONS The expression of cyclin D1 is down-regulated by GA through the inhibition of the PI3K/AKT pathway, effectively mitigating estradiol-induced EH in mice.
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Affiliation(s)
- Caijie Zheng
- The Second Clinical School of Zhejiang Chinese Medicine University, Hangzhou, 310053, China
| | - Yi Wang
- Colon and Rectal Surgery, Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, 210001, China
| | - Beilei Bi
- Department of Gynecology, Tongde Hospital of Zhejiang Province, 234 Gucui Road, Hangzhou, 310012, China
| | - Wencheng Zhou
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, 310006, China
| | - Xinran Cao
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, 163 Xianlin Avenue, Nanjing, 210023, China
| | - Chenyang Zhang
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, 163 Xianlin Avenue, Nanjing, 210023, China
| | - Wentian Lu
- The First Clinical Medical College, Nanjing University of Chinese Medicine, 155 Hanzhong Road, Nanjing, Jiangsu, 210029, China
| | - Yang Sun
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, 163 Xianlin Avenue, Nanjing, 210023, China; Jiangsu Collaborative Innovation Center of Traditional Chinese Medicine in Prevention and Treatment of Tumor, Nanjing, Jiangsu, 210029, China.
| | - Jiao Qu
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, 163 Xianlin Avenue, Nanjing, 210023, China.
| | - Wen Lv
- Department of Gynecology, Tongde Hospital of Zhejiang Province, 234 Gucui Road, Hangzhou, 310012, China.
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Olowofolahan A, Fatunsin O, Olorunsogo O. Modulatory effect of ciprofloxacin, a broad spectrum antibacterial drug, on mPT pore using rat model with estradiol benzoate-induced endometrial hyperplasia. Naunyn Schmiedebergs Arch Pharmacol 2024; 397:3331-3341. [PMID: 37943297 DOI: 10.1007/s00210-023-02824-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 10/27/2023] [Indexed: 11/10/2023]
Abstract
Mitochondrial permeability transition (mPT) pore has become a motive for drug evolvement pertinent to dysregulated apoptosis situations. Some chemical compounds impede tumor/cancer via the inception of mPT pore opening. Ciprofloxacin has been demonstrated to hinder growth and effect apoptosis in some cancer cells. However, using a rat model, this study investigated its effect on mitochondrial-mediated cell death via mPT pore opening and estradiol benzoate (EB)-induced endometrial hyperplasia. Mitochondria were isolated using differential centrifugation. The opening of the pore, cytochrome c release (CCR), mitochondrial ATPase (mATPase) activity, mitochondrial lipid peroxidation (mLPO), caspases 3 and 9 levels, and hepatic DNA fragmentation were determined. Histological evaluation of hepatic and uterine sections and immunoexpression levels of Bax, caspase 3, and anti-apoptotic Bcl-2 levels were quantified. The results show that ciprofloxacin caused mPT pore opening, CCR, mATPase activity, effected mLPO, caspases 3 and 9 activations, and hepatic DNA fragmentation. The histology of the liver section showed moderate to marked disseminated congestion at 100 mg/kg, while higher doses showed severe hepatic damage. Severe EH was detected in the EB-treated rats which was attenuated by ciprofloxacin in the treatment group. The Bax and caspase expressions were upregulated by ciprofloxacin while anti-apoptotic Bcl-2 was downregulated. Ciprofloxacin induces mitochondrial-mediated cell death via mPT pore opening and mitigates EB-induced EH in rat models via Bax/caspase/Bcl-2 signaling pathway.
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Affiliation(s)
- Adeola Olowofolahan
- Laboratories for Biomembrane Research and Biotechnology, Department of Biochemistry, Faculty of Basic Medical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria.
| | - Omowumi Fatunsin
- Laboratories for Biomembrane Research and Biotechnology, Department of Biochemistry, Faculty of Basic Medical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Olufunso Olorunsogo
- Laboratories for Biomembrane Research and Biotechnology, Department of Biochemistry, Faculty of Basic Medical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
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Gallo A, Di Spiezio Sardo A, Conforti A, Iorio GG, Zizolfi B, Buonfantino C, De Angelis MC, Strina I, Marrone V, Bifulco G, Alviggi C. Assessing ovarian stimulation with letrozole and levonorgestrel intrauterine system after combined fertility-sparing approach for atypical endometrial lesions: a retrospective case-control study. Reprod Biomed Online 2024; 48:103750. [PMID: 38430660 DOI: 10.1016/j.rbmo.2023.103750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/23/2023] [Accepted: 11/23/2023] [Indexed: 03/05/2024]
Abstract
RESEARCH QUESTION Is ovarian stimulation with levonorgestrel intrauterine system (LNG-IUS) in situ and co-treatment with letrozole safe and effective in patients undergoing fertility-sparing combined treatment for atypical endometrial hyperplasia (AEH) or early endometrial cancer limited to the endometrium? DESIGN Retrospective case-control study recruiting women who had undergone fertility-sparing 'combined' treatment and ovarian stimulation with letrozole and LNG-IUS in situ. The 'three steps' hysteroscopic technique was used. Once complete response was achieved, the ovaries were stimulated, and mature oocytes cryopreserved. The LNG-IUS was removed, and embryos transferred. A comparative analysis was conducted between the two control groups of the initial outcomes of ART (number of oocytes and MII oocytes retrieved): healthy infertile women undergoing ovarian stimulation for IVF/ICSI (control group A); and patients diagnosed with breast cancer who underwent ovarian stimulation with letrozole (control group B). RESULTS Of the 75 patients analysed, 15 underwent oocyte cryopreservation after achieving a complete response to fertility-sparing treatment (study group); 30 patients in control group A and B, respectively. No statistically significant differences were observed in retrieved oocytes and mature oocytes between the study and control groups. In the nine patients who underwent embryo transfer, clinical pregnancy (55.6%), cumulative live birth (44.4%) and miscarriage (20%) rates were reported. In three patients with AEH, recurrence occurred (12%) at 3, 6 and 16 months after removing the LNG-IUS to attempt embryo transfer, respectively. CONCLUSION Fertility-sparing hysteroscopic combined treatment and subsequent ovarian stimulation with letrozole and LNG-IUS in situ could be suggested to women with AEH or early endometrial cancer who ask for future fertility preservation.
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Affiliation(s)
- Alessandra Gallo
- University of Naples 'Federico II'. Department of Public Health. School of Medicine. Naples, Italy
| | - Attilio Di Spiezio Sardo
- University of Naples 'Federico II'. Department of Public Health. School of Medicine. Naples, Italy
| | - Alessandro Conforti
- University of Naples "Federico II". Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine. Naples, Italy.
| | - Giuseppe Gabriele Iorio
- University of Naples "Federico II". Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine. Naples, Italy
| | - Brunella Zizolfi
- University of Naples 'Federico II'. Department of Public Health. School of Medicine. Naples, Italy
| | - Cira Buonfantino
- University of Naples 'Federico II'. Department of Public Health. School of Medicine. Naples, Italy
| | - Maria Chiara De Angelis
- University of Naples 'Federico II'. Department of Public Health. School of Medicine. Naples, Italy
| | - Ida Strina
- University of Naples 'Federico II'. Department of Public Health. School of Medicine. Naples, Italy
| | - Vincenzo Marrone
- University of Naples 'Federico II'. Department of Public Health. School of Medicine. Naples, Italy
| | - Giuseppe Bifulco
- University of Naples 'Federico II'. Department of Public Health. School of Medicine. Naples, Italy
| | - Carlo Alviggi
- University of Naples 'Federico II'. Department of Public Health. School of Medicine. Naples, Italy
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5
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Lv X, Guo L, Wang C. Efficacy of fertility-sparing treatment with LNG-IUS is associated with different ProMisE subtypes of endometrial carcinoma or atypical endometrial hyperplasia. J Gynecol Oncol 2024; 35:e27. [PMID: 38216133 PMCID: PMC11107283 DOI: 10.3802/jgo.2024.35.e27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/03/2023] [Accepted: 11/26/2023] [Indexed: 01/14/2024] Open
Abstract
OBJECTIVE To determine whether proactive molecular risk classifier for endometrial cancer (ProMisE) could be used to assess the prognosis of patients with atypical endometrial hyperplasia (AEH) or early-stage endometrial cancer (EC) treated with levonorgestrel-releasing intrauterine system (LNG-IUS). METHODS A retrospective cohort study was conducted among 93 AEH or early-stage EC patients who received LNG-IUS to preserve fertility . By immunohistochemistry and gene sequencing, 4 subtypes of ProMisE were identified (p53 wild type [p53 wt], mismatch repair-deficient [MMRd], p53-abnormal, and POLE-mutated). The primary outcome was the time to complete response (CR) after LNG-IUS therapy. Secondary outcomes included the recurrence rate after CR and success rate of conception. RESULTS Among the 93 patients, 15 (16.1%) were classified as MMRd, 6 (6.5%) as POLE-mutated, 5 (5.4%) as p53-abnormal, and 67 (72.0%) as p53 wt. Comparison of serum cancer antigen 125, family history of tumor, and positive rates of programmed cell death 1 ligand 1 protein and Ki67 protein in 4 groups showed statistically significant differences (p<0.05). Patients with the p53-abnormal subtype had the lowest overall CR rate (40%) and the highest recurrence rate (2/2). Patients with POLE-mutated subtype had the best prognosis, and all 6 patients achieved CR. When patients achieved complete remission, assisted reproductive technology was more likely to help them conceive than natural conception (p<0.05). CONCLUSION Patients with early-stage EC or AEH who are more likely to benefit from fertility-sparing treatment can be identified using ProMisE classifier. Patients with POLE-mutated are suitable for fertility-sparing treatment with LNG-IUS.
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Affiliation(s)
- Xiaofeng Lv
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lili Guo
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Changyu Wang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Hu Z, Wu Z, Liu W, Ning Y, Liu J, Ding W, Fan J, Cai S, Li Q, Li W, Yang X, Dou Y, Wang W, Peng W, Lu F, Zhuang X, Qin T, Kang X, Feng C, Xu Z, Lv Q, Wang Q, Wang C, Wang X, Wang Z, Wang J, Jiang J, Wang B, Mills GB, Ma D, Gao Q, Li K, Chen G, Chen X, Sun C. Proteogenomic insights into early-onset endometrioid endometrial carcinoma: predictors for fertility-sparing therapy response. Nat Genet 2024; 56:637-651. [PMID: 38565644 DOI: 10.1038/s41588-024-01703-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 03/05/2024] [Indexed: 04/04/2024]
Abstract
Endometrial carcinoma remains a public health concern with a growing incidence, particularly in younger women. Preserving fertility is a crucial consideration in the management of early-onset endometrioid endometrial carcinoma (EEEC), particularly in patients under 40 who maintain both reproductive desire and capacity. To illuminate the molecular characteristics of EEEC, we undertook a large-scale multi-omics study of 215 patients with endometrial carcinoma, including 81 with EEEC. We reveal an unexpected association between exposome-related mutational signature and EEEC, characterized by specific CTNNB1 and SIGLEC10 hotspot mutations and disruption of downstream pathways. Interestingly, SIGLEC10Q144K mutation in EEECs resulted in aberrant SIGLEC-10 protein expression and promoted progestin resistance by interacting with estrogen receptor alpha. We also identified potential protein biomarkers for progestin response in fertility-sparing treatment for EEEC. Collectively, our study establishes a proteogenomic resource of EEECs, uncovering the interactions between exposome and genomic susceptibilities that contribute to the development of primary prevention and early detection strategies for EEECs.
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Affiliation(s)
- Zhe Hu
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Zimeng Wu
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Wei Liu
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, P. R. China
| | - Yan Ning
- Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, P. R. China
| | - Jingbo Liu
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Wencheng Ding
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Junpeng Fan
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Shuyan Cai
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, P. R. China
| | - Qinlan Li
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Wenting Li
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Xiaohang Yang
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Yingyu Dou
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Wei Wang
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Wenju Peng
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Funian Lu
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Xucui Zhuang
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Tianyu Qin
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Xiaoyan Kang
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Chenzhao Feng
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Zhiying Xu
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, P. R. China
| | - Qiaoying Lv
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, P. R. China
| | - Qian Wang
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, P. R. China
| | - Chao Wang
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, P. R. China
| | - Xinyu Wang
- The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P. R. China
| | - Zhiqi Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital; Peking University People's Hospital, Xicheng District, Beijing, P. R. China
| | - Jianliu Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital; Peking University People's Hospital, Xicheng District, Beijing, P. R. China
| | - Jie Jiang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P. R. China
| | - Beibei Wang
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | | | - Ding Ma
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Qinglei Gao
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China.
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China.
| | - Kezhen Li
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China.
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China.
| | - Gang Chen
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China.
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China.
| | - Xiaojun Chen
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, P. R. China.
| | - Chaoyang Sun
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China.
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P. R. China.
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Grenot M, Vandenbroucke T, Bucau M, Koskas M. Quality of information and decision regrets during fertility-sparing management for atypical hyperplasia and endometrial cancer in a prospective cohort study. J Gynecol Obstet Hum Reprod 2024; 53:102722. [PMID: 38185245 DOI: 10.1016/j.jogoh.2024.102722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 12/27/2023] [Accepted: 01/04/2024] [Indexed: 01/09/2024]
Abstract
OBJECTIVE To evaluate satisfaction with information, treatment, and decision regret during management to preserve fertility for atypical hyperplasia (AH) or endometrial cancer (EC). METHODS A cohort study with standardized management using chlormadinone acetate was established through a national referral centre between January 2013 and November 2019. During this period, a questionnaire was given to 136 patients aged 19 to 43 years who were followed for fertility preservation for AH or EC. The questionnaire included the validated EORTC-QLQ-INFO25, as well as questions from the validated EVAPIL questionnaire, the Treatment Satisfaction with Medicines Questionnaire, and the Decision Regret Scales concerning treatment tolerability and general satisfaction. The main outcomes measured were the quality and satisfaction with the information and treatment received and the decision regret. RESULTS 75 patients (55.1 %) responded to the questionnaire. Overall, patients were satisfied with the information received (median 75.0, range: 25-100) and thought it was helpful (median 100.0, range: 25-100). However, 54.7 % wished for more information. Most women (52.0 %) indicated that psychological support should be available. Patients who were less satisfied with the information received or wished to receive more information thought about stopping treatment more frequently. Decision regret was not related to treatment outcome (remission, hysterectomy, live birth), and 47 of the 56 patients who did not obtain a live birth did not regret fertility preservation. None of the nine patients who regretted fertility preservation obtained a live birth. Almost all the patients reported side effects. CONCLUSIONS Dedicated information tools that detail conservative treatment for AH and EC as well as its secondary effects should be provided to improve adherence to treatment and follow-up. Furthermore, psychological support should be systematically proposed.
