Full Surgical Staging Research Articles

Assessment of endometrial carcinoma on biopsy as a predictor of final surgical pathology: Are we doing it right? A completed audit cycle and recommendations.

Typing and grading of endometrial carcinomas (ECs) on small biopsy specimens is crucial to determine the need for full surgical staging. Histological subtype and grade are key factors available for risk stratification before surgery. However, this can be diagnostically challenging on small biopsy specimens, especially when morphologic features are subtle or overlapping. The aims of this audit were to assess concordance of endometrial carcinomas on biopsy specimens with hysterectomy specimens and to determine if the immunohistochemistry (IHC) panel being used in our practice was adequately subtyping ECs. The audit was approved by the Clinical Effectiveness Team of the Royal College of Pathologists (UK) as meeting all the criteria and standards set out by the College. Biopsies from 67 cases of EC were compared for histological subtype and grade of endometrioid carcinoma with resection specimens. A re-audit was carried out on 59 cases after implementation of changes recommended by the initial audit. Two of 35 (6%) tumours defined as G1 on biopsy were upgraded (to G2) on final pathology, as was one of 7 (14%) G2 tumours (to G3). One of these cases had solid areas just amounting to more than 6% on resection. In the second case, a comment was made that assessment had been difficult as the specimen was suboptimally fixed, but nuclei appeared atypical. Of seven G2 biopsies, one case was upgraded to grade 3 on final pathology based on proportion of solid areas. Our data show lower rates of discordance as compared to previous studies and on re-audit, the concordance between endometrioid and nonendometrioid serous carcinoma improved with the addition of immunohistochemistry (IHC) for Phosphatase and tensin homolog (PTEN) to biopsies. PTEN IHC can complement other stains and aid in the distinction of grade 3 endometrioid carcinoma from serous carcinoma on endometrial biopsies.

Serous endometrial intra-epithelial carcinoma: an observational study

BackgroundSerous endometrial intra-epithelial carcinoma is described as a malignant, superficial spreading lesion with risk of extra-uterine spread at time of diagnosis, and poor outcome.ObjectiveTo evaluate the surgical management of patients...

Clinical outcomes of patients with endometrioid epithelial ovarian cancer following surgical treatment.

Endometrioid epithelial ovarian cancer (EEOC) is rare, and its management poorly defined. We examined factors associated with 5-year progression-free survival (PFS) after surgery for EEOC. Retrospective study: treatment and outcomes of all EEOC patients undergoing initial surgery at, or presenting to, our institution within 3 months of initial surgery, 1/2002-9/2017. In total, 212 patients were identified. Median follow-up, 63.9 months (range, 0.7-192); median age at diagnosis, 52 years (range, 20-88); disease stage: I, n = 145 (68%); II, n = 47 (22%); III/IV, n = 20 (9%); FIGO grade: 1, 127 (60%); 2, 66 (31%); 3, 17 (8%); unknown, 2 (1%). One hundred twenty-eight (60%) had endometriosis; 75 (35%), synchronous endometrioid endometrial cancer (80%, IA); 101 (48%), complete surgical staging; 8 (5%), positive pelvic lymph nodes (LNs); 6 (4%), positive para-aortic LNs; 176 (97%), complete gross resection; 123 (60%), postoperative chemotherapy; 56(28%), no additional treatment. Five-year PFS, 83% (95% confidence interval [CI]: 76.6%-87.8%); 5-year overall survival (OS), 92.7% (95% CI: 87.7%-95.8%). Age, stage, and surgical staging were associated with improved 5-year PFS, and younger age at diagnosis with improved 5-year OS (p < 0.001). Chemotherapy did not improve 5-year PFS in IA/IB versus observation, but improved survival in IC (hazard ratio [HR]: 1.01, 95% CI: 0.22-4.59, p = 0.99; HR: 0.17, 95% CI: 0.04-0.7, p = 0.006). Age, stage, and full surgical staging were associated with improved 5-year PFS. Chemotherapy showed no benefit in IA/IB disease.

Impact of Previous Gynecologic Surgical Procedures on Outcomes of Non-Gynecologic Peritoneal Malignancies Mimicking Ovarian Cancer: Less Is More?

Non-gynecologic rare peritoneal surface malignancies (PSMs) often are misdiagnosed as disseminated ovarian cancer and initially treated by gynecologic surgeons. This study aimed to assess whether these previous maneuvers (i.e., full surgical staging and/or cytoreductive attempts) affect outcomes after the definitive surgery performed in a tertiary center. The study reviewed 298 women affected by non-gynecologic PSM who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) after previous gynecologic surgery. Prior surgery was categorized as limited surgery (pLS: abdominal exploration with biopsy plus adnexectomy and/or appendectomy) or extended surgery (pES: full surgical staging or cytoreductive attempts including hysterectomy with bilateral salpingo-oophorectomy). Of the 298 patients, 143 had pLS and 153 had pES. Morbidity was similar between the groups (P = 0.143), but the pES group had more severe urinary tract injuries (19 vs. 3; P < 0.001), longer operating time (585.9 vs. 506.7; P = 0.027), and more patients needing more than two anastomoses (41 vs. 26; P = 0.033). Ageolder than 55years (odds ratio [OR] 2.42; P = 0.009) and number of anastomoses (OR 3.17; P = 0.002) correlated with severe morbidity; pES correlated with urinary tract grades 3 and 4 injuries (OR 7.9; P = 0.001). The 5-year cumulative incidence of locoregional relapse was significantly higher in the pES group (0.41 vs. 0.27; P = 0.012; median follow-up period, 69months). The multivariate analysis identified a Peritoneal Carcinomatosis Index (PCI) higher than 20 and pES as independent risk factors. For women undergoing CRS±HIPEC for non-gynecologic PSM, the risk for locoregional relapse and severe postsurgical urinary tract complications is increased by pES. Therefore, prior full surgical staging or cytoreductive attempts without definitive gynecologic histology should be avoided. Prophylactic ureteral stenting and stricter oncologic follow-up assessment must be considered in this scenario.

Frozen section diagnosis of borderline ovarian tumors with suspicious features of invasive cancer is a devil's dilemma for the surgeon: A systematic review and meta-analysis.

IntroductionFrozen section diagnoses of borderline ovarian tumors are not always straightforward and a borderline frozen section diagnosis with suspicious features of invasive carcinoma (reported as “at least borderline” or synonymous descriptions) presents us with the dilemma of whether or not to perform a full surgical staging procedure. By performing a systematic review and meta‐analysis, the prevalence of straightforward borderline and “at least borderline” frozen section diagnoses, as well as proportion of patients with a final diagnosis of invasive carcinoma in these cases, were assessed and compared, as quantification of this dilemma may help us with the issue of this clinical decision.Material and methodsPubMed, EMBASE and Cochrane library databases were searched and studies discussing “at least borderline” frozen section diagnoses were included in the review. Numbers of specific frozen section diagnoses and subsequent final histological diagnoses were extracted and pooled analysis was performed to compare the proportion of patients diagnosed with invasive carcinoma following borderline and “at least borderline” frozen section diagnoses, presented as risk ratio and risk difference with 95% confidence intervals (95% CI).ResultsOf 4940 screened records, eight studies were considered eligible for quantitative analysis. A total of 921 women was identified and 230 (25.0%) of these women were diagnosed with “at least borderline” ovarian tumor at the time of frozen section. Final histological diagnoses were reported in five studies, including 61 women with an “at least borderline” diagnosis and 290 women with a straightforward borderline frozen section diagnosis. Twenty‐five of 61 women (41.0%) of the “at least borderline” group had invasive cancer at final diagnosis, compared with 28 of 290 women (9.7%) of the straightforward borderline frozen section group (risk difference −0.34, 95% CI −0.53 to −0.15; relative risk 0.25, 95% CI 0.13–0.50).ConclusionsWomen diagnosed with “at least borderline” frozen section diagnoses were found to have a higher chance of carcinoma upon final diagnosis when compared with women with a straightforward borderline frozen section diagnosis (41.0% vs 9.7%). Especially in the serous subtype, and after preoperative consent, full staging during initial surgery might be considered in these cases to prevent a second surgical procedure.

Low-Volume Nodal Metastasis in Endometrial Cancer: Risk Factors and Prognostic Significance.

Objective: To evaluate the oncological outcomes of patients with low-volume metastasis compared to those with macrometastasis and negative nodes in endometrial cancer. Methods: A single institutional retrospective study was carried out, which included all patients with endometrial cancer who underwent surgical treatment between January 2007 and December 2016. We analyzed the progression-free survival (PFS) and overall survival (OS) of all patients after sentinel node biopsy and full nodal surgical staging according to their final pathological nodal status, focusing on the impact of the size of nodal metastasis. Results: A total of 270 patients were operated on during the study period; among them, 230 (85.2%) patients underwent nodal staging. On final pathology, 196 (85.2%) patients had negative lymph nodes; low-volume metastasis (LVM) was present in 14 (6.1%) patients: 6 (2.6%) patients had isolated tumor cells (ITCs) and 8 (3.5%) patients presented just micrometastasis; additionally, 20 (8.7%) patients presented macrometastasis. After a median (range) follow-up of 60 (0–146) months, patients with macrometastasis showed a significantly worse PFS compared to LVM and node-negative patients (61.1% vs. 71.4% vs. 83.2%, respectively; p = 0.018), and similar results were obtained for 5-year OS (50% vs. 78.6% vs. 81.5%, respectively; p < 0.001). Half of the patients presenting LVM did not receive adjuvant treatment. Moreover, LVM had a moderate nonsignificant decrease in 5-year PFS compared to node-negative patients. Conclusions: Patients with endometrial cancer and low-volume nodal metastasis demonstrated a better prognosis than those presenting macrometastasis. Low-volume metastasis did not show worse oncological outcomes than node-negative patients, although there was a slight decrease in progression-free survival.

Adult Granulosa Cell Tumors: Clinical Characteristics, Outcomes and Prognostic Factors for Recurrence at Early Stages

Objective: The objectives of this study were to conduct a retrospective review of patients with adult granulosa cell tumors (AGCTs) to validate the effect of full surgical staging and adjuvant chemotherapy, and to identify the factors influencing disease-free survival (DFS) and overall survival (OS). Material and Methods: The database and patient files available at our gynecological oncology department were searched to identify women who had undergone primary surgery for an ovarian tumor and whose final diagnosis was stage I/II AGCT. A total of 41 patients with earlystage AGCT were included in the analysis. Results: The majority of the cases were Stage I AGCT (63.4%). The median OS of the patients was 54.3 months. Full stage surgery, age, and lymphadenectomy were not independent risk factors for the involvement of lymph nodes in AGCTs. For patients with full surgical staging, pelvic and para-aortic lymphadenectomy were not independent prognostic factors for DFS and OS. Conclusion: Initial stage, age, lymphadenectomy, and full stage surgery did not influence DFS, OS, or recurrence of AGCTs. Furthermore, age, bilaterality, and preoperative ultrasound image did not influence the involvement of lymph nodes in AGCTs.

Concomitant Laparoscopic and Thoracoscopic Resection of Recurrent High-Grade Ovarian Cancer

Study ObjectiveTo describe the first case of combined endoscopic management of a thoracic and abdominal recurrence of ovarian cancer. DesignAn instructive video showing the combined thoracic and abdominal surgical procedure. SettingDepartment of Gynecological Oncology, Churchill Hospital, Oxford University, UK. PatientsA 64-year-old woman undergoing endoscopic treatment for a third recurrence of ovarian cancer after a full surgical staging in 2007. The disease-free interval from the last recurrence was 31 months. InterventionThe operation was performed by a multidisciplinary team of thoracic and gynecologic oncologist surgeons. