Deep Myometrial Invasion Research Articles

Deep Myometrial Infiltration of Endometrial Cancer on MRI: A Radiomics-Powered Machine Learning Pilot Study

To evaluate an MRI radiomics-powered machine learning (ML) model's performance for the identification of deep myometrial invasion (DMI) in endometrial cancer (EC) patients and explore its clinical applicability. Preoperative MRI scans of EC patients were retrospectively selected. Three radiologists performed whole-lesion segmentation on T2-weighted images for feature extraction. Feature robustness was tested before randomly splitting the population in training and test sets (80/20% proportion). A multistep feature selection was applied to the first, excluding noninformative, low variance features and redundant, highly-intercorrelated ones. A Random Forest wrapper was used to identify the most informative among the remaining. An ensemble of J48 decision trees was tuned and finalized in the training set using 10-fold cross-validation, and then assessed on the test set. A radiologist evaluated all MRI scans without and with the aid of ML to detect the presence of DMI. McNemars's test was employed to compare the two readings. Of the 54 patients included, 17 had DMI. In all, 1132 features were extracted. After feature selection, the Random Forest wrapper identified the three most informative which were used for ML training. The classifier reached an accuracy of 86% and 91% and areas under the Receiver Operating Characteristic curve of 0.92 and 0.94 in the cross-validation and final testing, respectively. The radiologist performance increased from 82% to 100% when using ML (p = 0.48). We proved the feasibility of a radiomics-powered ML model for DMI detection on MR T2-w images that might help radiologists to increase their performance.

Neoadjuvant chemotherapy efficacy and prognostic factors in 187 cervical cancer patients with IB2 and IIA2 stage.

To investigate the efficacy and prognostic factors for patients receiving neoadjuvant chemotherapy (NACT) before operation in stage IB2 and IIA2 cervical cancer. A total of 187 patients with IB2 and IIA2 cervical cancer who received NACT combined surgery from January 2005 to January 2016 were enrolled. All patients were divided into an effective group (n=142) and an ineffective group (n=45) according to the chemotherapy efficacy. Clinical characteristics (containing tumor diameter, hematological inflammatory indexes, etc.) before chemotherapy and postoperative pathology between the two groups were compared. Patient survival analysis was performed by Kaplan-Meier method. The methods of univariate and multifactor analysis were used to analyze the relationship between NACT curative effect, postoperative pathological factors, and survival of patients. The number of patients with tumor diameter less than 5 cm was more in the chemotherapy effective group than that in the ineffective group (P=0.015). Three hematological inflammatory indexes (systemic inflammatory response index, neutrophil-lymphocyte ratio, and monocyte-lymphocyte ratio) in the effective group were lower than those in the ineffective group, respectively (P<0.05). The rates of pelvic lymph node metastasis and cervical deep myometrial invasion in the effective group were lower than those in the ineffective group (P<0.05). The 3-year and 5-year overall survival of NACT patients were 92.6% and 82.9%, respectively. Univariate analysis showed that chemotherapy efficacy, hematological inflammatory indexes, pelvic lymph node metastasis, and cervical deep myometrial invasion were related to the survival of patients (P<0.05). Further multivariate analysis demonstrated that pelvic lymph node metastasis was an independent risk factor for survival of patients (P<0.001), whereas effective NACT treatment was a protective factor for survival of patients (P<0.001). Tumor diameter and hematologic inflammation indexes before treatment are the relevant factors for NACT efficacy in patients with IB2 and IIA2 cervical cancer. Chemotherapy efficacy and pelvic lymph node metastasis are prognostic factors for NACT patients.

Association Between Maximum Standardize Uptake Value and Prognostic Factors at Endometrioid Type Endometrial Carcinoma

Objective: Investigate the relationship between the maximum standardize uptake value (SUVmax) values and the prognostic factors in endometrioid-type endometrial cancer (EEC) patients undergoing preoperative positron emission tomography / computed tomography (PET/CT).Study Design: We reviewed retrospectively the records of patients with EEC diagnosis who underwent hysterectomy in Gynecologic Oncology Clinic of Tepecik Training and Research Hospital between January 2010 and January 2017 in this retrospective study. Receiver operating characteristic (ROC) curve analysis was performed to determine the cut-off values of SUVmax for predicting clinical parameters. The area under the ROC curve (AUC) is presented as a measure of discrimination.Results: It was calculated that the SUVmax values in the uterine tumor were higher and statistically significant in the presence of advanced stage (III-IV), histologic grade III, deep myometrial invasion (≥1 / 2) and large tumor size (≥4 cm) from prognostic factors. The SUVmax values of the groups with and without cervical invasion did not different from each other. In order to use the SUVmax value as a diagnostic test in the ROC analysis, the AUC values were as follows; the grade of advanced stage tumor was 0,685, the grade 3 tumor was 0,797, the depth of myometrial invasion was 0,781, and the size of the large tumor was 0,905.Conclusion: SUVmax value in primary uterine tumor was found to be higher in prognostic factors in patients with advanced stage, high grade, deep myometrial invasion and large tumor.

BMI‑1 promotes invasion and metastasis in endometrial adenocarcinoma and is a poor prognostic factor.

Endometrial adenocarcinoma is one of the most common types of gynecological malignancies and its incidence and mortality rates are increasing. Due to tumor recurrence and metastasis, the overall five-year survival rate of patients with endometrial adenocarcinoma is shortened. The aim of the present was to investigate the role of the polycomb group protein B-lymphoma Mo-MLV insertion region 1 (BMI-1) in the invasion, metastasis and the epithelial-mesenchymal transition (EMT) of endometrial adenocarcinoma cells, as well its effects on the prognosis of patients with endometrial adenocarcinoma. Immunohistochemistry was used to examine the expression profile of BMI-1 in normal and endometrial adenocarcinoma tissues. Western blotting was used to examine the expression levels of BMI-1 and EMT markers. Kaplan-Meier plots and a Cox proportional hazards model were used to assess the overall survival. MTT cell viability assays were used to detect the proliferation of endometrial cancer cells. Transwell assays were used to examine cell migration and invasion. Small interfering RNA was used to downregulate BMI-1 expression levels, to study its effect on EMT. Immunohistochemical and clinicopathological analyses showed that BMI-1 expression was increased in endometrial adenocarcinoma tissue compared with the normal endometrial tissue (P<0.05). The increased expression levels of BMI-1 were closely associated with stage, myometrial invasion and lymph node metastasis (P<0.05). Kaplan-Meier plots and a Cox proportional hazards model showed that increased BMI-1 expression was associated with a less favorable prognosis [P=0.040, hazards ratio (HR)=1.596] and was associated with late-stage adenocarcinoma (P=0.006, HR=1.670). Myometrial invasion (P=0.006, HR=1.509) and lymph node metastasis (P=0.004, HR=1.703) were determined to predict a less favorable prognosis. Downregulation of BMI-1 reduced migration and invasion in endometrial cancer cells in vivo. It was also found that downregulation of BMI-1 increased the expression levels of the epithelial markers E-cadherin and keratin, and decreased the expression levels of the mesenchymal markers N-cadherin, vimentin and the downstream transcription factor, Slug. In conclusion, BMI-1 expression was correlated with tumor invasion and metastasis, contributing to deep myometrial invasion and lymph node metastasis, and was a poor prognostic factor for endometrial adenocarcinoma.

Adnexal Involvement in Endometrial Cancer: Prognostic Factors and Implications for Ovarian Preservation.

To determine the risk factors related to adnexal involvement in endometrial cancer (EC) and its implications for ovarian preservation in young women. We analyzed a series of 802 patients who were treated at AC Camargo Cancer Center from July 1991 to July 2017. Patients who had peritoneal or systemic dissemination (stage IV) were excluded. Chi square and Fisher's exact tests were used to analyze the correlations between categories and clinicopathological variables. Multivariate analysis was performed by logistic regression. Forty-nine (6.2%) patients had adnexal involvement-43 (5.4%) ovarian and 24 (2.9%) tubal. After excluding the 14 (28%) cases with suspicious findings, 788 subjects were analyzed and adnexal involvement found in 35 (4.4%) cases. Adnexal involvement was statistically related to non-endometrioid histologies (12.6% vs. 3.1%; p < 0.001), lymph node metastasis (17% vs. 2.6%; p < 0.001), histological grade 3 tumors (9.4% vs. 2.1%; p < 0.001), presence of LVSI (14.2% vs. 2.4%; p < 0.001), and deep myometrial invasion (≥ 50%) (10.8% vs. 3.5%; p < 0.001). Although age younger than 45years had higher risk of adnexal involvement, it was not statistically significant (8.9% vs. 4.2%; p = 0.13). Seven (14.2%) patients with adnexal involvement were aged < 45years, 3 of whom (42.8%) had suspicious adnexal masses that were detected before surgery. Notably, all patients aged < 45years and with adnexal involvement had at least 1 risk factor, such as presence of LVSI, grade 3 disease, node metastasis, or deep myometrial invasion. No patient with clinically normal ovaries and aged under 45years, with endometrioid grades 1 and 2, superficial myometrial invasion, or node negativity had adnexal involvement. Ovarian preservation may be considered for patients younger than 45years old with low-risk EC (grades 1 and 2 tumors, absence of LVSI, and myometrial invasion < 50%).