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Affiliation(s)
- Marie Grenot
- Resident in Gynaecology-Obstetrics, Bichat University Hospital Paris University, 8 rue Georges Boisseau Clichy-La-Garenne, Paris 92110, France.
| | - Tineke Vandenbroucke
- Department of Obstetrics and Gynaecology, and Department of Oncology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Margot Bucau
- Pathology Department, Bichat-Claude Bernard Hospital, Paris, France
| | - Martin Koskas
- Resident in Gynaecology-Obstetrics, Bichat University Hospital Paris University, 8 rue Georges Boisseau Clichy-La-Garenne, Paris 92110, France
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Takeda A, Yamamoto Y, Tamura K, Aoki H, Noguchi H, Minato S, Kamada S, Arakaki R, Kaji T, Iwasa T. Oncologic, fertility, and obstetric outcomes with MPA therapy in women with endometrial cancer and atypical endometrial hyperplasia. J Obstet Gynaecol Res 2024; 50:633-638. [PMID: 38154145 DOI: 10.1111/jog.15872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 12/15/2023] [Indexed: 12/30/2023]
Abstract
AIM Medroxyprogesterone acetate (MPA) is one of the treatments of atypical endometrial hyperplasia (AEH) and endometrial cancer (EC) to preserve the fertility. Efficacy of MPA therapy and fertility and obstetric outcomes after remission were evaluated in EC or AEH patients. METHODS Among patients diagnosed with EC or AEH at Tokushima University Hospital between January 2002 and October 2020, we retrospectively analyzed patients, ages range from 26 to 40, who underwent conservative management using MPA (400-600 mg/day). RESULTS In total, 19 patients underwent MPA therapy. The 18 (94%) patients achieved complete response (CR), and 1 (5%) patient achieved partial response (PR). Relapse occurred in 6 (32%) patients who had achieved CR. Of the patients who relapsed, 4 patients resumed MPA therapy and were in remission. Among 19 patients, 13 patients attempted pregnancy after CR. All of them underwent ovulation induction or assisted reproductive technology. As a result, 20 pregnancies in 10 (77%) patients and 12 live births in 9 (69%) patients were achieved. Rate of spontaneous abortion was 35% (7/20). CONCLUSIONS MPA therapy can produce a high remission rate, and be considered an effective treatment for patients who wish fertility preservation. Around 70% patients who attempt to pregnancy can have at least one baby by infertility treatments. Because recurrence rate after MPA therapy is high, it may be desirable to aim for early pregnancy by active intervention.
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Affiliation(s)
- Asuka Takeda
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Yuri Yamamoto
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Kou Tamura
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Hidenori Aoki
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Hiroki Noguchi
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Saki Minato
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Shuhei Kamada
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Ryosuke Arakaki
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Takashi Kaji
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Takeshi Iwasa
- Department of Obstetrics and Gynecology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
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9
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Dong YT, Guan J, Yang BY, Yierfulati G, Xue Y, Chen XJ. [The long-term efficacy of metformin in megestrol acetate-based fertility-sparing treatment for patients with endometrial atypical hyperplasia and endometrioid endometrial cancer]. Zhonghua Yi Xue Za Zhi 2024; 104:729-735. [PMID: 38462352 DOI: 10.3760/cma.j.cn112137-20231016-00768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Objective: To assess the long-term efficacy of metformin in megestrol acetate (MA)-based fertility-sparing treatment for patients with endometrial atypical hyperplasia (EAH) and endometrioid endometrial cancer (EEC). Methods: The randomized controlled trail study was conducted from October 2013 to October 2017 in the Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China. Patients with EAH or EEC were firstly stratified according to pathology, and randomized to receive MA (160 mg orally, daily) plus metformin (500 mg orally, three times a day) or MA (160 mg orally, daily). Baseline data between two groups of patients were compared. Estimates of time to complete remission (CR) and recurrence-free survival (RFS) were calculated using the Kaplan-Meier method. Cox proportional-hazards regression model was used to estimate hazard ratios (HR) of related factors for recurrence-free survival. Quantitative data were represented by M (Q1, Q3). Results: A total of 150 patients were included, and 76 patients were allocated to receive MA plus metformin with the age of 32.5 (28.0, 36.0), while 74 patients received MA alone with the age of 32.0 (28.0, 36.0). By the end of follow-up period, 96.7% (n=145) of patients achieved complete remission, with a median follow-up time of 57.7 (26.7, 70.5) months. The median CR time for the MA plus metformin group and the MA alone group were 6.3 (3.5, 8.3) months and 6.8 (4.0, 9.3) months, respectively (P=0.193), with 2-year cumulative CR rate of 98.6% and 98.5%, respectively (P=0.879). The median time of RFS was 28.1 (12.5, 57.3) months for the MA plus metformin group and 33.3 (14.1, 62.5) months for the MA alone group (P=0.213), with a cumulative RFS rate of 61.9% and 65.8%, respectively (P=0.560). In the subgroup of non-obese (body mass index<28 kg/m2) patients with EAH, the median RFS times were 25.7 (7.6, 60.3) months and 47.3 (17.5, 64.8) months for the MA plus metformin group and the MA alone group, respectively (P=0.033), with a cumulative RFS rate of 57.5% and 80.6%, respectively (P=0.029). According to Cox proportional hazards regression analysis, undergoing assisted reproductive treatment (HR=2.358, 95%CI: 1.069-5.204, P=0.034) was identified as an independent risk factor for recurrence-free survival after complete remission of endometrial lesions. Conclusion: The long-term follow-up outcome indicates that there is no significant difference in CR time and RFS time between MA plus metformin therapy and MA alone therapy for patients with EAH or EEC.
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Affiliation(s)
- Y T Dong
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200092, China
| | - J Guan
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200092, China
| | - B Y Yang
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200092, China
| | - Gulinazi Yierfulati
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200092, China
| | - Y Xue
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200092, China
| | - X J Chen
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200092, China
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10
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Li X, Wang Y, Wang J, Fan Y, Wang J. Prediction of complete regression in fertility-sparing patients with endometrial cancer and apical hyperplasia: the GLOBAL model in a large Chinese cohort. J Transl Med 2024; 22:127. [PMID: 38308352 PMCID: PMC10837883 DOI: 10.1186/s12967-023-04671-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/28/2023] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Fertility preservation treatment is increasingly essential for patients with apical endometrial hyperplasia (AEH) and early endometrial cancer (EEC) worldwide. Complete regression (CR) is the main endpoint of this treatment. Accurately predicting CR and implementing appropriate interventions during treatment are crucial for these patients. METHODS We conducted a retrospective study involving 193 patients diagnosed with atypical AEH or EEC, enrolled from January 2012 to March 2022 at our center. We evaluated 24 clinical parameters as candidate predictors and employed LASSO regression to develop a prediction model for CR. Subsequently, a nomogram was constructed to predict CR after the treatment. We evaluated the performance of the nomogram using receiver operator characteristic (ROC) curve and decision curve analysis (DCA) to assess its predictive accuracy. Additionally, we employed cumulative curves to determine the CR rate among patients. RESULTS Out of the 193 patients, 173 achieved CR after undergoing fertility preservation treatment. We categorized features with similar properties and provided a list of formulas based on their coefficients. The final model, named GLOBAL (including basic information, characteristics, blood pressure, glucose metabolism, lipid metabolism, immunohistochemistry, histological type, and medication), comprised eight variables identified using LASSO regression. A nomogram incorporating these eight risk factors was developed to predict CR. The GLOBAL model exhibited an AUC of 0.907 (95% CI 0.828-0.969). Calibration plots demonstrated a favorable agreement between the predicted probability by the GLOBAL model and actual observations in the cohort. The cumulative curve analysis revealed varying cumulative CR rates among patients in the eight subgroups. Categorized analysis demonstrated significant diversity in the effects of the GLOBAL model on CR among patients with different total points (p < 0.05). CONCLUSION We have developed and validated a model that significantly enhances the predictive accuracy of CR in AEH and EEC patients seeking fertility preservation treatment.
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Affiliation(s)
- Xingchen Li
- Department of Obstetrics and Gynecology, Peking University People's Hospital, No. 11, Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Yiqin Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, No. 11, Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Jiaqi Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, No. 11, Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Yuan Fan
- Department of Obstetrics and Gynecology, Peking University People's Hospital, No. 11, Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Jianliu Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, No. 11, Xizhimen South Street, Xicheng District, Beijing, 100044, China.
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11
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Ye X, Li T. Effects of hysteroscopic surgery combined with progesterone therapy on fertility and prognosis in patients with early endometrial cancer and atypical endometrial hyperplasia or endometrial intraepithelial neoplasia: a meta-analysis. Arch Gynecol Obstet 2024; 309:259-268. [PMID: 37540307 DOI: 10.1007/s00404-023-07173-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/20/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE This meta-analysis aimed to evaluate the effects of hysteroscopic surgery combined with progesterone therapy on fertility and prognosis in patients with early endometrial cancer (EC), atypical endometrial hyperplasia (AEH), or endometrial intraepithelial neoplasia (EIN). METHODS Studies on hysteroscopic surgery combined with progesterone therapy for patients with early-stage EC, AEH, or EIN were searched from Embase, Web of Science, PubMed, and Cochrane Library databases. The included studies contained one or more of the following outcome variables: pregnancy rate, live birth rate, complete response (CR) rate, and recurrence rate after conservative treatment. The meta-analysis was performed using Stata. RESULTS 13 pieces of literature containing 239 patients with EC and 199 patients with AEH/EIN were included. As per the results of meta-analysis, the pregnancy rates of EC patients and AEH/EIN patients were 49% (95% CI 33-65%) and 47% (95% CI 31-64%), respectively, and the live birth rates were 45% (95% CI 32-58%) and 44% (95% CI 34-54%), respectively. CR rates of EC patients and AEH/EIN patients were 90% (95% CI 85-94%) and 100% (95% CI 97-100%), respectively, and the disease recurrence rates were 17% (95% CI 8-28%) and 11% (95% CI 3-23%), respectively. CONCLUSION Hysteroscopic surgery combined with progesterone was linked to an improved overall response rate, reduced disease recurrence rate, and increased pregnancy and live birth rates among patients with EC and AEH/EIN.
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Affiliation(s)
- Xiabin Ye
- Obstetrics and Gynecology Department, LiShui City People's Hospital, No. 1188, Liyang Street, Lishui City, 323000, Zhejiang Province, China
| | - Tonghuai Li
- Obstetrics and Gynecology Department, LiShui City People's Hospital, No. 1188, Liyang Street, Lishui City, 323000, Zhejiang Province, China.
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12
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Stute P, Walker LJ, Eicher A, Pavicic E, Kolokythas A, Theis S, von Gernler M, von Wolff M, Vollrath S. Progestogens for endometrial protection in combined menopausal hormone therapy: A systematic review. Best Pract Res Clin Endocrinol Metab 2024; 38:101815. [PMID: 37634998 DOI: 10.1016/j.beem.2023.101815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
Menopausal women with an intact uterus choosing estrogens for menopausal symptom relief require a progestogen for endometrial protection. The aim of this systematic review was to evaluate the risks of endometrial hyperplasia resp. malignancy with different progestogens used in combined MHT. Overall, 84 RCTs were included. We found that 1) most studies were done with NETA, followed by MPA, MP and DYD and LNG, 2) most progestogens were only available as oral formulations, 3) the most frequently studied progestogens (oral MP, DYD, MPA, oral and transdermal NETA, transdermal LNG) were assessed in continuously as well as in sequentially combined MHT regimens, 4) FDA endometrial safety criteria were only fulfilled for some progestogen formulations, 5) most studies demonstrated endometrial protection for the progestogen dose and time period examined. However, 6) study quality varied which should be taken into account, when choosing a combined MHT, especially if off-label-use is chosen.
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Affiliation(s)
- Petra Stute
- Department of Obstetrics and Gynecology, University Clinic Inselspital, Friedbuehlstrasse 19, 3010 Bern, Switzerland.
| | - Linus Josef Walker
- School of Medicine, University of Bern, Murtenstrasse 11, 3008 Bern, Switzerland.
| | - Astrid Eicher
- School of Medicine, University of Bern, Murtenstrasse 11, 3008 Bern, Switzerland.
| | - Elena Pavicic
- School of Medicine, University of Bern, Murtenstrasse 11, 3008 Bern, Switzerland.
| | - Argyrios Kolokythas
- Department of Obstetrics and Gynecology, McGill University Health Centre, 1001 Bd Décarie, Montréal, QC H4A 3J1, Canada.
| | - Susanne Theis
- Department of Obstetrics and Gynecology, University of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany.
| | - Marc von Gernler
- Medical Library, University Library of Bern, University of Bern, Baltzerstrasse 4, 3012 Bern, Switzerland.
| | - Michael von Wolff
- Department of Obstetrics and Gynecology, University Clinic Inselspital, Friedbuehlstrasse 19, 3010 Bern, Switzerland.
| | - Sabrina Vollrath
- Department of Obstetrics and Gynecology, University Clinic Inselspital, Friedbuehlstrasse 19, 3010 Bern, Switzerland; Swiss Federal Institute of Sport Magglingen (SFISM), Hauptstrasse 247, 2532 Magglingen, Switzerland.
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13
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Gama Q, Luo S, Wu P, Wang L, Liu S, Zhang H, Sun L, Wang Y, Yu M, Chen X, Shan W, Luo X. The pregnancy and oncology outcome of fertility-sparing management for synchronous primary neoplasm of endometrium and ovary. J Ovarian Res 2023; 16:235. [PMID: 38062462 PMCID: PMC10704711 DOI: 10.1186/s13048-023-01316-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 11/26/2023] [Indexed: 12/18/2023] Open
Abstract
PURPOSE To investigate the efficacy of fertility-preserving treatment for young women with synchronous primary neoplasm of endometrium and ovary. METHODS We retrospectively reviewed eight patients with concurrent primary grade 1 presumed stage IA endometrioid endometrial adenocarcinoma (EEA) or endometrial atypical hyperplasia (EAH) and primary stage I ovarian tumors who underwent fertility-sparing treatment in the Obstetrics and Gynecology Hospital of Fudan University between April 2016 and December 2022. RESULTS Synchronous endometrial and ovarian cancers (SEOC) accounted for 50% of these eight patients. The median age of patients was 30.5 years (range, 28-34 years). None of them received chemotherapy. The median treatment time was 4 months (range, 3-8 months). 87.5% (7/8) cases achieved complete response (CR), and the median time to CR was 3.8 months (range, 1.5-7.7 months). Among patients who got CR, none of them showed any signs of recurrence. Pregnancies and successful deliveries were achieved in 4 of 5 patients. Till September 2023, the median follow-up period was 50.5 months (range:15.2-85.2 months). CONCLUSION Fertility-sparing treatment is feasible for highly selected patients with synchronous neoplasm of the endometrium and ovary, but strict screening and monitoring are mandatory. Though the results of our limited cases are encouraging, long follow-up and more clinical data are required. Enrolled patients must be fully informed of the risks during conservative treatment.
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Affiliation(s)
- Qujia Gama
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Yangpu District, Shanghai, 200090, P.R. China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, 200090, China
| | - Shuhan Luo
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Yangpu District, Shanghai, 200090, P.R. China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, 200090, China
| | - Pengfei Wu
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Yangpu District, Shanghai, 200090, P.R. China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, 200090, China
| | - Lulu Wang
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Yangpu District, Shanghai, 200090, P.R. China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, 200090, China
| | - Sijia Liu
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Yangpu District, Shanghai, 200090, P.R. China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, 200090, China
| | - Hongwei Zhang
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, 200090, China
- Department of Cervix, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, 200090, China
| | - Li Sun
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, 200090, China
- Department of Ultrasound, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, 200090, China
| | - Yiqin Wang
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, 200090, China
- Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, 200090, China
| | - Min Yu
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, 200090, China
- Department of Assisted Reproduction, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, 200090, China
| | - Xiaojun Chen
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Yangpu District, Shanghai, 200090, P.R. China.
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, 200090, China.
| | - Weiwei Shan
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Yangpu District, Shanghai, 200090, P.R. China.
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, 200090, China.
| | - Xuezhen Luo
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Yangpu District, Shanghai, 200090, P.R. China.
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, 200090, China.
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Ga H, Taguchi A, Honjoh H, Nishijima A, Eguchi S, Miyamoto Y, Sone K, Mori M, Osuga Y. Prognosis of patients with endometrial cancer or atypical endometrial hyperplasia after complete remission with fertility-sparing therapy. Arch Gynecol Obstet 2023; 308:1629-1634. [PMID: 37310452 PMCID: PMC10520125 DOI: 10.1007/s00404-023-07077-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/11/2023] [Indexed: 06/14/2023]
Abstract
PURPOSE Although many patients with endometrial cancer (EC) or atypical endometrial hyperplasia (AEH) achieve complete remission (CR) after high-dose medroxyprogesterone acetate (MPA) treatment, no consensus has been reached on management after CR. Currently, patients receive estrogen-progestin maintenance therapy, but no recommendations exist regarding the duration of maintenance therapy or whether hysterectomy should be considered. This study aimed to provide insights into the management of EC/AEH after achieving CR. METHODS We retrospectively investigated the prognosis of 50 patients with EC or AEH who achieved CR after MPA therapy. We assessed the association between disease recurrence and clinicopathological features and the pre- and post-operative histological diagnoses of patients who underwent hysterectomy. RESULTS The median follow-up duration was 34 months (range: 1-179 months). Recurrence was observed in 17 patients. Among the clinical characteristics investigated, only the primary disease was significantly associated with disease recurrence; patients with EC had a higher risk of recurrence than those with AEH (p = 0.037). During the observation period, 27 patients attempted pregnancy, and 14 pregnancies resulted in delivery. Patients who gave birth had significantly longer relapse-free survivals than those who did not (p = 0.031). Further, 16 patients underwent hysterectomies, and AEH was detected postoperatively in 4 of 11 patients (36.4%) with no preoperative abnormalities. CONCLUSIONS We identified several clinical features of patients with EC and AEH after CR. Given the high probability of endometrial abnormalities detected postoperatively, hysterectomy may be considered for patients who no longer want children.
