Endometrial Cancer Cohort Research Articles

Tumor Mismatch Repair Immunohistochemistry and DNA MLH1 Methylation Testing of Patients With Endometrial Cancer Diagnosed at Age Younger Than 60 Years Optimizes Triage for Population-Level Germline Mismatch Repair Gene Mutation Testing

Clinicopathologic data from a population-based endometrial cancer cohort, unselected for age or family history, were analyzed to determine the optimal scheme for identification of patients with germline mismatch repair (MMR) gene mutations. Endometrial cancers from 702 patients recruited into the Australian National Endometrial Cancer Study (ANECS) were tested for MMR protein expression using immunohistochemistry (IHC) and for MLH1 gene promoter methylation in MLH1-deficient cases. MMR mutation testing was performed on germline DNA of patients with MMR-protein deficient tumors. Prediction of germline mutation status was compared for combinations of tumor characteristics, age at diagnosis, and various clinical criteria (Amsterdam, Bethesda, Society of Gynecologic Oncology, ANECS). Tumor MMR-protein deficiency was detected in 170 (24%) of 702 cases. Germline testing of 158 MMR-deficient cases identified 22 truncating mutations (3% of all cases) and four unclassified variants. Tumor MLH1 methylation was detected in 99 (89%) of 111 cases demonstrating MLH1/PMS2 IHC loss; all were germline MLH1 mutation negative. A combination of MMR IHC plus MLH1 methylation testing in women younger than 60 years of age at diagnosis provided the highest positive predictive value for the identification of mutation carriers at 46% versus ≤ 41% for any other criteria considered. Population-level identification of patients with MMR mutation-positive endometrial cancer is optimized by stepwise testing for tumor MMR IHC loss in patients younger than 60 years, tumor MLH1 methylation in individuals with MLH1 IHC loss, and germline mutations in patients exhibiting loss of MSH6, MSH2, or PMS2 or loss of MLH1/PMS2 with absence of MLH1 methylation.

Prognostic Significance of FRA Expression in Epithelial Cancers using AQUA ® technology

Although agents that target FRA have advanced through clinical trials, comprehensive analyses of FRA expression in epithelial cancers compared with clinical variables and prognosis are limited. FRA expression was examined in non-small-cell lung cancer (NSCLC), ovarian cancer and endometrial cancer cohorts using AQUA(®) technology. For the NSCLC cohort, FRA expression was significantly higher in adenocarcinoma samples (p < 0.001) than other histologies, and in females (p = 0.003) versus males. High FRA expression was significantly associated with better survival in NSCLC cases (p = 0.01) while significantly and independently associated with worse prognosis in endometrial (p < 0.001) and ovarian cancers (p < 0.001). These studies confirm the prognostic value of FRA in multiple indications. The opposing prognostic effects observed may suggest differential biology.

Promoter Hypomethylation of EpCAM-Regulated Bone Morphogenetic Protein Gene Family in Recurrent Endometrial Cancer

Epigenetic regulation by promoter methylation plays a key role in tumorigenesis. Our goal was to investigate whether altered DNA methylation signatures associated with oncogenic signaling delineate biomarkers predictive of endometrial cancer recurrence. Methyl-CpG-capture sequencing was used for global screening of aberrant DNA methylation in our endometrial cancer cohort, followed by validation in an independent The Cancer Genome Atlas (TCGA) cohort. Bioinformatics as well as functional analyses in vitro, using RNA interference (RNAi) knockdown, were performed to examine regulatory mechanisms of candidate gene expression and contribution to aggressive phenotype, such as epithelial-mesenchymal transition (EMT). We identified 2,302 hypermethylated loci in endometrial tumors compared with control samples. Bone morphogenetic protein (BMP) family genes, including BMP1, 2, 3, 4, and 7, were among the frequently hypermethylated loci. Interestingly, BMP2, 3, 4, and 7 were less methylated in primary tumors with subsequent recurrence and in patients with shorter disease-free interval compared with nonrecurrent tumors, which was validated and associated with poor survival in the TCGA cohort (BMP4, P = 0.009; BMP7, P = 0.007). Stimulation of endometrial cancer cells with epidermal growth factor (EGF) induced EMT and transcriptional activation of these genes, which was mediated by the epithelial cell adhesion molecule (EpCAM). EGF signaling was implicated in maintaining the promoters of candidate BMP genes in an active chromatin configuration and thus subject to transcriptional activation. Hypomethylation signatures of candidate BMP genes associated with EpCAM-mediated expression present putative biomarkers predictive of poor survival in endometrial cancer.