Microcystic, Elongated and Fragmented Pattern Invasion Can Adversely Influence Preoperative Staging for Low-grade Endometrial Carcinoma.

Purpose:To investigate the influence of microcystic, elongated and fragmented (MELF) pattern invasion on preoperative evaluation of lymph node (LN) metastasis and myometrial invasion in patients with low-grade endometrial carcinoma.Methods:The study included 192 consecutive patients with low-grade endometrial carcinoma who underwent preoperative computed tomography (CT) and magnetic resonance imaging (MRI), followed by surgery. One hundred sixty one of 192 patients underwent LN dissection and were analyzed for LN metastasis. All patients were analyzed for myometrial invasion. Presence of enlarged LN was evaluated by using size criteria on CT. Depth of myometrial invasion was evaluated on MRI using T2-weighted imaging, diffusion-weighted imaging and contrast-enhanced T1-weighted imaging comprehensively. Sensitivity and specificity for LN metastasis and deep myometrial invasion were evaluated for MELF group and non-MELF group. The difference of sensitivity between two groups was compared using Chi-square and Fisher’s exact test.Results:MELF pattern invasion was identified in 43/192 patients (22%). LN metastases were observed in 18/39 patients in MELF group and 6/122 patients in non-MELF group for pelvic LN and 11/29 patients in MELF group and 4/57 patients in non-MELF group for para-aortic LN. Sensitivity for the detection of pelvic LN metastasis in MELF group was significantly lower than in non-MELF group (16.7% vs 66.7%). As for the assessment of the deep myometiral invasion, pathological deep myometrial invasion were found in 31/43 patients in MELF group and 32/149 patients in non-MELF group. Sensitivity in MELF group showed lower values than in non-MELF group (54.8% vs 78.1% for reader 1, 54.8% vs 62.5% for reader 2), although there was no statistically significant difference (P = 0.09 for reader 1 and P = 0.72 for reader 2).Conclusion:In case of low-grade endometrial carcinoma with MELF pattern invasion, preoperative staging by CT and MRI have a risk for underestimation.

Effectiveness of Pap Smears as Predictor in the Diagnosis of Carcinoma Endometrium at a Tertiary Oncology Centre in India

Endometrial carcinoma is the commonest malignancy of female genital tract in the developed world. No widely accepted screening test exists for endometrial cancer. However, cervical cytology may be useful in predicting endometrial disease. The aim of this study was to review the Pap smears of endometrial carcinoma patients for normal/ abnormal cytology and then correlate with clinico-pathological parameters. This was a retrospective study from January 2008 to December 2013. A total of 226 patients underwent surgery for endometrial cancer at this centre in this duration. Of these, medical records were available in 204 cases. Pap smear reports within previous 6 months of surgery were available in 180 cases. The relevant data of these patients were statistically analysed using standard statistical tests. A p value of ≤ 0.05 was considered significant. The patients were in the age group of 32 to 85 years. A total of 38 (21.1%) cases showed abnormal cytology on Pap test. The cervical cytology of carcinoma endometrium patients was then correlated and statistically analysed with various parameters like age, stage, grade of the disease, histology type and depth of myometrial invasion. The association was significant for higher histologic grade, advanced stage, deeper myometrial invasion and non-endometrioid histology. In our study, the rate of detection of abnormal cervical cytology in carcinoma endometrium is less in early stages but high in advanced stages and in the presence of poor prognostic factors, like higher histologic grade, deeper myometrial invasion and non-endometrioid histology.

Clinicopathological significance of deficient DNA mismatch repair and MLH1 promoter methylation in endometrioid endometrial carcinoma.

The pathogenesis of DNA mismatch repair (MMR)-deficient endometrial carcinoma (EC) is driven by inactivating methylation or less frequently mutation of an MMR gene (MLH1, PMS2, MSH2, or MSH6). This study evaluated the prognostic and clinicopathologic differences between methylation-linked and nonmethylated MMR-deficient endometrioid ECs. We performed MMR immunohistochemistry and methylation-specific multiplex ligation-dependent probe amplification, and classified 682 unselected endometrioid ECs as MMR proficient (MMRp, n = 438) and MMR deficient (MMRd, n = 244), with the latter subcategorized as methylated (MMRd Met) and nonmethylated tumors. Loss of MMR protein expression was detected in 35.8% of the tumors as follows: MLH1 + PMS2 in 29.8%, PMS2 in 0.9%, MSH2 + MSH6 in 1.3%, MSH6 in 2.8%, and multiple abnormalities in 0.9%. Of the 244 MMRd cases, 76% were methylation-linked. MMR deficiency was associated with older age, high grade of differentiation (G3), advanced stage (II-IV), larger tumor size, abundant tumor-infiltrating lymphocytes, PD-L1 positivity in immune cells and combined positive score, wild-type p53, negative L1CAM, ARID1A loss, and type of adjuvant therapy. MMRd-Met phenotype correlated with older age and larger tumor size, and predicted diminished disease-specific survival in the whole cohort. In the MMRd subgroup, univariate analysis demonstrated an association between disease-specific survival and disease stage II-IV, high grade (G3), deep myometrial invasion, lymphovascular invasion, ER negativity, and L1CAM positivity. In conclusion, MMR methylation profile correlates with clinicopathologic characteristics of endometrioid EC, and MMRd-Met phenotype predicts lower disease-specific survival. MMR deficiency, but not MLH1 methylation status, correlates with T-cell inflammation and PD-L1 expression.

Performances de l’IRM dans le bilan d’extension locale préopératoire des cancers de l’endomètre : l’expérience nantaise

ObjectivesTo determine the diagnostic accuracy of magnetic resonance imaging (MRI) for local preoperative staging in endometrial cancer in our center (Centre Hospitalier Universitaire de Nantes: CHU), since the French National Cancer Institute's surgery recommendations publication in 2010, especially for the prediction of myometrial and cervical stromal invasion. MethodsRetrospective monocentric study of consecutive women operated of endometrial cancer in gynecology department of CHU de Nantes, who underwent preoperative pelvic MRI in our Radiology department from November 2010 to November 2016. MRI data collected from initial report and compared to surgical histological findings as gold standard. ResultsSixty-four patients were included. Deep myometrial invasion was present in 35 patients in MRI versus 34 patients on postoperative histology (5 false positives, 4 false negatives). Cervical stromal invasion was present in 9 patients in MRI versus 19 patients on postoperative histology (2 false positives, 12 false negatives). The sensitivity and the specificity were respectively 88.23% (95% confidence intervals (CI) [0.71–0.96]) and 83.33% (CI [0.64–0.93]) for the deep myometrial invasion; 36.84% (CI [0.17–0.61]) and 95.55% (CI [0.83–0.99]) for the cervical stromal invasion. ConclusionOur results were comparable to the literature data, with a low sensitivity for the cervical stromal invasion detection, driving us to change our MRI protocol with optional high-resolution T2 sequences perpendicular to the cervical canal if necessary.

Adjuvant chemotherapy in endometrial cancer.

The role of adjuvant chemotherapy (CT) is controversial in endometrial carcinoma (EC). Surgery alone is usually curative for women who are at a low risk of disease recurrence. The treatment of EC following surgical staging is based on the risk of relapse, which is defined by the cancer stage at diagnosis, histology of the tumor and other prognostic factors such as grade differentiation, the presence of substantial lymphovascular invasion (LVSI), or depth of myometrial invasion (MI). External beam radiotherapy (EBRT) and/or vaginal brachytherapy (VBT) improved local control and are used as adjuvant treatment for early-stage disease. The role of adjuvant CT is controversial in early-stage EC, and there is no uniform approach to the treatment of women with stage III EC or early-staged non-endometrioid EC. Available evidence did not support the indication of adjuvant CT in stage I-II endometroid EC. In those cases at higher risk of relapse, defined as grade 3 tumors with substantial (no focal) LVSI, specifically with deep MI or cervical involvement, could be considered. Adjuvant CT should be administered to stage III EC patients. When RT is indicated (extensive lymph node involvement or deep MI), sequential treatment with RT or "sandwich" regimen may be considered rather than concurrent CRT. The patients with stage IA MI or IB USC may be offered adjuvant CT alone or in combination with VBT, whereas in stage II uterine serous carcinoma patients adding EBRT may be reasonable. Management approach for patients with stage IA without MI USC who underwent a comprehensive surgery remains controversial, and surveillance alone or CT plus VBT is an appropriate option. Early-stage clear-cell carcinoma patients might not benefit for adjuvant CT, but stage III patients might benefit from the combination of CT and EBRT. Stage I-III uterine carcinosarcoma patients might be offered adjuvant CT followed by RT or as a "sandwich" régimen.

Histopathological characterization of ProMisE molecular groups of endometrial cancer

BackgroundAfter the Proactive Molecular Risk Classifier for Endometrial Cancer (ProMisE) development, endometrial cancer (EC) may be reclassified in four novel prognostic groups: POLE-mutated (POLE-mt), mismatch-repair-deficient (MMR-d), p53-abnormal (p53abn), p53-wild-type (p53wt). However, histopathological characteristics of each ProMisE group are still undefined. Such characterization may be useful to understand how this novel molecular classifier may change the current patient management, reducing over- and undertreatment. AimTo provide a histopathological characterization of ProMisE groups of EC, in terms of histological grade (G3 vs G1–2), histotype, lymphovascular space invasion (LVSI), deep myometrial invasion (>50%), lymph node involvement, and European Society for Medical Oncology (ESMO) risk category. Materials and methodsA systematic review and meta-analysis was performed by searching seven electronic databases from their inception to May 2019, for studies that reported histopathological characteristics of each ProMisE group. Pooled prevalence of each histopathological characteristic of EC in each ProMisE group was calculated. ResultsFour studies with 1171 patients were included in the systematic review, out of which three studies with 912 patients were included in the meta-analysis. Pooled prevalence estimates were:-in the MMR-d group, G3 = 47.4%, G1–2 = 52.6%; endometrioid = 85.8%, non-endometrioid = 14.2%; LVSI-present = 41.3%, −absent = 58.7%; deep myometrial invasion-present = 44.5%, −absent = 55.5%; lymph node involvement-present = 9.9%, −absent = 90.1%; low-risk = 30.1%, intermediate risk = 19.9%, high-risk = 50%;-in the POLE-mt group, G3 = 39.6%, G1–2 = 60.4%; endometrioid = 86.1%, non-endometrioid = 13.9%; LVSI-present = 32.7%, −absent = 67.3%; deep myometrial invasion-present = 27.3%, −absent = 72.7%; lymph node involvement-present = 0%, −absent = 100%; low-risk = 44.1%, intermediate-risk = 22.5%, high-risk = 33.4%;-in the p53-wt group, G3 = 15.6%, G1–2 = 84.4%; endometrioid = 96.7%, non-endometrioid = 3.3%; LVSI-present = 13.8%, −absent = 86.2%; deep myometrial invasion-present = 27.4%, −absent = 72.6%; lymph node involvement-present = 4.3%, −absent = 95.7%; low-risk = 59.5%, intermediate-risk = 17.3%, high-risk = 23.2%;-in the p53-abn group, G3 = 90%, G1–2 = 10%; endometrioid = 27%, non-endometrioid = 73%; LVSI-present = 48.8%, −absent = 51.2%; deep myometrial invasion-present = 48.9%, −absent = 51.1%; lymph node involvement-present = 23.7%, −absent = 76.3%; low-risk = 7.2%, intermediate-risk = 8.1%, high-risk = 84.7%. ConclusionsThe histopathological characterization of the ProMisE groups suggests that many patients are currently undertreated or overtreated (especially in the POLE-mt and MMR-d groups).

Predicting myometrial invasion in endometrial cancer based on whole-uterine magnetic resonance radiomics.

The objective of this study was to evaluate whether whole-uterine magnetic resonance imaging (MRI) radiomic features can predict myometrial invasion (MI) depth in endometrial cancer (EC). The preoperative 3.0 T magnetic resonance examinations of EC patients were retrospectively reviewed. Whole-uterus segmentation was performed, and features were extracted based on sagittal T2-weighted imaging (T2WI) and axial diffusion-weighted imaging (DWI). The logistic regression (LR) classifier algorithm was used to establish the radiomic model, which was verified by ten times five-fold cross-validation. The areas under the receiver operating characteristic (ROC) curves (AUCs) were assessed by the DeLong test to compare differences among the models based on different sequences. The LR model was compared with the subjective diagnosis results by the Chi-square test. Of the 163 EC patients included, 44 had deep myometrial invasion (DMI). The feature consistency of the whole uterus was higher than that of the lesion (P < 0.05). The sagittal T2WI, axial DWI, and combined models had AUCs of 0.76, 0.80, and 0.85 in the validation set, respectively. The DeLong test showed that there were no significant differences in AUCs among the models (P > 0.05). The single-sequence LR models had lower specificity and accuracy than the corresponding subjective diagnostic results (P < 0.05), while the sensitivity was higher (P > 0.05). The combined model included 24 radiomic features, and the accuracy, sensitivity, and specificity were 0.83, 0.77, and 0.85 for DMI, respectively. There was no significant difference compared with subjective diagnosis (P > 0.05). Whole-uterine MRI radiomic features based on sagittal T2WI and axial DWI show potential in predicting MI in EC.

Prognostic significance of lymphovascular space invasion in patients with endometrioid endometrial cancer: a retrospective study from a single center

ObjectiveThis study aims to analyze factors associated with lymphovascular space invasion (LVSI) and evaluate the prognostic significance of LVSI in Chinese endometrioid endometrial cancer (EEC) patients.MethodsFive-hundred eighty-four EEC patients undergoing surgery in our center from 2006 to 2016 were selected for analysis. Univariate analysis and multivariate logistic regression were used to examine relevant factors of LVSI. To evaluate the prognostic role of LVSI, survival analyses were conducted. In survival analyses, both multivariate Cox regression and propensity score matching were used to control the confounders.ResultsThe incidence of LVSI was 12.16% (71/584). Diabetes history (p=0.021), lymph node metastasis (p=0.005), deep myometrial invasion (p<0.001) and negative PR expression (p=0.007) were independently associated with LVSI. Both Kaplan-Meier method and univariate Cox regressions showed LVSI negative and positive cases had similar tumor-specific survival (TSS) and disease-free survival (DFS). After adjusting for the influence of adjuvant therapy and other clinicopathological factors with multivariate Cox regressions, LVSI still could not bring additional survival risk to the patients (p=0.280 and p=0.650 for TSS and DFS, respectively). This result was verified by Kaplan-Meier survival analyses after propensity score matching (p=0.234 and p=0.765 for TSS and DFS, respectively).ConclusionLVSI does not significantly compromise the survival outcome of Chinese EEC patients.

Diagnostic Accuracy of Pre-operative Magnetic Resonance Imaging in Assessing Prognostic Pathological Parameters in Endometrial Carcinoma

Introduction: The 2nd most common gynecological malignancy and sixth among commonly diagnosed cancer is Endometrial carcinoma (EC). The risk and prognosis of the disease are assessed by appropriate staging according to the FIGO classification. Size and grade of the tumor, depth of myometrial invasion, endocervical stromal invasion, and pelvic and paraaortic lymph node involvement play an important role in the prognosis of the disease. For preoperative staging of endometrial cancer, magnetic resonance imaging (MRI), transvaginal ultrasonography (TVUS), and computed tomography (CT) are widely used as diagnostic tools. Accurate pre-operative staging provides a better platform to decide the therapeutic plan and extent of surgery. Accurate preoperative staging provides a better platform to decide the therapeutic plan and extent of surgery. Objective: To determine the efficiency of magnetic resonance imaging in the preoperative determination of the prognostic parameters in endometrial carcinoma taking histopathology as the gold standard is the objective of the study. Material and Methods: This is a retrospective study conducted at Liaquat National Hospital (LNH), Stadium Road Karachi, Pakistan. Four years record (2015-2018) was retrieved and fifty-one patients who had undergone preoperative MRI followed by surgery and biopsy-proven endometrial carcinoma were included in the study. Results: A total of 51 records were reviewed. The mean age of the patient was 61.45 ± 7.83 years. The frequent histological type was endometroid (n=37, 72.55%). For deep myometrial invasion, MRI sensitivity, specificity, PPV, and NPV were 95.83%, 77.87%, 79.31%, 94.45% respectively. In assessing endocervical invasion, MRI sensitivity, specificity, PPV, and NPV were 83.33%, 80%, 35.71%, and 97.30% respectively. For lymph node invasion, these diagnostic accuracy parameters were 71.43%, 97.73%, 83.33%, 95.56% respectively. For tumor size, sensitivity, specificity, PPV, and NPV of MRI were 100%, 36.36%, 67%, 100% respectively.

Validation of ultrasound strategies to assess tumor extension and to predict high-risk endometrial cancer in women from the prospective IETA (International Endometrial Tumor Analysis)-4 cohort.

To compare the performance of ultrasound measurements and subjective ultrasound assessment (SA) in detecting deep myometrial invasion (MI) and cervical stromal invasion (CSI) in women with endometrial cancer, overall and according to whether they had low- or high-grade disease separately, and to validate published measurement cut-offs and prediction models to identify MI, CSI and high-risk disease (Grade-3 endometrioid or non-endometrioid cancer and/or deep MI and/or CSI). The study comprised 1538 patients with endometrial cancer from the International Endometrial Tumor Analysis (IETA)-4 prospective multicenter study, who underwent standardized expert transvaginal ultrasound examination. SA and ultrasound measurements were used to predict deep MI and CSI. We assessed the diagnostic accuracy of the tumor/uterine anteroposterior (AP) diameter ratio for detecting deep MI and that of the distance from the lower margin of the tumor to the outer cervical os (Dist-OCO) for detecting CSI. We also validated two two-step strategies for the prediction of high-risk cancer; in the first step, biopsy-confirmed Grade-3 endometrioid or mucinous or non-endometrioid cancers were classified as high-risk cancer, while the second step encompassed the application of a mathematical model to classify the remaining tumors. The 'subjective prediction model' included biopsy grade (Grade 1 vs Grade 2) and subjective assessment of deep MI or CSI (presence or absence) as variables, while the 'objective prediction model' included biopsy grade (Grade 1 vs Grade 2) and minimal tumor-free margin. The predictive performance of the two two-step strategies was compared with that of simply classifying patients as high risk if either deep MI or CSI was suspected based on SA or if biopsy showed Grade-3 endometrioid or mucinous or non-endometrioid histotype (i.e. combining SA with biopsy grade). Histological assessment from hysterectomy was considered the reference standard. In 1275 patients with measurable lesions, the sensitivity and specificity of SA for detecting deep MI was 70% and 80%, respectively, in patients with a Grade-1 or -2 endometrioid or mucinous tumor vs 76% and 64% in patients with a Grade-3 endometrioid or mucinous or a non-endometrioid tumor. The corresponding values for the detection of CSI were 51% and 94% vs 50% and 91%. Tumor AP diameter and tumor/uterine AP diameter ratio showed the best performance for predicting deep MI (area under the receiver-operating characteristics curve (AUC) of 0.76 and 0.77, respectively), and Dist-OCO had the best performance for predicting CSI (AUC, 0.72). The proportion of patients classified correctly as having high-risk cancer was 80% when simply combining SA with biopsy grade vs 80% and 74% when using the subjective and objective two-step strategies, respectively. The subjective and objective models had an AUC of 0.76 and 0.75, respectively, when applied to Grade-1 and -2 endometrioid tumors. In the hands of experienced ultrasound examiners, SA was superior to ultrasound measurements for the prediction of deep MI and CSI of endometrial cancer, especially in patients with a Grade-1 or -2 tumor. The mathematical models for the prediction of high-risk cancer performed as expected. The best strategies for predicting high-risk endometrial cancer were combining SA with biopsy grade and the subjective two-step strategy, both having an accuracy of 80%. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Preoperative Assessment for High–Risk Endometrial Cancer by Developing a MRI–and Clinical–Based Radiomics Nomogram: A Multicenter Study in Eastern China

Background: High–risk and low–risk endometrial cancer (EC) differ in the extent of the surgical procedure. Assessment of the risk stratification of EC is essential for planning the appropriate surgery. The aim of this study was to develop an radiomics nomogram for preoperative prediction of high–risk EC. Methods: A total of 718 histopathologically confirmed EC patients from five centers were retrospectively divided into a primary cohort (n = 285, Center A), an internal validation cohort (n = 109, Center A), and an external validation cohort (n = 324, Centers B to E). A binary least absolute shrinkage and selection operator logistic regression analysis was used to select radiomics features from MRIs and multivariate logistic regression analysis was used to select clinical features for high–risk EC. A radiomics nomogram was generated by combining the selected radiomics features (radiomics signatures) with the selected clinical features (clinical signatures). A receiver operating characteristic curve and a decision curve were generated to evaluate the predictive performance and clinical usefulness of radiomics signatures, clinical signatures, and radiomics nomogram. The radiomics nomogram was further used to assess deep myometrial invasion (DMI) and other risk factors of EC. Findings: Of the 358 extracted radiomics features, 17 were ultimately selected from MRIs. The clinical signatures consisted of metabolic syndrome, cancer antigen 125, age, tumor size, and tumor grade following curettage. The radiomics nomogram had highest areas under the curve and achieved the highest clinical net benefit for the decision curve. The radiomics nomogram assessed DMI and other risk factors of EC with high clinical benefit. Interpretation: The radiomics nomogram exhibited good performance in the individual prediction of high–risk EC with good clinical net benefit and good application in assessing DMI and other risk factors of EC. Funding Statement: National Natural Science Foundation of China (No. 81971579). Declaration of Interests: The authors stated: There are no conflicts of interest. Ethics Approval Statement: This study was approved by the Obstetrics and Gynecology Hospital of Fudan University Institutional Review Board, and informed consent was waived.

Outcomes and relapse patterns of stage IB grade 2 or 3 endometrial cancer treated with adjuvant vaginal brachytherapy

IntroductionRisk factors for pelvic recurrence in early stage endometrial cancer are poorly understood. We sought to describe outcomes, patterns of failure, and risk factors for recurrence among patients with grade...

Does tumor size have prognostic value in patients undergoing lymphadenectomy in endometrioid-type endometrial cancer confined to the uterine corpus?

Background/aimWe aimed to define the effect of tumor size on recurrence and survival rates in patients with stage I–II endometrioid-type endometrial cancer.Materials and methodsA total of 550 patients who had total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic-paraaortic lymphadenectomy were included. Patients with extrauterine spread, sarcomatous components, or synchronized tumor and those who did not undergo lymphadenectomy or did not have data on tumor size were excluded.ResultsThe median tumor size was 35 mm (range: 3–335 mm). According to the 2009 International Federation of Obstetrics and Gynecology (FIGO) criteria, 245 cases were defined as stage IA, 271 as stage IB, and 34 as stage II. The 5-year disease-free survival (DFS) rate was 92% and the 5-year disease-specific survival (DSS) rate was 99%. The effects of prognostic factors on DFS were evaluated. Older age, stage II disease, deep myometrial invasion, and receiving adjuvant radiotherapy were associated with decreased DFS. There was no statistically significant association between tumor size and DFS. The 5-year DFS for patients with a tumor diameter of <35 mm, which was the median tumor size of the entire group, was 94%, while it was 89% for patients having a tumor diameter of >35 mm (P = 0.128).ConclusionTumor size was not a risk factor predicting recurrence in patients with stage I or II endometrioid-type endometrial cancer who had lymphadenectomy.

The Diagnostic Value of MRI for Preoperative Staging in Patients with Endometrial Cancer: A Meta-Analysis

To assess the diagnostic accuracy of magnetic resonance imaging (MRI) for detecting myometrial invasion, cervical invasion, and lymph node metastases in endometrial cancer. A systematic literature search was performed in PubMed, Embase, Cochrane Library, Web of Science, and Clinical trials. The methodological quality of each study was assessed by using the standard Quality Assessment of Diagnostic Accuracy Studies-2. Statistical analysis included evaluating publication bias, assessing threshold effect, exploring heterogeneity, pooling data, meta-regression, forest plot, and summary receiver-operating characteristics curves construction. Fourteen studies could be analyzed. For detecting deep myometrial invasion, the pooled sensitivity and specificity were 0.79 and 0.81 respectively, and patients younger than 60 years old demonstrated higher sensitivity (0.84) and specificity (0.90). The diagnostic accuracy is highest by jointly using T2-weighted image, dynamic contrast-enhanced MRI, and diffusion weighted imaging to detect the deep myometrial invasion. There were low sensitivity and high specificity for the diagnosis of cervical invasion (0.53, 0.95), cervical stromal invasion (0.50, 0.95), pelvic or/and para-aortic lymph node metastases (0.59, 0.95), and pelvic lymph node metastases (0.65, 0.95). MRI has good diagnostic performance for assessing myometrial invasion in patients with endometrial cancer, especially in patients younger than 60 years old. Dynamic contrast-enhanced MRI and diffusion weighted imaging can help improve sensitivity and specificity for detecting myometrial invasion. MRI shows high specificity for detecting cervical invasion and lymph node metastases in endometrial cancer.

MR volumetry in predicting the aggressiveness of endometrioid adenocarcinoma: correlation with final pathological results.

Background Magnetic resonance (MR) has been widely used in predicting the aggressiveness of endometrioid adenocarcinoma. However, the diagnostic value of the MR volume of the lesion has been controversial. Purpose To determine whether the whole-lesion MR volume measurement could be used as a better predictor for evaluating the aggressiveness of endometrioid adenocarcinoma. Material and Methods In this retrospective study, we include 357 patients with pathologically demonstrated endometrioid adenocarcinoma at our institution between 1 January 2013 and 31 December 2018. Whole-lesion MR volume was calculated on sagittal T2-weighted images with ITK-SNAP software on a personal computer. Results According to the receiver operating characteristics curve analysis, whole-lesion MR volume has the competitive advantage in evaluating deep myometrial invasion compared with the frozen results, generating area under the curve (AUC) values of 0.751 vs. 0.834 ( P = 0.0629, Z = 1.860). The AUC of tumor maximum diameter, simple tumor volume, and whole-lesion MR volume in predicting deep myometrial invasion was 63.8%, 67.6%, and 75.1%, respectively. Conclusion Whole-lesion MR volume is a good diagnostic tool for prediction of deep myometrial invasion, lymph node metastasis, and lymphovascular invasion. MR volumetry could reflect the aggressiveness of endometrioid adenocarcinoma more accurately than traditional lesion measurements.