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Affiliation(s)
- Hiromi Ga
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Ayumi Taguchi
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan.
- Laboratory of Human Single Cell Immunology, World Premier International Immunology Frontier Research Center (WPI-IFReC), Osaka University, 3-1 Yamadaoka Suita-shi, Osaka, 565-0871, Japan.
| | - Harunori Honjoh
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Akira Nishijima
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Satoko Eguchi
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Yuichiro Miyamoto
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Kenbun Sone
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Mayuyo Mori
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-Ku, Tokyo, 113-8655, Japan
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Shao WY, Dong YT, Lyu QY, Liao JB, Xue Y, Chen XJ. [Fertility-preserving treatment outcomes in endometrial cancer and atypical hyperplasia patients with different molecular profiles]. Zhonghua Fu Chan Ke Za Zhi 2023; 58:742-754. [PMID: 37849255 DOI: 10.3760/cma.j.cn112141-20230719-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
Objective: To investigate the impact of molecular classification and key oncogenes on the oncologic outcomes in patients with endometrial carcinoma (EC) and atypical endometrial hyperplasia (AEH) receiving fertility-preserving treatment. Methods: Patients with EC and AEH undergoing progestin-based fertility-preserving treatment and receiving molecular classification as well as key oncogenes test at Obstetrics and Gynecology Hospital, Fudan University from January 2021 to March 2023 were reviewed. Hysteroscopic lesion resection and endometrial biopsy were performed before initiating hormone therapy and every 3 months during the treatment to evaluate the efficacy. The risk factors which had impact on the treatment outcomes in EC and AEH patients were further analyzed. Results: Of the 171 patients analyzed, the median age was 32 years, including 86 patients with EC and 85 patients with AEH. The distribution of molecular classification was as follows: 157 cases (91.8%) were classified as having no specific molecular profile (NSMP); 9 cases (5.3%), mismatch repair deficient (MMR-d); 3 cases (1.8%), POLE-mutated; 2 cases (1.2%), p53 abnormal. No difference was found in the cumulative 40-week complete response (CR) rate between the patients having NSMP or MMR-d (61.6% vs 60.0%; P=0.593), while the patients having MMR-d had increased risk than those having NSMP to have recurrence after CR (50.0% vs 14.4%; P=0.005). Multi-variant analysis showed PTEN gene multi-loci mutation (HR=0.413, 95%CI: 0.259-0.658; P<0.001) and PIK3CA gene mutation (HR=0.499, 95%CI: 0.310-0.804; P=0.004) were associated with a lower cumulative 40-week CR rate, and progestin-insensitivity (HR=3.825, 95%CI: 1.570-9.317; P=0.003) and MMR-d (HR=9.014, 95%CI: 1.734-46.873; P=0.009) were independent risk factors of recurrence in EC and AEH patients. Conclusions: No difference in cumulative 40-week CR rate is found in the patients having NSMP or MMR-d who received progestin-based fertility-preserving treatment, where the use of hysteroscopy during the treatment might be the reason, while those having MMR-d have a higher risk of recurrence after CR. Oncogene mutation of PTEN or PIK3CA gene might be associated with a lower response to progestin treatment. The molecular profiles help predict the fertility-preserving treatment outcomes in EC and AEH patients.
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Affiliation(s)
- W Y Shao
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200092, China
| | - Y T Dong
- Clinical Medical College, Fudan University, Shanghai 200032, China
| | - Q Y Lyu
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200092, China
| | - J B Liao
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200092, China
| | - Y Xue
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200092, China
| | - X J Chen
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200092, China
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Bilir E, Kahramanoğlu İ. The role of hysteroscopy in fertility preservation in endometrial cancer and atypical endometrial hyperplasia: a semi-systematic literature review. Arch Gynecol Obstet 2023; 308:1113-1126. [PMID: 36807742 DOI: 10.1007/s00404-023-06960-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 02/01/2023] [Indexed: 02/23/2023]
Abstract
PURPOSE Endometrial premalignancies are among the common reasons for outpatient gynecology visits among women in reproductive ages. Due to the continued increase in global obesity incidence among them, endometrial malignancies are expected to become even further prevalent. Hence, fertility-sparing interventions are essential and needed. In this semi-systematic literature review, we aimed to investigate the role of hysteroscopy in fertility preservation in endometrial cancer and atypical endometrial hyperplasia. Our secondary goal is to analyze the pregnancy outcomes following fertility preservation. METHODS We conducted a computed search in PubMed. We included original research articles including hysteroscopic interventions in pre-menopausal patients with endometrial malignancies and premalignancies who underwent fertility-preserving treatments. We collected data on medical treatment, response, pregnancy outcomes, and hysteroscopy. RESULTS Of the query results (n = 364), our final analysis included 24 studies. Overall, 1186 patients with endometrial premalignancies and endometrial cancer (EC) were included. More than half of the studies were retrospective design. They included almost ten different forms of progestins. Of the reported pregnancies (n = 392), the overall pregnancy rate was 33.1%. The majority of the studies used operative hysteroscopy (87.5%). Only three (12.5%) reported their hysteroscopy technique in detail. Although more than half of the studies did not provide any information on adverse effects due to hysteroscopy, there were no serious adverse effects among the reported ones. CONCLUSION Hysteroscopic resection may increase the success rate of fertility-preserving treatment of EC and atypical endometrial hyperplasia. The clinical significance of the theoretical concern of the dissemination of cancer is not known. Standardization of the use of hysteroscopy in fertility-preserving treatment is needed.
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Affiliation(s)
- Esra Bilir
- Department of Obstetrics and Gynecology, Die Klinik in Preetz, Preetz, Germany
- Department of Global Health, Koç University Graduate School of Health Sciences, Istanbul, Turkey
| | - İlker Kahramanoğlu
- Private Gynecologic Oncology Clinic, Bağdat Caddesi, No: 168/16, Fenerbahçe, Kadıköy, Istanbul, Turkey.
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Martire FG, Giorgi M, Labanca L, Centini G, Catania F, Exacoustos C, Zupi E, Lazzeri L. Unilateral hydroureteronephrosis after introduction of a levonorgestrel-releasing intrauterine system: a case report and literature review. Minerva Obstet Gynecol 2023; 75:491-497. [PMID: 36255159 DOI: 10.23736/s2724-606x.22.05112-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Insertion of a LNG-Intra-uterine System (LNG-IUS) has many gynecological indications. The approved indications worldwide are contraception, treatment of abnormal uterine bleeding depending on not organic disease, and endometrial protection in case of an estrogenic therapy. Instead adenomyosis, fibroids, and fertility-sparing management of endometrial hyperplasia or early endometrial cancer in patients with desire of pregnancy are off label indications. Hydroureteronephrosis is an uncommon complication during LNG-IUS insertion. There are few cases described in the literature. The first diagnostic approach for this complication is an abdominal-pelvic ultrasound scan to identify the abnormal position of the device. Diagnostic management includes computed tomography (CT) or magnetic resonance imaging (MRI), which are necessary to confirm hydroureteronephrosis and to assess the exact location of the LNG-IUS in the abdomen. A minimally invasive approach is the standard of care with the removal of the device, while the therapeutic management of the hydroureteronephrosis depends on ureteral and kidney involvement. We report the history of a dislocated LNG-IUS in the left paracervical space with subsequent ipsilateral hydroureteronephrosis. In our case we removed the device through hysteroscopy and later inserted a J-J stent. Follow-up at three months revealed the persistence of left hydroureteronephrosis, so we performed ureter reimplantation. We also performed a review of the literature to analyze common diagnostic and therapeutic pathways for this rare complication.
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Affiliation(s)
- Francesco G Martire
- Unit of Gynecology, Department of Surgical Sciences, Tor Vergata University, Rome, Italy
- Unit of Gynecology, Department of Surgical Sciences, Valdarno Hospital, Azienda USL Toscana Sud Est, Montevarchi, Arezzo, Italy
| | - Matteo Giorgi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, Italy -
| | - Luca Labanca
- Unit of Gynecology, Department of Surgical Sciences, Valdarno Hospital, Azienda USL Toscana Sud Est, Montevarchi, Arezzo, Italy
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, Italy
| | - Gabriele Centini
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, Italy
| | - Francesco Catania
- Unit of Gynecology, Department of Surgical Sciences, Valdarno Hospital, Azienda USL Toscana Sud Est, Montevarchi, Arezzo, Italy
| | - Caterina Exacoustos
- Unit of Gynecology, Department of Surgical Sciences, Tor Vergata University, Rome, Italy
| | - Errico Zupi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, Italy
| | - Lucia Lazzeri
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, Italy
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Wu W, Wang W, Zou J. Recurrent endometrial atypical hyperplasia diagnosed by pathological examination of the placenta from a live birth: a case report. BMC Pregnancy Childbirth 2023; 23:691. [PMID: 37749522 PMCID: PMC10519068 DOI: 10.1186/s12884-023-05972-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 09/04/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Pregnancy complicated with endometrial atypical hyperplasia, which is often observed during early pregnancy, is extremely rare. CASE PRESENTATION The patient was a 30-year-old woman who had premature delivery at 30+ 1 weeks gestation, and endometrial atypical hyperplasia was discovered by placental examination. CONCLUSIONS For patients who undergo fertility-sparing treatment for endometrial atypical hyperplasia, the evaluation of the decidua via the placental pathological examination is particularly important. These examinations make a great clinical contribution to the early detection and diagnosis of endometrial atypical hyperplasia.
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Affiliation(s)
- Weilu Wu
- Department of Pathology, West China Second University Hospital, Sichuan University, No. 20, Section 3, Renmin NanLu Chengdu, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), West China Second Hospital, Ministry of Education, Sichuan University, Chengdu, 610044, China
| | - Wei Wang
- Department of Pathology, West China Second University Hospital, Sichuan University, No. 20, Section 3, Renmin NanLu Chengdu, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), West China Second Hospital, Ministry of Education, Sichuan University, Chengdu, 610044, China
| | - Juan Zou
- Department of Pathology, West China Second University Hospital, Sichuan University, No. 20, Section 3, Renmin NanLu Chengdu, Chengdu, 610041, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), West China Second Hospital, Ministry of Education, Sichuan University, Chengdu, 610044, China.
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Girbash EF, Sherif HE, Radwan AM, Abdeldayem HM. Dienogest versus norethisterone acetate in management of endometrial hyperplasia without atypia. Arch Gynecol Obstet 2023; 308:947-952. [PMID: 37010614 PMCID: PMC10348941 DOI: 10.1007/s00404-023-07015-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/14/2023] [Indexed: 04/04/2023]
Abstract
OBJECTIVES To compare the effectiveness of dienogest (DIE) and norethisterone acetate (NETA) regimens in the treatment of endometrial hyperplasia (EH) without atypia. METHODS Participants were premenopausal women with irregular uterine bleeding, and endometrial hyperplasia without atypia on endometrial biopsy. Enrolled patients were randomly allocated into two groups: group I got DIE 2 mg/day (orally Visanne) for 14 days (10th to the 25th day of cycle) while group II received between the 16th and 25th day of the cycle, norethisterone acetate (NETA) 15 mg/d (orally Primolut Nor) was administered for 10 days. Both groups continued the therapy for six months. RESULTS The DIE group showed a higher resolution (32.7%) and regression (57.7%) than NETA group (31% & 37.9%, respectively) with significant regression (p = 0.039). No progression in DIE group while four (6.9%) women in NETA group were recorded a progression to complex type without a significance. Also, NETA group showed a significant persistence rate (22.5%) than DIE group (3.8%) (p = 0.005). Also number in NETA group managed by hysterectomy with significant difference (p = 0.042). CONCLUSION If used as first-line treatment, Dienogest produces a better rate of regression and a lower incidence of hysterectomy than Norethisterone Acetate does when used in EH without atypia.
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Affiliation(s)
- Ehab F. Girbash
- Obstetrics and Gynecology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hala E. Sherif
- Obstetrics and Gynecology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed M. Radwan
- Obstetrics and Gynecology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hussein M. Abdeldayem
- Obstetrics and Gynecology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Management of Endometrial Intraepithelial Neoplasia or Atypical Endometrial Hyperplasia: ACOG Clinical Consensus No. 5. Obstet Gynecol 2023; 142:735-44. [PMID: 37590985 DOI: 10.1097/AOG.0000000000005297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Indexed: 08/19/2023]
Abstract
SUMMARY Endometrial intraepithelial neoplasia (EIN) or atypical endometrial hyperplasia (AEH) often is a precursor lesion to adenocarcinoma of the endometrium. Hysterectomy is the definitive treatment for EIN-AEH. When a conservative (fertility-sparing) approach to the management of EIN-AEH is under consideration, it is important to attempt to exclude the presence of endometrial cancer to avoid potential undertreatment of an unknown malignancy in those who have been already diagnosed with EIN-AEH. Given the high risk of progression to cancer, those who do not have surgery require progestin therapy (oral, intrauterine, or combined) and close surveillance. Although data are conflicting and limited, studies have demonstrated that treatment with the levonorgestrel-releasing intrauterine device results in a higher regression rate when compared with treatment with oral progestins alone. Limited data suggest that cyclic progestational agents have lower regression rates when compared with continuous oral therapy. After initial conservative treatment for EIN-AEH, early detection of disease persistence, progression, or recurrence requires careful follow-up. Gynecologists and other clinicians should counsel patients that lifestyle modification resulting in weight loss and glycemic control can improve overall health and may decrease the risk of EIN-AEH and endometrial cancer.
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Schäffler H, Dimpfl M, Schochter F, Janni W, de Gregorio N. Curative Polyendocrine Therapy in a 21-year-Old Patient with Endometrial Carcinoma: Case Report and Review of the Literature. Oncol Res Treat 2023; 46:330-335. [PMID: 37364543 DOI: 10.1159/000531661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 06/13/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION As the numbers of young patients diagnosed with early-stage endometrial carcinoma continue to rise, the question regarding fertility-preserving therapeutic options will increasingly gain significance in the future. CASE PRESENTATION Here, we present the case of a 21-year-old patient diagnosed with symptomatic atypical endometrial hyperplasia. After 4 months of treatment with medroxyprogesterone acetate, a follow-up dilatation and curettage revealed early-stage, well-differentiated endometrioid endometrial carcinoma. Despite national guidelines recommending hysterectomy, the nulliparous patient expressed a desire to preserve her fertility. Subsequently, she underwent polyendocrine therapy with letrozole, everolimus, metformin, and Zoladex. Forty-three months after diagnosis, the patient successfully gave birth to a healthy child, and there have been no indications of recurrence thus far. DISCUSSION This case suggests that triple endocrine therapy may be an option for selected patients with early endometrial cancer and a desire for fertility-sparing therapy.
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Affiliation(s)
- Henning Schäffler
- Department of Obstetrics and Gynecology, University of Ulm, Ulm, Germany
| | - Moritz Dimpfl
- Department of Obstetrics and Gynecology, University of Ulm, Ulm, Germany
| | - Fabienne Schochter
- Department of Obstetrics and Gynecology, University of Ulm, Ulm, Germany
| | - Wolfgang Janni
- Department of Obstetrics and Gynecology, University of Ulm, Ulm, Germany
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22
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Shao F, Li Y, Zhao Y. Progestin plus metformin improves outcomes in patients with endometrial hyperplasia and early endometrial cancer more than progestin alone: a meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1139858. [PMID: 37415671 PMCID: PMC10320576 DOI: 10.3389/fendo.2023.1139858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 05/31/2023] [Indexed: 07/08/2023] Open
Abstract
Objective Progestin based therapy is the preferred option for fertility-sparing treatment of reproductive-age women with preserved fertility in endometrial hyperplasia (EH) or early endometrial cancer (EEC). Our objective was to investigate whether metformin could enhance the efficacy of progestin-based therapies by meta-analysis. Methods We conducted a meta-analysis of randomized or non-randomized controlled trials by searching of PubMed, Embase, Web of science, and Cochrane database from inception to November 8, 2022. The results of enrolled studies were pooled using meta-analysis to estimate the effect of progestin plus metformin on remission, recurrence, pregnancy rate and live birth rate. Results In the analysis of progestin administered systemically or locally, complete response (CR) was significantly higher in progestin plus metformin versus progestin alone in the EH group (pooled OR 2.08, 95% CI 1.29 to 3.34, P=0.003), in the EEC group (pooled OR 1.86, 95% CI 1.13 to 3.05, P=0.01), but not in EEC and EH group (pooled OR 1.46, 95% CI 0.97 to 2.21, P=0.07). In the analysis of progestin administered systemically, complete response was improved in progestin plus metformin versus progestin alone, in the EH group (pooled OR 2.47, 95% CI 1.45 to 4.21, P=0.0009), in the EEC group (pooled OR 2.09, 95% CI 1.18 to 3.71, P=0.01), and in the EEC and EH group (pooled OR 2.03, 95% CI 1.16 to 3.54, P=0.01). The relapse rates of patients with EEC and EH were not different (pooled OR 0.54, 95% CI 0.24 to 1.20, P=0.13). For obstetric outcomes, the addition of metformin improved pregnancy rate (pooled OR 1.55, 95% CI 0.99 to 2.42, P=0.05), but not live birth rate (pooled OR 0.95, 95% CI 0.45 to 2.01, P=0.89). Conclusion For fertility-sparing management, compared to progestin alone, the outcomes of patients with endometrial hyperplasia and early endometrial cancer were more improved with progestin plus metformin because progestin plus metformin increases the rate of remission and pregnancy.
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Affiliation(s)
| | | | - Yunhe Zhao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
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23
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Oishi M, Kasuga Y, Fukuma Y, Hamuro A, Tamai J, Tanaka Y, Hasegawa K, Yoshimura T, Ikenoue S, Ochiai D, Yamagami W, Tanaka M. Obstetric outcomes after medroxyprogesterone acetate treatment for early stage endometrial cancer or atypical endometrial hyperplasia: a single hospital-based study. Int J Clin Oncol 2023; 28:587-591. [PMID: 36662363 DOI: 10.1007/s10147-023-02297-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/11/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND To investigate perinatal outcomes in pregnancy after high-dose medroxyprogesterone acetate (MPA) therapy for early stage endometrial cancer (EC) and atypical endometrial hyperplasia (AEH) and to determine whether pregnancy after MPA therapy is at a higher risk of placenta accreta. METHODS Data of 51 pregnancies in 46 women who received MPA therapy for EC or AEH and delivered after 22 weeks of gestation at Keio University Hospital were reviewed. A retrospective matched case-control study was performed to determine the risk of placenta accreta in pregnancy after MPA therapy compared with singleton pregnancies without any history of maternal malignancy treatments. RESULTS The incidence of placenta accreta was higher in the MPA group than in the control group (15.7 vs. 0%, p = 0.0058). However, no differences in other perinatal outcomes were observed between groups. While gestational weeks at delivery in the MPA group were later than those in the control group (p = 0.0058), no difference in the incidence of preterm delivery was recorded between groups. In the MPA therapy group, the number of patients who underwent ≥ 6 dilation and curettage (D&C) was higher in the placenta accreta group than in the non-placenta accreta group (50.0 vs. 14.0%, p = 0.018). Patients with ≥ 6 D&Cs demonstrated a 6.0-fold increased risk of placenta accreta (p = 0.043, 95% CI 1.05-34.1) than those receiving ≤ 3 D&Cs. CONCLUSION Pregnancy after MPA therapy is associated with a high risk of placenta accreta. In cases in which the frequency of D&C is high, placenta accreta should be considered.
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Affiliation(s)
- Maki Oishi
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Yoshifumi Kasuga
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan.
| | - Yuka Fukuma
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Asuka Hamuro
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Junko Tamai
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Yuya Tanaka
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Keita Hasegawa
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Takuma Yoshimura
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Satoru Ikenoue
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Daigo Ochiai
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
- Department of Obstetrics and Gynecology, School of Medicine, Kitasato University, 1-15-1, Kitasato, Minami-Ku, Sagamihara-Shi, Kanagawa, 252-0375, Japan
| | - Wataru Yamagami
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Mamoru Tanaka
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
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Liu S, Cao X, Zhang T, Zhang C, Qu J, Sun Y, Lv W, Qu F. Paeonol ameliorates endometrial hyperplasia in mice via inhibiting PI3K/AKT pathway-related ferroptosis. Phytomedicine 2023; 109:154593. [PMID: 36610113 DOI: 10.1016/j.phymed.2022.154593] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/24/2022] [Accepted: 12/09/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Paeonol (Pae) is one of the active ingredients from components of Guizhi Fuling Capsule, a traditional Chinese medicine widely used for the treatment of women's diseases, which exhibits various biological and pharmacological activities. PURPOSE The objective of this study was to investigate the molecular mechanism underlying the role of Pae in protecting against endometrial hyperplasia (EH). METHODS CCK-8 assay was performed to detect the effect of Pae on cell proliferation. Hematoxylin and eosin (H&E) staining was performed to evaluate uterine tissue structure. A network pharmacology study was performed to search the disease targets. Single-cell transcriptome analysis was performed with uterine tissues from 3 healthy donors and 3 EH patients on 10X Genomics platform. Changes in lipid peroxidation were detected by the MDA reaction. IHC assay, Western blot, immunofluorescence and RT-qPCR were used to study the effects of estradiol and Pae on the expression levels of GPX4, PI3K, AKT, p-PI3K, p-AKT in mice. RESULTS Pae treatment resulted in a decrease in cell viability of endometrial epithelial cells. Loss of uterus weight and morphology changes were observed in mice. In addition, Fe iron concentration and MDA levels increased, while the expression of GPX4, p-PI3K and p-AKT diminished. CONCLUSIONS Pae exhibited obvious alleviative activity in estradiol-induced mice via PI3K/AKT signaling pathway-regulated ferroptosis.
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Affiliation(s)
- Songjun Liu
- Women's Hospital, School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou 310006, Zhejiang, China; Department of Gynecology, Tongde Hospital of Zhejiang Province, 234 Gucui Road, Hangzhou 310012, Zhejiang, China
| | - Xinran Cao
- State Key Laboratory of Pharmaceutical Biotechnology, Department of Biotechnology and Pharmaceutical Sciences, School of Life Sciences, Nanjing University, 163 Xianlin Avenue, Nanjing 210023, China
| | - Tao Zhang
- State Key Laboratory of Pharmaceutical Biotechnology, Department of Biotechnology and Pharmaceutical Sciences, School of Life Sciences, Nanjing University, 163 Xianlin Avenue, Nanjing 210023, China
| | - Chenyang Zhang
- State Key Laboratory of Pharmaceutical Biotechnology, Department of Biotechnology and Pharmaceutical Sciences, School of Life Sciences, Nanjing University, 163 Xianlin Avenue, Nanjing 210023, China
| | - Jiao Qu
- State Key Laboratory of Pharmaceutical Biotechnology, Department of Biotechnology and Pharmaceutical Sciences, School of Life Sciences, Nanjing University, 163 Xianlin Avenue, Nanjing 210023, China
| | - Yang Sun
- State Key Laboratory of Pharmaceutical Biotechnology, Department of Biotechnology and Pharmaceutical Sciences, School of Life Sciences, Nanjing University, 163 Xianlin Avenue, Nanjing 210023, China.
| | - Wen Lv
- Department of Gynecology, Tongde Hospital of Zhejiang Province, 234 Gucui Road, Hangzhou 310012, Zhejiang, China.
| | - Fan Qu
- Women's Hospital, School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou 310006, Zhejiang, China.
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Hu M, Sun D, Yu J, Fu Y, Qin Z, Huang B, Zhang Q, Chen X, Wei Y, Zhu H, Wang Y, Feng Y, Zheng W, Liao H, Li J, Wu S, Zhang Z. Brusatol sensitizes endometrial hyperplasia and cancer to progestin by suppressing NRF2-TET1-AKR1C1-mediated progestin metabolism. J Transl Med 2022; 102:1335-1345. [PMID: 36038734 DOI: 10.1038/s41374-022-00816-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/28/2022] [Accepted: 05/31/2022] [Indexed: 11/09/2022] Open
Abstract
Progestin resistance is the main obstacle for the conservative therapy to maintain fertility in women with endometrial cancer. Brusatol was identified as an inhibitor of the NRF2 pathway; however, its impact on progestin resistance and the underlying mechanism remains unclear. Here, we found that brusatol sensitized endometrial cancer to progestin by suppressing NRF2-TET1-AKR1C1-mediated progestin metabolism. Brusatol transcriptionally suppressed AKR1C1 via modifying the hydroxymethylation status in its promoter region through TET1 inhibition. Suppression of AKR1C1 by brusatol resulted in decreased progesterone catabolism and maintained potent progesterone to inhibit endometrial cancer growth. This inhibition pattern has also been found in the established xenograft mouse and organoid models. Aberrant overexpression of AKR1C1 was found in paired endometrial hyperplasia and cancer samples from the same individuals with progestin resistance, whereas attenuated or loss of AKR1C1 was observed in post-treatment samples with well progestin response as compared with paired pre-treatment tissues. Our findings suggest that AKR1C1 expression pattern may serve as an important biomarker of progestin resistance in endometrial cancer.
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Affiliation(s)
- Meiyan Hu
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, 200080, China
- Department of Obstetrics and Gynecology, Zhongshan Hospital Wusong Branch, Fudan University, Shanghai, 201900, China
| | - Di Sun
- Center for Reproductive Medicine and Fertility Preservation Program, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China
| | - Jing Yu
- Department of Pathology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 200040, China
| | - Yue Fu
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, 200080, China
| | - Zuoshu Qin
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, 200080, China
| | - Baozhu Huang
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, 200080, China
| | - Qiuju Zhang
- Department of Obstetrics and Gynecology, Zhongshan Hospital Wusong Branch, Fudan University, Shanghai, 201900, China
| | - Xiong Chen
- Department of Obstetrics and Gynecology, Zhongshan Hospital Wusong Branch, Fudan University, Shanghai, 201900, China
| | - Youheng Wei
- College of Bioscience and Biotechnology, Yangzhou University, Yangzhou, China
| | - Huiting Zhu
- Department of Pathology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 200040, China
| | - Yue Wang
- Department of Obstetrics and Gynecology, Henan Province People's Hospital, Zhengzhou, China
| | - Youji Feng
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, 200080, China
| | - Wenxin Zheng
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Hong Liao
- Department of Lab Medicine, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 200040, China
| | - Jingjie Li
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, 200080, China.
| | - Sufang Wu
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, 200080, China.
| | - Zhenbo Zhang
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, 200080, China.
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Elassall GM, Sayed EG, Abdallah NA, El-Zohiry MM, Radwan AA, AlMahdy AM, Sedik AS, Elazeem HASA, Shazly SA. Levonorgestrel-releasing intrauterine system versus systemic progestins in management of endometrial hyperplasia: A systemic review and meta-analysis. J Gynecol Obstet Hum Reprod 2022; 51:102432. [PMID: 35760334 DOI: 10.1016/j.jogoh.2022.102432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/15/2022] [Accepted: 06/20/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Endometrial hyperplasia is associated with varying risk of endometrial cancer. The aim of this review is to assess effectiveness of levonorgestrel-releasing intrauterine system (LNG-IUS), compared to systemic progestins, in management of endometrial hyperplasia MATERIALS AND METHODS: A search on studies comparing LNG-IUS to systemic progestins was conducted on Scopus, Web of science, Cochrane, PubMed and Embase databases, from the date of inception to September 20th, 2020. Studies were excluded if they were non-comparative, animal studies, review articles, case reports, case series, and conference papers. Primary outcomes include resolution/regression rate, failure rate, and hysterectomy rate. Analysis was pooled using random effect model and was expressed as pooled odds ratios (OR) and 95% confidence interval (CI). Quality assessment was performed using Cochrane Risk of Bias Tool and the Newcastle-Ottawa Scale (NOS) assessment tool. MOGGE Meta-analysis Matrix was used to illustrate multiple subgroup analyses. RESULTS Out of 341 studies retrieved from literature search, 12 were eligible. LNG-IUS yielded significantly higher resolution/regression rate (91.3% vs 68.6%, OR 3.42, 95% CI 1.86-6.30). Failure and hysterectomy rates were significantly lower in LNG-IUS group compared to systemic progestins' group (19.2% vs. 32.3%, OR 0.34, 95% CI 0.20-0.57 and 9.3% vs. 24.1%, OR 0.41, 95% CI 0.29-0.57, respectively). Subgroup analysis of studies including complex hyperplasia only did not show significant difference in resolution/regression rate was not statistically significant. CONCLUSION LNG-IUS is associated with high success rate in management of women with endometrial hyperplasia. However, specific effectiveness of LNG-IUS on more advanced histologic subtypes is less studied.
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Affiliation(s)
- Gena M Elassall
- Middle-East Obstetrics and Gynecology Graduate Education (MOGGE) Foundation Research Office, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Esraa G Sayed
- Middle-East Obstetrics and Gynecology Graduate Education (MOGGE) Foundation Research Office, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Nada A Abdallah
- Middle-East Obstetrics and Gynecology Graduate Education (MOGGE) Foundation Research Office, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mariam M El-Zohiry
- Middle-East Obstetrics and Gynecology Graduate Education (MOGGE) Foundation Research Office, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed A Radwan
- Middle-East Obstetrics and Gynecology Graduate Education (MOGGE) Foundation Research Office, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - AlBatool M AlMahdy
- Middle-East Obstetrics and Gynecology Graduate Education (MOGGE) Foundation Research Office, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed S Sedik
- Middle-East Obstetrics and Gynecology Graduate Education (MOGGE) Foundation Research Office, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Hossam Aldein S Abd Elazeem
- Middle-East Obstetrics and Gynecology Graduate Education (MOGGE) Foundation Research Office, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Sherif A Shazly
- Middle-East Obstetrics and Gynecology Graduate Education (MOGGE) Foundation Research Office, Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt.
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Wang YQ, Kang N, Li LW, Wang ZQ, Zhou R, Shen DH, Wang JL. [Significance of molecular classification in fertility-sparing treatment of endometrial carcinoma and atypical endometrial hyperplasia]. Zhonghua Fu Chan Ke Za Zhi 2022; 57:692-700. [PMID: 36177581 DOI: 10.3760/cma.j.cn112141-20220628-00419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Objective: To investigate the molecular classification of endometrial carcinoma (EC) and atypical endometrial hyperplasia (AEH) treated with fertility-sparing therapy, and to analyze its relationship with clinicopathological factors and treatment efficacy. Methods: A total of 46 EC and AEH patients who received fertility-sparing therapy and molecular classification tested by next generation sequencing in Peking University People's Hospital from June 2020 to December 2021, were retrospectively collected. The relationships between molecular classification and clinicopathological factors and treatment outcomes were analyzed. Results: (1) Of the 46 patients, including 40 EC and 6 AEH patients, 32 cases (71%, 32/45) had complete response (CR) after treatment, with median CR time of 8 months, 6 cases (13%, 6/45) had partial response, and 8 cases (25%, 8/32) had recurrence. (2) The cases were distributed as no specific molecular profile (NSMP) 34 cases (74%, 34/46) subtype mainly, high microsatellite instability (MSI-H) 7 cases (15%, 7/46), POLE ultra-mutated 3 cases (7%, 3/46), and copy number high (CNH) 2 cases (4%, 2/46). Patients with CNH had the hightest serum cancer antigen 125 (CA125) level [(34.3±35.2) kU/L]. MSI-H subtype had more family history of tumors (6/7), more with loss of mismatch repair (MMR) protein expression by immunohistochemical (7/7), and higher nuclear antigen associated with cell proliferation (Ki-67) expression level (3/3). (3) Patients in MSI-H subgroup had the lowest CR rate at 6 months (0/6; P=0.019), and survival analysis showed that they were less likely to achieve CR than those with NSMP subtype (P=0.022). Subgroup analysis of patients with NSMP showed that age ≥30 years related with longer treatment time to CR (P=0.010). In addition, CR was obtained after treatment in 2/3 POLE ultra-mutated cases and 2/2 CNH, respectively. Conclusions: Molecular classification relates with the treatment response in patients with EC and AEH treated with fertility-sparing therapy. Patients with MSI-H subtype have poor treatment efficacy, and patients with NSMP need to be further studied and predict treatment benefit. However, there are few cases in POLE ultra-mutated and CNH subtypes, which need further clinical research.
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Affiliation(s)
- Y Q Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing 100044, China
| | - N Kang
- Department of Pathology, Peking University People's Hospital, Beijing 100044, China
| | - L W Li
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing 100044, China
| | - Z Q Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing 100044, China
| | - R Zhou
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing 100044, China
| | - D H Shen
- Department of Pathology, Peking University People's Hospital, Beijing 100044, China
| | - J L Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing 100044, China
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Ding Y, Fan Y, Li X, Wang Y, Wang J, Tian L. Metabolic syndrome is an independent risk factor for time to complete remission of fertility-sparing treatment in atypical endometrial hyperplasia and early endometrial carcinoma patients. Reprod Biol Endocrinol 2022; 20:134. [PMID: 36064542 PMCID: PMC9442985 DOI: 10.1186/s12958-022-01006-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/23/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Fertility-sparing treatment of atypical endometrial hyperplasia (AEH) and early endometrial carcinoma (EC) patients has recently emerged important social health topic. This study is designed to explore the risk factors for time to complete remission (CR) of fertility-sparing treatment in woman with AEH and early EC. METHODS A retrospective study was designed with clinical data from 106 patients admitted between January 2012 to December 2019. Univariate and multivariate logistic analysis were used to explore independent risk factors for time to CR. These factors were employed in receiver operator characteristic (ROC) curve and the decision curve analysis (DCA) to evaluate predictive accuracy of time to CR. Stratified analysis and interactive analysis was also performed for more in-depth perspective. RESULTS Univariate analysis showed that fasting blood glucose levels (FBG, OR = 1.6, 95%CI: 0.6-2.5, P = 0.020), metabolic syndrome (MetS, OR = 3.0, 95%CI: 1.1-5.0, P = 0.003), and polycystic ovary syndrome (PCOS, OR = 2.0, 95%CI: 0.5-3.4, P = 0.009) were associated with time to CR. Among these factors, multivariate analysis confirmed MetS (OR = 3.1, 95%CI: 1.0-5.2, P = 0.005) was an independent risk factor. The area under the ROC curve (AUC) of MetS was higher than FBG and PCOS (AUC = 0.723 vs 0.612 and 0.692). The AUC of FBG combined with PCOS was 0.779, and it was improved to 0.840 when MetS was included (P < 0.05). Additionally, MetS played different roles in time to CR in various groups. Moreover, we found high-density lipoprotein (HDL) and MetS had an interactive effect for time to CR. CONCLUSION MetS is an independent risk factor for time to CR and should be taken seriously in fertility-sparing management of AEH and early EC patients.
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Affiliation(s)
- Yingqiao Ding
- Reproductive Medical Center, Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
| | - Yuan Fan
- Reproductive Medical Center, Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
| | - Xingchen Li
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
| | - Yiqin Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
| | - Jianliu Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
| | - Li Tian
- Reproductive Medical Center, Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China.
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China.
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Binmahfouz LS, Eid BG, Bagher AM, Shaik RA, Binmahfouz NS, Abdel-Naim AB. Piceatannol SNEDDS Attenuates Estradiol-Induced Endometrial Hyperplasia in Rats by Modulation of NF-κB and Nrf2/HO-1 Axes. Nutrients 2022; 14:nu14091891. [PMID: 35565857 PMCID: PMC9102083 DOI: 10.3390/nu14091891] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 02/08/2023] Open
Abstract
Endometrial hyperplasia (EH) is the most common risk factor for endometrial malignancy in females. The pathogenesis of EH has been directly linked to uterine inflammation, which can result in abnormal cell division and decreased apoptosis. Piceatannol (PIC), a natural polyphenolic stilbene, is known to exert anti-inflammatory, antioxidant and anti-proliferative activities. The aim of the present study was to examine the potential preventive role of PIC in estradiol benzoate (EB)-induced EH in rats. A self-nanoemulsifying drug delivery system (SNEDDS) was prepared to improve the solubility of the PIC. Therefore, thirty female Wistar rats were divided into five groups: (1) control, (2) PIC SNEDDS (10 mg/kg), (3) EB (0.6 mg/kg), (4) EB + PIC SNEDDS (5 mg/kg) and (5) EB + PIC SNEDDS (10 mg/kg). The administration of PIC SNEDDS prevented EB-induced increases in uterine weights and histopathological changes. Additionally, it displayed pro-apoptotic and antioxidant activity in the endometrium. Immunohistochemical staining of uterine sections co-treated with PIC SNEDDS showed significantly decreased expression of tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6) and nuclear transcription factor-kappa B (NF-κB). This anti-inflammatory effect was further confirmed by a significant increase in Nrf2 and heme oxygenase-1 (HO-1) expression. These results indicate that SNEDDS nanoformulation of PIC possesses protective effects against experimentally induced EH.
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Affiliation(s)
- Lenah S. Binmahfouz
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (B.G.E.); (A.M.B.); (R.A.S.); (A.B.A.-N.)
- Correspondence:
| | - Basma G. Eid
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (B.G.E.); (A.M.B.); (R.A.S.); (A.B.A.-N.)
| | - Amina M. Bagher
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (B.G.E.); (A.M.B.); (R.A.S.); (A.B.A.-N.)
| | - Rasheed A. Shaik
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (B.G.E.); (A.M.B.); (R.A.S.); (A.B.A.-N.)
| | - Najlaa S. Binmahfouz
- Department of Anatomical Histopathology, East Jeddah General Hospital, Jeddah 22253, Saudi Arabia;
| | - Ashraf B. Abdel-Naim
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (B.G.E.); (A.M.B.); (R.A.S.); (A.B.A.-N.)
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Nomura H, Sugiyama Y, Nishino S, Ikki A, Murakami A, Matsumoto T, Fusegi A, Omi M, Aoki Y, Abe A, Tanigawa T, Netsu S, Okamoto S, Omatsu K, Yunokawa M, Kanao H. Clinical Management of Atypical Endometrial Cells of Undetermined Significance Followed by Negative Cytology. Acta Cytol 2022; 66:420-425. [PMID: 35421861 DOI: 10.1159/000524145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/15/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION In Japan, endometrial cytology is widely performed to evaluate the status of the endometrium in women with suspected endometrial cancer. A new classification system for endometrial cytology has recently been used: the Yokohama system, based on a descriptive reporting format. This study aimed to clarify the triage for patients with atypical endometrial cells of undetermined significance (ATEC-US) when followed by negative endometrial cytology. METHODS We enrolled patients diagnosed with ATEC-US at the Cancer Institute Hospital between January 2016 and December 2017, based on the following inclusion criteria: (1) ATEC-US diagnosed by office endometrial cytology, with or without office endometrial biopsy; (2) follow-up endometrial cytology was performed 3-6 months after initial sampling, with a negative result for malignancy; and (3) no prior history of conservative treatment with progestin for endometrial cancer or atypical endometrial hyperplasia (ATEC-A). Among eligible patients, we analyzed those later diagnosed by endometrial biopsy with ATEC-A or carcinoma. RESULTS Among 187 patients, 65 met the inclusion criteria. Forty-two patients (64.6%) were observed for more than 24 months. Two patients (3.1%) developed ATEC-A during a median observation time of 26.5 months; the times to diagnosis were 32 months and 22 months. DISCUSSION/CONCLUSION No patient developed ATEC-A or worse within 1 year. For patients with ATEC-US, if negative cytology is obtained at the next examination, a close follow-up is not necessary.
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Affiliation(s)
- Hidetaka Nomura
- Department of Gynecology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yuko Sugiyama
- Department of Gynecology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shogo Nishino
- Department of Gynecology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ai Ikki
- Department of Gynecology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Atsushi Murakami
- Department of Gynecology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tsuyoshi Matsumoto
- Department of Gynecology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Atsushi Fusegi
- Department of Gynecology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Makiko Omi
- Department of Gynecology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoichi Aoki
- Department of Gynecology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akiko Abe
- Department of Gynecology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Terumi Tanigawa
- Department of Gynecology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Sachiho Netsu
- Department of Gynecology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Sanshiro Okamoto
- Department of Gynecology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kohei Omatsu
- Department of Gynecology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Mayu Yunokawa
- Department of Gynecology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiroyuki Kanao
- Department of Gynecology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
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He YJ, Wang YQ, Dai YB, Zhou R, Lu Q, Liu GL, Wang JL. [Clinical outcomes analysis of fertility-preserving therapy for atypical endometrial hyperplasia and early endometrial carcinoma]. Zhonghua Zhong Liu Za Zhi 2022; 44:291-296. [PMID: 35316880 DOI: 10.3760/cma.j.cn112152-20201014-00897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Objective: To analyze the clinical efficacy of fertility-preserving therapy in patients with atypical endometrial hyperplasia (AEH) and early endometrial carcinoma (EC). Methods: The general condition, pathological type, treatment plan, tumor outcomes and pregnancy outcomes of 110 patients with AEH and EC treated with fertility-preserving therapy in Peking University People's Hospital from December 2005 to September 2019 were retrospectively analyzed. Kaplan-Meier and Log rank tests were used for survival analysis. Results: The response rate of 110 cases of AEH (62 cases) and EC (48 cases) was 94.5% (104/110) after fertility-preserving therapy. There were 93 cases (84.5%) achieved complete response and 11 cases (10.0%) achieved partial response, and the recurrence rate was 29.0% (27/93). The complete response rates of AEH and EC were 90.3% (56/62) and 77.1% (37/48), respectively, without significant difference (P=0.057). The recurrence rates of EC were significantly higher than that of AEH (40.5% vs 21.4%; P=0.022). Forty-one patients with complete response had pregnancy intention, the pregnancy rate was 70.7% (29/41), and the live birth rate was 56.1% (23/41). The live birth rate of AEH was 68.2% (15/22) and that of EC was 42.1% (8/19), the difference was statistically significant (P=0.032). The pathological type was related with the recurrence (P=0.044). Conclusions: Patients with AEH and EC can obtain high complete response rate and pregnancy rate after fertility-preserving therapy. The recurrence rate of EC is higher than that of AEH, while the live birth rate of AEH is higher than that of EC.
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Affiliation(s)
- Y J He
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing 100044, China
| | - Y Q Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing 100044, China
| | - Y B Dai
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing 100044, China
| | - R Zhou
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing 100044, China
| | - Q Lu
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing 100044, China
| | - G L Liu
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing 100044, China
| | - J L Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing 100044, China
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Ganesan R, Gilks CB, Soslow RA, McCluggage WG. Survey on Reporting of Endometrial Biopsies From Women on Progestogen Therapy for Endometrial Atypical Hyperplasia/Endometrioid Carcinoma. Int J Gynecol Pathol 2022; 41:142-150. [PMID: 33935157 PMCID: PMC10284089 DOI: 10.1097/pgp.0000000000000791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Histologic assessment of response to progestogen therapy is a cornerstone of nonsurgical management of atypical hyperplasia/low-grade endometrioid carcinoma. Pathologists are required to assess whether there is ongoing preneoplastic or neoplastic change in the biopsies (often multiple) taken during therapy. There have been few studies documenting the specific histologic changes induced by therapeutic progestogens and currently there are no guidelines on terminology used in this scenario. Given the need for uniformity in reporting and the lack of guidance in the current literature, we initiated an online survey (including questions, categories of reporting, and scanned slides for assessment) which was sent to all members of British Association of Gynaecological Pathologists (BAGP) and the International Society of Gynecological Pathologists (ISGyP) with the aim to assess the variability among pathologists in reporting these specimens and to come up with a consensus-based terminology for reporting of endometrial biopsies from women on progestogen therapy for endometrial atypical hyperplasia/endometrioid carcinoma. In total, 95 pathologists participated in this survey. This manuscript elaborates on the results of the survey with recommendations aimed at promoting uniform terminology in reporting these biopsies.
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Affiliation(s)
- Raji Ganesan
- Department of Cellular Pathology, Birmingham Women’s Hospital, Birmingham, United Kingdom
| | - C Blake Gilks
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Robert A Soslow
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - W Glenn McCluggage
- Department of Pathology, Belfast Health and Social Care Trust, Belfast, United Kingdom
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Contreras NA, Sabadell J, Verdaguer P, Julià C, Fernández-Montolí ME. Fertility-Sparing Approaches in Atypical Endometrial Hyperplasia and Endometrial Cancer Patients: Current Evidence and Future Directions. Int J Mol Sci 2022; 23:ijms23052531. [PMID: 35269674 PMCID: PMC8910633 DOI: 10.3390/ijms23052531] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 12/12/2022] Open
Abstract
Endometrial cancer (EC) is the fourth most common cancer in women in developed countries. Although it is usually diagnosed in postmenopausal women, its incidence has increased in young women, as well in recent decades, with an estimated rate of 4% in those under 40 years of age. Factors involved in this increase, particularly in resource-rich countries, include delayed childbearing and the rise in obesity. The new molecular classification of EC should help to personalize treatment, through appropriate candidate selection. With the currently available evidence, the use of oral progestin either alone or in combination with other drugs such as metformin, levonorgestrel-releasing intrauterine devices and hysteroscopic resection, seems to be feasible and safe in women with early-stage EC limited to the endometrium. However, there is a lack of high-quality evidence of the efficacy and safety of conservative management in EC. Randomized clinical trials in younger women and obese patients are currently underway.
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Affiliation(s)
| | - Jordi Sabadell
- Department of Gynaecology, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain;
| | - Paula Verdaguer
- Department of Gynaecology-ASSIR, Ronda General Prim 35, Mataró, 08302 Barcelona, Spain;
| | - Carla Julià
- Department of Gynaecology, Hospital de Viladecans, Avda de Gavà 38, Viladecans, 08840 Barcelona, Spain;
| | - Maria-Eulalia Fernández-Montolí
- Department of Gynaecology, Hospital Universitari de Bellvitge, Universitat de Barcelona-IDIBELL, Feixa Llarga s/n, L´Hospitalet de LLobregat, 08907 Barcelona, Spain
- Correspondence: or
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Liu J, Xu W. Naringenin and morin reduces insulin resistance and endometrial hyperplasia in the rat model of polycystic ovarian syndrome through enhancement of inflammation and autophagic apoptosis. Acta Biochim Pol 2022; 69:91-100. [PMID: 35143137 DOI: 10.18388/abp.2020_5722] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 10/25/2021] [Indexed: 11/10/2022]
Abstract
Polycystic Ovary Syndrome (PCOS) is a gynecologic disorder with unsatisfactory treatment options. Hyperandrogenism and insulin resistance (IR) are two symptoms of PCOS. The majority of PCOS patients (approximately 50% to 70%) have IR and moderate diffuse inflammation of varying degrees. We investigated in-vitro and in-vivo effects of naringenin, morin and their combination on PCOS induced endometrial hyperplasia by interfering with the mTORC1 and mTORC2 signaling pathways. The vaginal smear test ensured the regular oestrous cycles in female rats. Serum cytokines (TNF-α and IL-6) were assessed using the ELISA test, followed by in-vivo and in-vitro determination of prominent gene expressions (mTORC1and C2, p62, LC3-II, and Caspase-3 involved in the inflammatory signaling mechanisms through RT-PCR, western bloting, or immunohistochemical analysis. In addition, the viability of naringenin or morin treated cells was determined using flow cytometry analysis. The abnormal oestrous cycle and vaginal keratosis indicated that PCOS was induced successfully. The recovery rate of the oestrous cycle with treatments was increased significantly (P<0.01) when compared to the PCOS model. Narigenin, morin, or a combination of the two drugs substantially decreased serum insulin, TNF-α, IL-6 levels with improved total anti-oxidant capacity and SOD levels (P<0.01). Treatments showed suppression of HEC-1-A cells proliferation with increased apoptosis (P<0.01) by the upregulation of Caspase-3 expression, followed by downregulation of mTORC, mTORC1, and p62 (P<0.01) expressions with improved LC3-II expressions (P<0.05) respectively. The histological findings showed a substantial increase in the thickness of granulose layers with improved corpora lutea and declined the number of cysts. Our findings noticed improved inflammatory and oxidative microenvironment of ovarian tissues in PCOS treated rats involving the autophagic and apoptotic mechanisms demonstrating synergistic in-vitro and in-vivo therapeutic effects of treatments on PCOS-induced endometrial hyperplasia.
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Affiliation(s)
- Jiuying Liu
- Department of Gynecology and Obstetrics, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, P.R. China
| | - Weiwei Xu
- Department of Gynecology and Obstetrics, Second People's Hospital of Huanggang, Huanggang, Hubei, 438315, P.R. China
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Kong WY, Liu ZA, Zhang N, Wu X, Zhao XB, Yan L. A Prospective Cohort Study of Metformin as an Adjuvant Therapy for Infertile Women With Endometrial Complex Hyperplasia/Complex Atypical Hyperplasia and Their Subsequent Assisted Reproductive Technology Outcomes. Front Endocrinol (Lausanne) 2022; 13:849794. [PMID: 35846327 PMCID: PMC9280669 DOI: 10.3389/fendo.2022.849794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/12/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To investigate the adjuvant efficacy of metformin treatment to achieve pathological complete response (CR) in patients with endometrial complex hyperplasia (CH) and complex atypical hyperplasia (CAH), and secondarily, to evaluate their pregnancy outcomes after following assisted reproductive technology (ART). STUDY DESIGN This prospective cohort study analyzed 219 patients diagnosed with infertility and CH/CAH from January 2016 to December 2020. Among these patients, 138 were assigned to the control group (progesterone alone) and 81 were assigned to the study group (progesterone+metformin). After 8/12 weeks of therapy, the treatment responses were assessed by histological examination of curettage specimens obtained by hysteroscopy. Once the pathological results indicated CR, the patients were able to receive ART. The ART treatment and follow-up data of these patients were collected and analyzed. RESULTS 116 patients in the control group achieved CR, compared with 76 patients in the study group. The CR rate in the control group was significantly lower than that in the study group (P=0.034). We then divided the patients into subgroups to compare the treatment responses. In the subgroup analyses, patients with body mass index (BMI) ≥25 kg/m2 and patients with polycystic ovarian syndrome (PCOS) had higher CR rates in the metformin group compared with the control group (P=0.015, P=0.028 respectively). Subsequently, 68 patients in the control group and 47 patients in the study group received an ART cycle. We examined the pregnancy indications and found no significant differences in the clinical pregnancy rate and live birth rate between the two groups (P>0.05). CONCLUSION Regression of CH/CAH may be improved by progesterone+metformin compared with progesterone alone. The effect was particularly pronounced in patients with BMI ≥25 kg/m2 and patients with PCOS. Metformin had no obvious effect on subsequent ART outcomes. The trial is registered on the publicly accessible website. CLINICAL TRIAL REGISTRATION http://www.chictr.org.cn/showproj.aspx?proj=15372, identifier ChiCTR-ONR-16009078.
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Affiliation(s)
- Wei-ya Kong
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Zheng-ai Liu
- Department of Reproduction, Maternal and Child Health Hospital of Zoucheng, Zoucheng, China
| | - Na Zhang
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xue Wu
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xing-bo Zhao
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- *Correspondence: Xing-bo Zhao, ; Lei Yan,
| | - Lei Yan
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
- *Correspondence: Xing-bo Zhao, ; Lei Yan,
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Guan J, Chen XJ. The present status of metformin in fertility-preserving treatment in atypical endometrial hyperplasia and endometrioid endometrial cancer. Front Endocrinol (Lausanne) 2022; 13:1041535. [PMID: 36387903 PMCID: PMC9646621 DOI: 10.3389/fendo.2022.1041535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 10/17/2022] [Indexed: 11/13/2022] Open
Abstract
Progestin therapy is the main fertility-sparing treatment for women with endometrial cancer (EC) and atypical endometrial hyperplasia (AEH). However, still 15-25% of these women failed to achieve complete response (CR) and then lost their fertility after definitive surgery. Metformin has been demonstrated to play an anti-cancer role in multiple cancers including EC. Several studies also suggested metformin had potential benefit in improving the therapeutic outcome of fertility-preserving treatment alongside with progestin. This review has discussed existed evidence regarding the effect of metformin combined with progestin for women with AEH and EC who desire childbearing. Nevertheless, the therapeutic effect of metformin varied in different studies due to the high heterogeneity in the patient's characteristics, the inconsistency in dose and treatment duration of metformin, the combined use of hysteroscopy, the insufficient sample size and underpowered study-design. Therefore, care should be taken when interpreting the current results on this issue. Till now, there is still no strong evidence supporting the use of metformin in fertility-preserving treatment in AEH and EEC patients. Further research is needed to provide high-quality data to validate the role of metformin as adjunctive therapy alongside with progestin to preserve fertility for AEH and EEC patients.
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Affiliation(s)
- Jun Guan
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Xiao-Jun Chen
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
- *Correspondence: Xiao-Jun Chen,
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Vahedpour Z, Boroumand H, Tabatabaee Anaraki S, Tabasi Z, Motedayyen H, Akbari H, Raygan F, Ostadmohammadi V. Effects of Isoflavone Supplementation on the Response to Medroxyprogesterone in Premenopausal Women with Nonatypical Endometrial Hyperplasia: A Randomized, Double-Blind, Placebo-Controlled Trial. Int J Clin Pract 2022; 2022:1263544. [PMID: 36531558 PMCID: PMC9715344 DOI: 10.1155/2022/1263544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 11/03/2022] [Accepted: 11/17/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate the impact of isoflavone supplementation compared with placebo on endometrial histology and serum estradiol levels in premenopausal women with nonatypical endometrial hyperplasia. MATERIALS AND METHODS The present double-blindplacebo-controlled clinical trial was conducted on 100 women with nonatypical endometrial hyperplasia in the age range of 30 to 45 years. Participants were randomly assigned to receive 50 mg of isoflavone (n = 50) or placebos (n = 50) daily for three months. Both groups received the standard treatment of nonatypical endometrial hyperplasia. Endometrial biopsy and blood samples were taken at the baseline and three months after the intervention. The incidence of drug side effects was assessed as well. RESULTS After three months, 88.4% of isoflavone-administered subjects had a significant histological improvement compared to 68.9% subjects in the placebo group (P=0.02). There were no significant differences between the two groups in the changes of serum estradiol levels and the incidence of drug side effects. CONCLUSION The findings of the present study demonstrated that the coadministration of 50 mg of isoflavones and medroxyprogesterone acetate increases the treatment efficacy in women with nonatypical endometrial hyperplasia. Clinical Trial Registration. This trial was registered on the Iranian website for clinical trial registration (https://www.irct.ir/trial/53553).
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Affiliation(s)
- Zahra Vahedpour
- Department of Gynecology and Obstetrics, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Homa Boroumand
- Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Shirin Tabatabaee Anaraki
- Department of Gynecology and Obstetrics, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Zohre Tabasi
- Department of Gynecology and Obstetrics, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Hossein Motedayyen
- Autoimmune Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Hossein Akbari
- Department of Biostatistics and Epidemiology, Faculty of Public Health, Kashan University of Medical Sciences, Kashan, Iran
| | - Fariba Raygan
- Department of Cardiology, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
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Luijten MMW, van Weelden WJ, de Kroon CD, Pijnenborg JMA, van Gent MDJM. [Fertility sparing treatment of endometrial carcinoma]. Ned Tijdschr Geneeskd 2021; 165:D5765. [PMID: 35129891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND The incidence of endometrial carcinoma (EC) is rising worldwide due to an increased life expectancy and obesity. Approximately 2% of patients with EC is under the age of 45. Because the incidence is also rising in young women, there is a clinical need for safe fertility sparing alternative treatments. CASE DESCRIPTION A 32-year-old women was diagnosed with low-grade endometrioid EC. Hysteroscopic tumour resection and progestin treatment resulted in complete tumour regression. The patient became pregnant through in vitro fertilisation (IVF). CONCLUSION This case illustrates that fertility sparing treatment, with oral progestin treatment is an alternative treatment option in selected young women with low grade, early stage endometrial carcinoma to achieve pregnancy. This treatment is internationally accepted.
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Fan Y, Li X, Wang J, Wang Y, Tian L, Wang J. Analysis of pregnancy-associated factors after fertility-sparing therapy in young women with early stage endometrial cancer or atypical endometrial hyperplasia. Reprod Biol Endocrinol 2021; 19:118. [PMID: 34344384 PMCID: PMC8330111 DOI: 10.1186/s12958-021-00808-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 07/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fertility-sparing therapy is an alternative conservative treatment for patients with early stage endometrioid cancer or atypical endometrial hyperplasia. In this study, we investigated pregnancy outcomes and pregnancy-associated factors in young patients receiving hormonal therapy. METHODS We retrospectively analyzed 68 patients who attempted to conceive after fertility-sparing therapy and achieving complete remission (CR). They were divided into a pregnancy group and a non-pregnancy group. A Cox proportional hazard regression model was applied for univariate and multivariate analysis to determine factors associated with pregnancy. Kaplan-Meier analysis, combined with the log-rank test, was used to calculate a patient's pregnancy probability and the distribution of recurrence-free survival (RFS). RESULTS A total of 36 patients became pregnant with 47 pregnancies. Univariate and multivariate Cox analysis revealed that several factors were associated with pregnancy, including BMI at the time of pregnancy permission, the time to CR, prolonged treatment time, the number of hysteroscopy procedures, the endometrium thickness after CR, and relapse before pregnancy. The mean RFS of patients who achieved pregnancy, and those who did not, was 27.6 months and 14.8 months, respectively (P = 0.002). No significant difference was detected in terms of cumulative RFS when compared between assisted reproductive technology (ART) cases and those involving natural conception (NC) (P = 0.707). CONCLUSIONS Normal BMI, a shorter time to CR, a prolonged three-month treatment, fewer hysteroscopy procedures, and a thicker endometrium may be positive indicators for successful pregnancies, while relapse before pregnancy may have a negative effect on conception. Moreover, a successful pregnancy protects the endometrium while ART does not increase the risk of recurrence.
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Affiliation(s)
- Yuan Fan
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
| | - Xingchen Li
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
| | - Jiaqi Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
| | - Yiqin Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China
| | - Li Tian
- Reproductive Medical Center, Peking University People's Hospital, Beijing, 100044, China.
| | - Jianliu Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, 100044, China.
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Zhang M, Zhang T, Song C, Qu J, Gu Y, Liu S, Li H, Xiao W, Kong L, Sun Y, Lv W. Guizhi Fuling Capsule ameliorates endometrial hyperplasia through promoting p62-Keap1-NRF2-mediated ferroptosis. J Ethnopharmacol 2021; 274:114064. [PMID: 33771639 DOI: 10.1016/j.jep.2021.114064] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/01/2021] [Accepted: 03/18/2021] [Indexed: 06/12/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Guizhi Fuling Capsule (GFC) is a classical traditional Chinese medicine officially recorded in Synopsis of the Golden Chamber and has long been used to treat gynecological diseases in China. However, scientific evidence for the anti-endometrial hyperplasia potential of GFC used in traditional medicine is lacking. AIM OF THE STUDY This study evaluated whether GFC protects against endometrial hyperplasia and its potential mechanism in mice. METHODS AND MATERIALS We used estrogen (estradiol) to induce endometrial hyperplasia in mice. C57BL/6 mice were treated with estradiol subcutaneously for 21 days, and GFC (75 mg/kg and 150 mg/kg) was given intragastric administration from the first day of the modeling. H&E staining is used to evaluate endometrial tissue structure change. Malondialdehyde was measured to explore lipid peroxidation. Western blot, immunohistochemistry and immunofluorescence were performed to observe the expressions of GPX4, p62, Keap1 and NRF2. RESULTS The degree of ferroptosis in endometrial tissue of patients with endometrial hyperplasia was lower than normal endometrial tissue. In addition, ferroptosis inducer imidazole ketone erastin could improve endometrial hyperplasia in mice. Interestingly, GFC significantly alleviated endometrial hyperplasia through triggering ferroptosis. Furthermore, GFC inhibited p62-Keap1-NRF2 pathway in estradiol-induced endometrial hyperplasia model. CONCLUSIONS GFC may attenuate estrogen-induced endometrial hyperplasia in mice through triggering ferroptosis via inhibiting p62-Keap1-NRF2 pathway. These findings suggest that GFC might act as a promising traditional Chinese medicine to treat endometrial hyperplasia.
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Affiliation(s)
- Minyi Zhang
- Department of Gynecology, Tongde Hospital of Zhejiang Province, 234 Gucui Road, Hangzhou, 310012, China
| | - Tao Zhang
- State Key Laboratory of Pharmaceutical Biotechnology, Department of Biotechnology and Pharmaceutical Sciences, School of Life Sciences, Nanjing University, 163 Xianlin Ave, Nanjing, 210023, China
| | - Chenglin Song
- State Key Laboratory of Pharmaceutical Biotechnology, Department of Biotechnology and Pharmaceutical Sciences, School of Life Sciences, Nanjing University, 163 Xianlin Ave, Nanjing, 210023, China
| | - Jiao Qu
- State Key Laboratory of Pharmaceutical Biotechnology, Department of Biotechnology and Pharmaceutical Sciences, School of Life Sciences, Nanjing University, 163 Xianlin Ave, Nanjing, 210023, China
| | - Yanpin Gu
- Department of Gynecology, Tongde Hospital of Zhejiang Province, 234 Gucui Road, Hangzhou, 310012, China
| | - Songjun Liu
- Department of Gynecology, Tongde Hospital of Zhejiang Province, 234 Gucui Road, Hangzhou, 310012, China
| | - Haibo Li
- Jiangsu Kanion Pharmaceutical Co. Ltd. and State Key Laboratory of New-tech for Chinese Medicine Pharmaceutical Process, Jiangsu, Lianyungang, 222001, China
| | - Wei Xiao
- Jiangsu Kanion Pharmaceutical Co. Ltd. and State Key Laboratory of New-tech for Chinese Medicine Pharmaceutical Process, Jiangsu, Lianyungang, 222001, China
| | - Lingdong Kong
- State Key Laboratory of Pharmaceutical Biotechnology, Department of Biotechnology and Pharmaceutical Sciences, School of Life Sciences, Nanjing University, 163 Xianlin Ave, Nanjing, 210023, China
| | - Yang Sun
- State Key Laboratory of Pharmaceutical Biotechnology, Department of Biotechnology and Pharmaceutical Sciences, School of Life Sciences, Nanjing University, 163 Xianlin Ave, Nanjing, 210023, China.
| | - Wen Lv
- Department of Gynecology, Tongde Hospital of Zhejiang Province, 234 Gucui Road, Hangzhou, 310012, China; Center for Uterine Cancer Diagnosis & Therapy Research in Zhejiang Province, Hangzhou, 310012, China.
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Zhang G, Yu X, Sun Z, Zhu L, Lang J. Value of endometrial thickness in diagnosis of endometrial hyperplasia during selective estrogen receptor modulator therapy in premenopausal breast cancer patients. J Gynecol Obstet Hum Reprod 2020; 50:101929. [PMID: 33022449 DOI: 10.1016/j.jogoh.2020.101929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 07/12/2020] [Accepted: 09/30/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The weak estrogenic-like effect of selective estrogen receptor modulator (SERM) may lead to series of endometrial lesions, including proliferation, hyperplasia, polyp formation, and even endometrial cancer. This study aimed to explore the effectiveness of different endometrial thickness in diagnosis of endometrial hyperplasia during SERM therapy in premenopausal patients. METHODS The clinical data of 115 patients receiving hysteroscopic endometrial biopsy during SERM therapy in Peking Union Medical College Hospital, China from January 2010 to December 2018 were retrospectively analyzed. RESULTS Average age at the beginning of SERM therapy was 43.4 ± 5.7 years old. Mean duration time of SERM therapy was 31.0 ± 22.1 months. The mean endometrial thickness was 14.3 ± 6.1 mm. 4 cases of atypical endometrial hyperplasia (3.5 %), and 4 cases of endometrial hyperplasia without atypia (3.5 %) were detected. Endometrial thickness was higher in endometrial hyperplasia patients than in no endometrial hyperplasia patients (18.8 vs 13.9 mm, p = 0.029). Endometrial thickness in 8 out of 8 endometrial hyperplasia patients and 38 out of 107 no endometrial hyperplasia patients were ≥ 15 mm (p = 0.002). The negative predictive value in the diagnosis of endometrial hyperplasia during SERM therapy in premenopausal patients was 100 % when endometrial thickness < 15 mm chosen as cutoff value. CONCLUSION Endometrial hyperplasia was less likely to occur in premenopausal patients during SERM therapy when endometrial thickness < 15 mm.
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Affiliation(s)
- Guorui Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Xin Yu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Zhijing Sun
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Lan Zhu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China.
| | - Jinghe Lang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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Abstract
BACKGROUND In the absence of treatment, endometrial hyperplasia (EH) can progress to endometrial cancer, particularly in the presence of histologic nuclear atypia. The development of EH results from exposure of the endometrium to oestrogen unopposed by progesterone. Oral progestogens have been used as treatment for EH without atypia, and in some cases of EH with atypia in women who wish to preserve fertility or who cannot tolerate surgery. EH without atypia is associated with a low risk of progression to atypia and cancer; EH with atypia is where the cells are structurally abnormal, and has a higher risk of developing cancer. Oral progestogen is not always effective at reversing the hyperplasia, can be associated with side effects, and depends on patient adherence. The levonorgestrel-intrauterine system (LNG-IUS) is an alternative method of administration of progestogen and may have some advantages over non-intrauterine progestogens. OBJECTIVES To evaluate the effectiveness and safety of the levonorgestrel intrauterine system (LNG-IUS) in women with endometrial hyperplasia (EH) with or without atypia compared to medical treatment with non-intrauterine progestogens, placebo, surgery or no treatment. SEARCH METHODS We searched the following databases: the Cochrane Gynaecology and Fertility Group (CGF) Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO, and conference proceedings of 10 relevant organisations. We handsearched references in relevant published studies. We also searched ongoing trials in ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry, and other trial registries. We performed the final search in May 2020. SELECTION CRITERIA Randomised controlled trials (RCTs) and cross-over trials of women with a histological diagnosis of endometrial hyperplasia with or without atypia comparing LNG-IUS with non-intrauterine progestogens, placebo, surgery or no treatment. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. Our primary outcome measures were regression of EH and adverse effects associated with the LNG-IUS device (such as pelvic inflammatory disease, device expulsion, uterine perforation) when compared to treatment with non-intrauterine progestogens, placebo, surgery or no treatment. Secondary outcomes included hysterectomy, hormone-related adverse effects (such as bleeding/spotting, pelvic pain, breast tenderness, ovarian cysts, weight gain, acne), withdrawal from treatment due to adverse effects, satisfaction with treatment, and cost or resource use. We rated the overall quality of evidence using GRADE methods. MAIN RESULTS Thirteen RCTs (1657 women aged 22 to 75 years) met the inclusion criteria. Two studies had insufficient data for meta-analysis, thus the quantitative analysis included 11 RCTs. All trials evaluated treatment duration of six months or less. The evidence ranged from very low to moderate quality: the main limitations were risk of bias (associated with lack of blinding and poor reporting of study methods), inconsistency and imprecision. LNG-IUS versus non-intrauterine progestogens Primary outcomes Regression of endometrial hyperplasia The LNG-IUS probably improves regression of EH compared with non-intrauterine progestogens at short-term follow-up (up to six months) (OR 2.94, 95% CI 2.10 to 4.13; I² = 0%; 10 RCTs, 1108 participants; moderate-quality evidence). This suggests that if regression of EH following treatment with a non-intrauterine progestogen is assumed to be 72%, regression of EH following treatment with LNG-IUS would be between 85% and 92%. Regression of EH may be improved by LNG-IUS compared with non-intrauterine progestogens at long-term follow-up (12 months) (OR 3.80, 95% CI 1.75 to 8.23; 1 RCT, 138 participants; low-quality evidence), Adverse effects associated with LNG-IUS There was insufficient evidence to determine device-related adverse effects; only one study reported on expulsion with insufficient data for analysis. Secondary outcomes The LNG-IUS may be associated with fewer hysterectomies (OR 0.26, 95% CI 0.15 to 0.46; I² = 19%; 4 RCTs, 452 participants; low-quality evidence), fewer withdrawals from treatment due to hormone-related adverse effects (OR 0.41, 95% CI 0.12 to 1.35; I² = 0%; 4 RCTs, 360 participants; low-quality evidence) and improved patient satisfaction with treatment (OR 5.28, 95% CI 2.51 to 11.10; I² = 0%; 2 RCTs, 202 participants; very low-quality evidence) compared to non-intrauterine progestogens. The LNG-IUS may be associated with more bleeding/spotting (OR 2.13, 95% CI 1.33 to 3.43; I² = 78%; 3 RCTs, 428 participants) and less nausea (OR 0.52, 95% CI 0.28 to 0.95; I² = 0%; 3 RCTs, 428 participants) compared to non-intrauterine progestogens. Data from single trials for mood swings and fatigue had a similar direction of effect as for bleeding/spotting, nausea and weight gain. There was insufficient evidence to determine cost or resource use. LNG-IUS versus no treatment Regression of endometrial hyperplasia One study demonstrated that the LNG-IUS is associated with regression of EH without atypia (OR 78.41, 95% CI 22.86 to 268.97; I² = 0%; 1 RCT, 190 participants; moderate-quality evidence) compared with no treatment. This study did not report on any other review outcome. AUTHORS' CONCLUSIONS There is moderate-quality evidence that treatment with LNG-IUS used for three to six months is probably more effective than non-intrauterine progestogens at reversing EH in the short term (up to six months) and long term (up to two years). Adverse effects (device-related and hormone-related) were poorly and incompletely reported across studies. Very low quality to low-quality evidence suggests the LNG-IUS may reduce the risk of hysterectomy, and may be associated with more bleeding/spotting, less nausea, less withdrawal from treatment due to adverse effects, and increased satisfaction with treatment, compared to non-intrauterine progestogens. There was insufficient evidence to reach conclusions regarding device-related adverse effects, or cost or resource use.
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Affiliation(s)
- Theresa Mittermeier
- Department of Obstetrics and Gynaecology, Auckland District Health Board, Auckland, New Zealand
| | | | - Michelle R Wise
- Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
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Sletten ET, Smaglyukova N, Ørbo A, Sager G. Expression of nuclear progesterone receptors (nPRs), membrane progesterone receptors (mPRs) and progesterone receptor membrane components (PGRMCs) in the human endometrium after 6 months levonorgestrel low dose intrauterine therapy. J Steroid Biochem Mol Biol 2020; 202:105701. [PMID: 32479983 DOI: 10.1016/j.jsbmb.2020.105701] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/11/2020] [Accepted: 05/15/2020] [Indexed: 02/08/2023]
Abstract
The classical steroid receptors (nuclear receptors), including those for progesterone (nPRs), are thoroughly characterized. The knowledge about so-called non-genomic effects, which are mediated by extra-nuclear initiated signals, has increased immensely the last decades. In a previous clinical study of endometrial hyperplasia, we observed that the antiproliferative progestin effect persisted after 3 months treatment with levonorgestrel (LNG) intrauterine system (IUS) even with a complete downregulation of nPRs. This raised the question of what other mechanisms than signaling through nPRs could explain such an observation. In the present study, RT-qPCR was employed to characterize mRNA expression for nPRs, membrane progesterone receptors (mPRs) and progesterone receptor membrane components (PGRMCs) in women (n = 42) with endometrial hyperplasia that received intrauterine low dose LNG for 6 months. At the end of this period endometrial tissue showed that nPRs were virtually completely downregulated (≈ 10 % of baseline) whereas the levels of remaining mPRs, subtype-α, -β and -γ were 76 %, 59 % and 73 % of baseline, respectively. PGRMC1 was downregulated to 15 % of baseline, in contrast to PGRMC2, which was upregulated to about 30 % above baseline. We used human cancer cells from uterine cervix (C-4I cells) as control. Progesterone caused a concentration-dependent antiproliferative effect but in several and separate studies, we were unable to detect nPRs (immunocytochemistry) in the C-4I cells. The use of RT-qPCR showed that nPRs were undetectable in C-4I cells, in contrast to mPRs and PGRMCs with a distinct mRNA expression. The present study suggests that mPRs and/or PGRMCs preserve the antiproliferative effect of LNG in the human endometrium and are responsible for the concentration-dependent antiproliferative effect of progesterone in C-4I cells.
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Affiliation(s)
- Elise Thoresen Sletten
- Department of Gynecologic Oncology, Clinic for Surgery, Cancer and Women's Diseases, University Hospital of North Norway, Tromsø, Norway; Research group for Gynecologic Oncology, Department of Medical Biology, Faculty of Health Sciences, The Arctic University of Norway, Tromsø, Norway; Department of Clinical Medicine, Faculty of Health Sciences, The Arctic University of Norway, Tromsø, Norway
| | - Natalia Smaglyukova
- Research group for Experimental and Clinical Pharmacology, Department of Medical Biology, The Arctic University of Norway, Tromsø, Norway
| | - Anne Ørbo
- Research group for Gynecologic Oncology, Department of Medical Biology, Faculty of Health Sciences, The Arctic University of Norway, Tromsø, Norway; Department of Clinical Pathology, University Hospital of North Norway, Tromsø, Norway
| | - Georg Sager
- Research group for Experimental and Clinical Pharmacology, Department of Medical Biology, The Arctic University of Norway, Tromsø, Norway; Clinical Pharmacology, Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway.
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Xu Z, Tian Y, Fu J, Xu J, Bao D, Wang G. Efficacy and prognosis of fertility-preserved hysteroscopic surgery combined with progesterone in the treatment of complex endometrial hyperplasia and early endometrial carcinoma. J BUON 2020; 25:1525-1533. [PMID: 32862600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE To evaluate the complete response (CR) rate, recurrence rate and pregnancy outcome of complex endometrial hyperplasia (CEH) and early endometrial carcinoma (EC) patients treated with hysteroscopic surgery combined with progesterone, and to analyze the related influencing factors for prognosis. METHODS The clinical data of 96 patients histopathologically diagnosed with CEH or early EC and treated with hysteroscopic surgery combined with levonorgestrel-releasing intrauterine system (LNG-IUS) and/or high-efficient megestrole acetale (MA) in our hospital from January 2014 to January 2016 were retrospectively analyzed. The hysteroscopic examination was performed for patients, and the improvement of endometrium was evaluated via curettage every 3 months after treatment. The recurrence, pregnancy and fertility conditions after CR were recorded through follow-up, and the influencing factors for prognosis were analyzed. RESULTS Among the 96 patients, there were 83 cases (86.5%) of CR and 11 cases (13.3%) of recurrence. Among the CR patients, 76 cases had the desire for pregnancy, and there were 46 cases (60.5%) of natural pregnancy or pregnancy using assisted reproductive technology after treatment. CR was achieved more easily in patients with a body mass index (BMI) <30 kg/m2. Moreover, the BMI <30 kg/m2 and pregnancy after CR could reduce the recurrence rate, and BMI <30 kg/m2 and assisted reproductive technology could improve the pregnancy outcome after remission. CONCLUSIONS For CEH and early EC patients who strongly urge to preserve the fertility, hysteroscopic surgery combined with LNG-IUS and/or high-efficient progesterone can obtain satisfactory efficacy. Strictly controlling the body weight of patients with BMI ≥30kg/m2 can improve the remission rate and pregnancy rate and reduce the recurrence rate. Timely pregnancy after remission can reduce the recurrence rate, and the application of assisted reproductive technology can significantly enhance the pregnancy rate and live birth rate.
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Affiliation(s)
- Zonglan Xu
- Gynecology Ward 2, Linyi Central Hospital, Linyi, China
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Neal AS, Nunez M, Lai T, Tosevska A, Morselli M, Amneus M, Zakhour M, Moatamed NA, Pellegrini M, Memarzadeh S. Expression of Stromal Progesterone Receptor and Differential Methylation Patterns in the Endometrium May Correlate with Response to Progesterone Therapy in Endometrial Complex Atypical Hyperplasia. Reprod Sci 2020; 27:1778-1790. [PMID: 32124398 PMCID: PMC7395059 DOI: 10.1007/s43032-020-00175-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 02/03/2020] [Indexed: 12/22/2022]
Abstract
Progesterone therapy is a viable treatment for complex atypical hyperplasia (CAH) and endometrial adenocarcinoma, though reliable molecular determinants of response are not available. To explore if analysis of pre-therapy endometrial biopsies could yield biomarkers of response to progesterone, patients with CAH or adenocarcinoma undergoing treatment with progestins were included in this cross-sectional study. Immunohistochemistry for progesterone receptor (PR) was performed. Manual PR expression scores (PRES) were first calculated for biopsies by counting PR-positive nuclei in 12 sensitive vs 9 resistant samples. Significant differences in manual PRES were detected in the stroma (p < 0.01) and total endometrium (p < 0.01) for sensitive vs resistant patients. Manual PRES in the stroma had the highest accuracy in segregating sensitive vs resistant patients (96%). Differences in epithelial PRES were not significant. To validate these findings, a correlation between manual PRES and visual PRES was performed in the 21 patients. An additional 11 patients were analyzed to test if visual PRES would be predictive of response to progesterone. Visual PRES in epithelia and stroma in the 32 specimens was calculated. Significant differences in visual PRES were detected in the stroma for sensitive vs resistant samples (p < 0.01), while differences in epithelial and total endometrium were not significant. Whole genome bisulfite sequencing was performed on DNA isolated using pre-therapy biopsies from 6 sensitive and 6 resistant patients in this cohort. Differentially methylated regions were identified in the stroma and epithelium when evaluating sensitive vs resistant samples. Pathways involved in cell adhesion demonstrated the greatest difference in methylation in these samples.
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Affiliation(s)
- Adam S Neal
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, 90095, USA
- UCLA Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Miguel Nunez
- University of California San Fransisco School of Medicine, 516 Parnassus Avenue, San Fransisco, CA, 94143, USA
| | - Tiffany Lai
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, 90095, USA
- UCLA Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Anela Tosevska
- Department of Molecular, Cell and Developmental Biology, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Marco Morselli
- Institute for Genomics and Proteomics, University of California Los Angeles, Los Angeles, CA, 90095, USA
- Institute for Quantitative and Computational Biology-The Collaboratory, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Malaika Amneus
- Department of Obstetrics and Gynecology, Southern California Permanente Medical Group, Panorama City, CA, 91402, USA
| | - Mae Zakhour
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Neda A Moatamed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Matteo Pellegrini
- UCLA Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research, University of California Los Angeles, Los Angeles, CA, 90095, USA
- Department of Molecular, Cell and Developmental Biology, University of California Los Angeles, Los Angeles, CA, 90095, USA
- Institute for Quantitative and Computational Biology-The Collaboratory, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Sanaz Memarzadeh
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, 90095, USA.
- UCLA Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research, University of California Los Angeles, Los Angeles, CA, 90095, USA.
- Molecular Biology Institute, University of California Los Angeles, Los Angeles, CA, 90095, USA.
- The VA Greater Los Angeles Healthcare System, Los Angeles, CA, 90073, USA.
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Mitsuhashi A, Kawasaki Y, Hori M, Fujiwara T, Hanaoka H, Shozu M. Medroxyprogesterone acetate plus metformin for fertility-sparing treatment of atypical endometrial hyperplasia and endometrial carcinoma: trial protocol for a prospective, randomised, open, blinded-endpoint design, dose-response trial (FELICIA trial). BMJ Open 2020; 10:e035416. [PMID: 32114477 PMCID: PMC7050341 DOI: 10.1136/bmjopen-2019-035416] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Progestin therapy is the only fertility-sparing treatment option for patients with atypical endometrial hyperplasia (AEH) and endometrial cancer (EC). However, the results of three meta-analyses revealed a high remission rate, as well as an association with a high rate of relapse. We previously conducted a phase II of medroxyprogesterone acetate (MPA) plus metformin as a fertility-sparing treatment for AEH and EC patients, and reported that metformin inhibited disease relapse after remission. METHODS AND ANALYSIS A randomised, open, blinded-endpoint design phase IIb dose response trial was planned to commence in July 2019. The trial aims to identify the appropriate dose of metformin to be combined with MPA therapy for fertility-sparing treatment of patients with AEH and EC. The primary endpoint of the trial is the 3-year relapse-free survival (RFS) rate. The secondary endpoints are RFS rate, the overall rate of response to MPA therapy, the conception rate after treatment, the outcome of pregnancy, toxicity evaluation and changes in insulin resistance and body mass index. A total of 120 patients will be enrolled from 15 Japanese institutions within a 2.5-year period and followed up for at least 3 years. ETHICS AND DISSEMINATION The protocol was approved by the institutional review board at Chiba University Hospital and boards at 14 other institutions. The trial will be conducted according to the principles of the World Medical Association's Declaration of Helsinki and in accordance with Good Clinical Practice (GCP) standards. The trial findings will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER Japan Registry of Clinical Trials (jRCT2031190065).
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Affiliation(s)
- Akira Mitsuhashi
- Department of Reproductive Medicine, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
| | - Yohei Kawasaki
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Makoto Hori
- Clinical Research Center, Chiba University Hospital, Chiba, Chiba, Japan
| | - Tadami Fujiwara
- Clinical Research Center, Chiba University Hospital, Chiba, Chiba, Japan
| | - Hideki Hanaoka
- Clinical Research Center, Chiba University Hospital, Chiba, Chiba, Japan
| | - Makio Shozu
- Department of Reproductive Medicine, Chiba University Graduate School of Medicine School of Medicine, Chiba, Japan
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Ciccone MA, Whitman SA, Conturie CL, Brown N, Dancz CE, Özel B, Matsuo K. Effectiveness of progestin-based therapy for morbidly obese women with complex atypical hyperplasia. Arch Gynecol Obstet 2019; 299:801-808. [PMID: 30706187 DOI: 10.1007/s00404-019-05059-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 01/18/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE While progestins can effectively treat women with complex atypical hyperplasia (CAH), the impact of body habitus on treatment outcome is not well studied. We examine the association between body mass index (BMI) and progestin treatment outcomes. METHODS We conducted a retrospective cohort study of patients diagnosed with hyperplasia between 2003 and 2011. Demographics, past medical history, BMI, hormonal therapy, and histologic treatment response were abstracted. Patients with CAH who received progestin therapy were examined, and rates of regression were assessed. RESULTS Of 623 patients identified, 117 had CAH and satisfied the inclusion criteria. Median age was 34, and nearly, two-thirds (64%) were nulliparous. Mean BMI was 40.2, and 81% were obese (BMI 30-39.9: 36%, BMI ≥ 40: 45%). 103 patients (88%) received systemic progestin therapy and 14 patients (12%) received levonorgestrel-releasing intrauterine devices (LNG-IUS). 47 patients (40%) had a complete response to progestin-based therapy. BMI had no effect on the rate of complete response. The proportions of CAH patients with complete regression after hormonal therapy were BMI < 30: 39%, 30-39.9: 40%, and ≥ 40: 36% (P = 0.73). Women treated with LNG-IUS displayed higher rates of complete regression than those receiving systemic therapy (62% versus 38%, P = 0.096), and those with class III obesity were more likely than non-obese patients to receive LNG-IUS although neither reached statistical significance (< 40: 6.7% versus ≥ 40: 17%, P = 0.09). CONCLUSION In this morbidly obese population, response to progestin therapy was generally low; body habitus did not impact treatment outcome for CAH, but local therapy may be more effective than systemic therapy.
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Affiliation(s)
- Marcia A Ciccone
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD 520, Los Angeles, CA, 90089, USA
| | - Stephanie A Whitman
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Charlotte L Conturie
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Niquelle Brown
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Christina E Dancz
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Begum Özel
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD 520, Los Angeles, CA, 90089, USA.
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
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Abstract
BACKGROUND Endometrial carcinoma is the most common gynaecologic malignancy in the world and develops through preliminary stages of endometrial hyperplasia. Atypical endometrial hyperplasia suggests a significant pre-malignant state with frank progression to endometrial carcinoma, and tends to occur at a young age. Oral progestins have been used as conservative treatment in young women with atypical endometrial hyperplasia, but they are associated with poor tolerability and side effects that may limit their overall efficacy. So it has become increasingly important and necessary to find a safe and effective fertility-sparing treatment with better tolerability and fewer side effects than the options currently available. The levonorgestrel-releasing intrauterine system (LNG-IUS) has been used to provide endometrial protection in women with breast cancer who are on adjuvant tamoxifen. The antiproliferative function of levonorgestrel is thought to reduce the risk of endometrial hyperplasia. OBJECTIVES To determine the efficacy and safety of oral and intrauterine progestogens in treating atypical endometrial hyperplasia. SEARCH METHODS In July 2018 we searched CENTRAL; MEDLINE; Embase; CINAHL, PsycINFO and the China National Knowledge Infrastructure for relevant trials. Cochrane Gynaecology and Fertility (CGF) Specialised Register and Embase were searched in November 2018. We attempted to identify trials from references in published studies. We also searched for ongoing trials in five major clinical trials registries. SELECTION CRITERIA Randomised controlled trials (RCTs) of oral and intrauterine progestogens (LNG-IUS) versus each other or placebo in women with a confirmed histological diagnosis of simple or complex endometrial hyperplasia with atypia. DATA COLLECTION AND ANALYSIS Two review authors assessed trial eligibility and risk of bias and extracted the data. The primary outcomes of the review were rate of regression and adverse effects. Secondary outcomes included rate of recurrence and proportion of women undergoing hysterectomy. We have used GRADE methodology to judge the quality of the evidence. MAIN RESULTS We included one RCT (153 women) comparing the LNG-IUS administering 20 micrograms (μu) levonorgestrel per day versus 10 milligrams of continuous or cyclical oral medroxyprogesterone (MPA) for treating any type of endometrial hyperplasia. Only 19 women in this study were histologically confirmed with atypical complex hyperplasia before treatment. The evidence was of low or very low quality. The included study was at low risk of bias, but the quality of the evidence was very seriously limited by imprecision and indirectness. We did not find any RCTS comparing the LNG-IUS or oral progestogens versus placebo in women with atypical endometrial hyperplasia.Among the 19 women with atypical complex hyperplasia, after six months of treatment there was insufficient evidence to determine whether there was a difference in regression rates between the LNG-IUS group and the progesterone group (odds ratio (OR) 2.76, 95% confidence interval (CI) 0.26 to 29.73; 1 RCT subgroup, 19 women, very low-quality evidence). The rate of regression was 100% in the LNG-IUS group (n = 6/6) and 77% in the progesterone group (n = 10/13).Among the total study population (N = 153), over the six months' treatment the main adverse effects were nausea and vaginal bleeding. There was no evidence of a difference between the groups in rates of nausea (OR 0.58, 95% CI 0.28 to 1.18; 1 RCT, 153 women, very low-quality evidence). Vaginal bleeding was more common in the LNG-IUS group (OR 2.89, 95% CI 1.11 to 7.52; 1 RCT, 153 women, low-quality evidence). Except for nausea and vaginal bleeding, no other adverse effects were reported. AUTHORS' CONCLUSIONS We did not find any RCTS of women with atypical endometrial hyperplasia, and our findings derive from a subgroup of 19 women in a larger RCT. All six women who used the LNG-IUS system achieved regression of atypical hyperplasia, but there was insufficient evidence to draw any conclusions regarding the relative efficacy of LNG-IUS versus oral progesterone (MPA) in this group of women. When assessed in a population of women with any type of endometrial hyperplasia, there was no clear evidence of a difference between LNG-IUS and oral progesterone (MPA) in risk of nausea, but vaginal bleeding was more likely to occur in women using the LNG-IUS. Larger studies are necessary to assess the efficacy and safety of oral and intrauterine progestogens in treating atypical endometrial hyperplasia.
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Affiliation(s)
- Li Luo
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 20, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
- Ministry of EducationKey Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University)ChengduChina
| | - Bing Luo
- Chengdu Women and Children Central HospitalDepartment of Obstetrics and GynecologyNo.1617, Ri Yue StreetChengduSichuanChina610091
| | - Ying Zheng
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 20, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
- Ministry of EducationKey Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University)ChengduChina
| | - Heng Zhang
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyNo. 20, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
- Ministry of EducationKey Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University)ChengduChina
| | - Jing Li
- West China Hospital, Sichuan UniversityChinese Cochrane CentreNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Neil Sidell
- Emory University School of MedicineDepartment of Gynecology and Obstetrics1639 Pierce DriveAtlantaUSAWMB 4303 Atlanta
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Bahmani F, Rahimi Galougahi F, Vahedpoor Z, Jamilian M, Mahmoodi S, Baghban R, Bagherian T, Zarezade Mehrizi M, Asemi Z. The Effects of Folic Acid Supplementation on Recurrence and Metabolic Status in Endometrial Hyperplasia: A Randomized, Double-Blind, Placebo-Controlled Trial. Arch Iran Med 2018; 21:452-459. [PMID: 30415553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/04/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Data on the effects of folic acid supplementation on clinical symptoms and metabolic profiles of patients with endometrial hyperplasia (EH) are limited. This investigation was performed to evaluate the effects of folic acid supplementation on clinical symptoms and metabolic status of patients with EH. METHODS This randomized, double-blind, placebo-controlled trial was conducted among 60 women diagnosed with EH. Diagnosis of EH was made based on biopsy results. Participants were randomly allocated to 2 groups to take 5 mg/d folic acid supplements (n = 30) or placebo (n = 30) for 12 weeks. RESULTS After the 12-week intervention, folic acid supplementation significantly decreased fasting plasma glucose (β -3.99 mg/ dL; 95% CI, -7.39, -0.59; P = 0.02), serum insulin levels (β -2.82 µIU/mL; 95% CI, -4.86, -0.77; P = 0.008), homeostasis model assessment for insulin resistance (β -0.68; 95% CI, -1.20, -0.17; P = 0.009), triglycerides (β -16.47 mg/dL; 95% CI, -28.72, -4.22; P = 0.009) and very-low-density lipoprotein (VLDL) cholesterol (β -3.29 mg/dL; 95% CI, -5.74, -0.84; P = 0.009), and significantly increased the quantitative insulin sensitivity check index (β 0.01; 95% CI, 0.004, 0.03; P = 0.01) compared with the placebo. Additionally, folic acid intake resulted in a significant reduction in serum high sensitivity C-reactive protein (hs-CRP) (β -0.36 mg/L; 95% CI, -0.52, -0.21; P < 0.001) compared with the placebo. Folic acid supplementation did not affect other metabolic parameters. CONCLUSION In conclusion, we found that folic acid administration for 12 weeks to subjects with EH improved glycemic control, triglycerides, VLDL-cholesterol and hs-CRP levels, but did not influence recurrence and other metabolic profiles.
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Affiliation(s)
- Fereshteh Bahmani
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, I.R. Iran
| | - Fatemeh Rahimi Galougahi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, I.R. Iran
| | - Zahra Vahedpoor
- Department of Gynecology and Obstetrics, School of Medicine, Kashan University of Medical Sciences, Kashan, I.R. Iran
| | - Mehri Jamilian
- Endocrinology and Metabolism Research Center, Department of Gynecology and Obstetrics, School of Medicine, Arak University of Medical Sciences, Arak, Iran
| | - Samaneh Mahmoodi
- Department of Gynecology and Obstetrics, School of Medicine, Kashan University of Medical Sciences, Kashan, I.R. Iran
| | - Raheleh Baghban
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, I.R. Iran
| | - Tayebeh Bagherian
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, I.R. Iran
| | - Maryam Zarezade Mehrizi
- Department of Gynecology and Obstetrics, School of Medicine, Kashan University of Medical Sciences, Kashan, I.R. Iran
| | - Zatollah Asemi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, I.R. Iran
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Pal N, Broaddus RR, Urbauer DL, Balakrishnan N, Milbourne A, Schmeler KM, Meyer LA, Soliman PT, Lu KH, Ramirez PT, Ramondetta L, Bodurka DC, Westin SN. Treatment of Low-Risk Endometrial Cancer and Complex Atypical Hyperplasia With the Levonorgestrel-Releasing Intrauterine Device. Obstet Gynecol 2018; 131:109-116. [PMID: 29215513 PMCID: PMC5739955 DOI: 10.1097/aog.0000000000002390] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess efficacy of the levonorgestrel-releasing intrauterine device (LNG-IUD) for treatment of complex atypical hyperplasia or low-grade endometrial cancer. METHODS This retrospective case series included all patients treated with the LNG-IUD for complex atypical hyperplasia or early-grade endometrial cancer from January 2003 to June 2013. Response rates were calculated and the association of response with clinicopathologic factors, including age, body mass index, and uterine size, was determined. RESULTS Forty-six patients diagnosed with complex atypical hyperplasia or early-grade endometrial cancer were treated with the LNG-IUD. Of 32 evaluable patients at the 6-month time point, 15 had complex atypical hyperplasia (47%), nine had G1 endometrial cancer (28%), and eight had grade 2 endometrial cancer (25%). Overall response rate was 75% (95% CI 57-89) at 6 months; 80% (95% CI 52-96) in complex atypical hyperplasia, 67% (95% CI 30-93) in grade 1 endometrial cancer, and 75% (CI 35-97) in grade 2 endometrial cancer. Of the clinicopathologic features evaluated, there was a trend toward the association of lack of exogenous progesterone effect in the pathology specimen with nonresponse to the IUD (P=.05). Median uterine diameter was 1.3 cm larger in women who did not respond to the IUD (P=.04). CONCLUSION Levonorgestrel-releasing IUD therapy for the conservative treatment of complex atypical hyperplasia or early-grade endometrial cancer resulted in return to normal histology in a majority of patients.
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Affiliation(s)
- Navdeep Pal
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Russell R. Broaddus
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Diana L. Urbauer
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Nyla Balakrishnan
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Andrea Milbourne
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Kathleen M. Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Larissa A. Meyer
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Pamela T. Soliman
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Karen H. Lu
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Pedro T. Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Lois Ramondetta
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Diane C. Bodurka
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Shannon N. Westin
- Department of Gynecologic Oncology and Reproductive Medicine and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center, Houston, TX
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