Serum HE4 as a prognostic marker in endometrial cancer — A population based study

ObjectiveHE4 has emerged as a promising biomarker in gynaecological oncology. The purpose of this study was to evaluate serum HE4 as a biomarker for high-risk phenotypes in a population-based endometrial cancer cohort. MethodsPeri-operative serum HE4 and CA125 were measured in 373 patients identified from the prospective Australian National Endometrial Cancer Study (ANECS). HE4 and CA125 were quantified on the ARCHITECT instrument in a clinically accredited laboratory. Receiver operator curves (ROC), Spearman rank correlation coefficient, and chi-squared and Mann–Whitney tests were used for statistical analysis. Survival analysis was performed using Kaplan–Meier and Cox multivariate regression analyses. ResultsMedian CA125 and HE4 levels were higher in stage III and IV tumours (p<0.001) and in tumours with outer-half myometrial invasion (p<0.001). ROC analysis demonstrated that HE4 (area under the curve (AUC)=0.76) was a better predictor of outer-half myometrial invasion than CA125 (AUC=0.65), particularly in patients with low-grade endometrioid tumours (AUC 0.77 vs 0.64 for CA125). Cox multivariate analysis demonstrated that elevated HE4 was an independent predictor of recurrence-free survival (HR=2.40, 95% CI 1.19–4.83, p=0.014) after adjusting for stage and grade of disease, particularly in the endometrioid subtype (HR=2.86, 95% CI 1.25–6.51, p=0.012). ConclusionThese findings demonstrate the utility of serum HE4 as a prognostic biomarker in endometrial cancer in a large, population-based study. In particular they highlight the utility of HE4 for pre-operative risk stratification to identify high-risk patients within low-grade endometrioid endometrial cancer patients who might benefit from lymphadenectomy.

Prospective assessment of the prevalence of pelvic, paraaortic and high paraaortic lymph node metastasis in endometrial cancer

ObjectiveTo prospectively define the prevalence of lymph node metastasis (LNM) in at risk endometrial cancer (EC). MethodsFrom 2004 to 2008, frozen section based Mayo Criteria prospectively identified patients “not at-risk” of LNM (30% EC population; grade I/II, <50% myometrial invasion and tumor diameter ≤2cm) where lymphadenectomy was not recommended. The remaining 70% EC cohort was considered “at-risk” of LNM; where a systematic pelvic and infrarenal paraaortic lymphadenectomy was recommended. Patients were prospectively followed. The area between renal vein and inferior mesenteric artery (IMA) was labeled as high paraaortic area. For calculating the prevalence of LNM in high paraaortic area, the denominator was the population with known anatomic location of nodal tissue in relation to the IMA. ResultsOf the 742 patients, 514 were at risk; of which 89% underwent recommended lymphadenectomy. A mean (±standard deviation) of 36 (±14) pelvic and 18 (±9) paraaortic nodes were harvested. The prevalence of pelvic and paraaortic LNM was 17% and 12%, respectively. In presence of pelvic LNM, 51% had paraaortic LNM. In absence of pelvic LNM, 3% had paraaortic LNM; of which 67% was located exclusively in high paraaortic area. Among patients with paraaortic LNM, 88% had high paraaortic LNM; and 35% had only high paraaortic LNM. The cases of paraaortic LNM with negative pelvic nodes seemed to cluster in moderate to high grade endometrioid EC with ≥50% myometrial invasion. ConclusionWe present reference data for the prevalence of LNM in at-risk EC patients to guide lymphadenectomy decisions for clinical and research purposes.

Endometrial tumour BRAF mutations and MLH1 promoter methylation as predictors of germline mismatch repair gene mutation status: a literature review

Colorectal cancer (CRC) that displays high microsatellite instability (MSI-H) can be caused by either germline mutations in mismatch repair (MMR) genes, or non-inherited transcriptional silencing of the MLH1 promoter. A correlation between MLH1 promoter methylation, specifically the 'C' region, and BRAF V600E status has been reported in CRC studies. Germline MMR mutations also greatly increase risk of endometrial cancer (EC), but no systematic review has been undertaken to determine if these tumour markers may be useful predictors of MMR mutation status in EC patients. Endometrial cancer cohorts meeting review inclusion criteria encompassed 2675 tumours from 20 studies for BRAF V600E, and 447 tumours from 11 studies for MLH1 methylation testing. BRAF V600E mutations were reported in 4/2675 (0.1%) endometrial tumours of unknown MMR mutation status, and there were 7/823 (0.9%) total sequence variants in exon 11 and 27/1012 (2.7%) in exon 15. Promoter MLH1 methylation was not observed in tumours from 32 MLH1 mutation carriers, or for 13 MSH2 or MSH6 mutation carriers. MMR mutation-negative individuals with tumour MLH1 and PMS2 IHC loss displayed MLH1 methylation in 48/51 (94%) of tumours. We have also detailed specific examples that show the importance of MLH1 promoter region, assay design, and quantification of methylation. This review shows that BRAF mutations occurs so infrequently in endometrial tumours they can be discounted as a useful marker for predicting MMR-negative mutation status, and further studies of endometrial cohorts with known MMR mutation status are necessary to quantify the utility of tumour MLH1 promoter methylation as a marker of negative germline MMR mutation status in EC patients.

Comorbidities and endometrial cancer survival in Hispanics and non-Hispanic whites

We investigated comorbidities and endometrial cancer survival by ethnicity because Hispanic whites (HWs) have worse survival than non-Hispanic whites (NHWs). An endometrial cancer cohort (1992-2004) established with the Surveillance, Epidemiology and End Results-Medicare-linked database (n=3,286) was followed through 2007. Endometrial cancer-specific and other cause mortality were evaluated with multivariate hazard ratios (mHRs). HWs were more likely than NHWs to have regional/distant disease (31.7 vs. 24.8%), diabetes (31.7 vs. 11.0%), and hypertension (49.4 vs. 37.6%). HWs had poorer endometrial cancer-specific survival than NHWs (age-adjusted HR=1.28; 95% CI 1.01-1.61), but not after adjustment for tumor characteristics and treatment (mHR=1.02; 95% CI 0.81-1.29). In contrast, even after adjustment for cancer-related factors, other cause mortality in HWs was elevated (mHR=1.27; 95% CI 1.01-1.59), but not after further adjustment for comorbid conditions (mHR=1.07; 95% CI 0.85-1.35). Comorbidities, particularly diabetes, were more common in HWs than in NHWs and impacted other cause mortality. Improving diabetes management may be an effective means of improving other cause mortality. This may be particularly true for HWs, given their particularly high prevalence of diabetes.

Correlation between molecular features (MFs) and clinical results in endometrial cancer (EC): A single-institution experience.

e15572 Background: EC is the most common gynecologic tumor. Although overall survival (OS) is greater than 80%, a subgroup of patients (pts) has a poorer prognosis. Different MFs have been described in EC. PTEN loss and PIK3CA mutations (mut) are the most frequent up to 70%. Currently, there are paucity data of their clinical outcome influence. We have determined PTEN loss and PIK3CA mut in an EC pts cohort to correlate these findings with established prognostic factors and OS. Methods: Formalin-fixed paraffin-embedded tissue of 42 consecutive EC pts treated between 2001 and 2010 were obtained. PTEN loss expression (Hscore≤50) and PIK3CA mut were evaluated by inmunohistochemistry and Sequenom MassARRAY system respectively. Clinical and pathological data were reviewed from medical records. Statistical methods included univariate and multivariate analysis (Histological Type, Tumor grade, FIGO Stage and MFs). Results: A total of 42 pts were analyzed: 21 (50%) Type I (endometrioid) and 21 (50%) Type II (17 Serous-papillary and 4 clear cell) histology. Median age was 62 y (33-79). Sixteen (38%) and 26 pts (62%) were FIGO stage I-II and III-IV respectively. Thirty pts (77%) had grade 3 tumor. All pts but one were initially treated with surgery, 8 pts received adjuvant chemotherapy, 12 pelvic radiotherapy and 15 both. Regarding MFs, 17 pts (41%) had PTEN loss, 5 (12%) PIK3CA mut and 11 (26%) had both. Seven PIK3CA mut were identified, being R88Q the most frequent (31%). Molecular findings were balanced between early and advanced stages (80% and 81% respectively). Median OS was 41 m (27-56). Analyzing OS regarding clinical and molecular features, only the presence of PTEN loss and/or PIK3CA mut has a negative impact. An alteration in the PI3K pathway does not reached statistical significance for OS in the univariate (p=0.059) but it does in the multivariate model (p=0.025, CI 0.020- 0.765). Median OS was 33 m (16-50) and 45 m in the group with and without molecular changes respectively. Conclusions: In our EC cohort, OS is influenced by molecular changes in PI3K pathway reaching statistical significance. Although there could be a bias due to the sample size, our findings warrant further investigation.

Protection Against Endometrial Carcinoma by Combination-Product Oral Contraceptives

To the Editor.— I was quite surprised by the conclusions that were drawn by Hulka and co-workers from a small sample of patients (79 patients with endometrial carcinoma and 203 control subjects) in an article published recently inThe Journal(1982; 247:475). The very factors that predisposed to endometrial carcinoma— hypertension, diabetes, and obesity— are also factors that are relative contraindications to the use of oral hormonal contraceptive agents. Perhaps the reason that fewer women in the endometrial cancer cohort had taken oral contraceptive agents was that their clinicians chose some other method of contraception as more suitable in the hypertensive, diabetic, and obese individual. This would seem to provide a more logical explanation of why fewer individual patients with endometrial cancer had been using oral contraceptive agents, rather than to indicate that the oral contraceptive agents had a protective effect against cancer. The authors' published data are incomplete, in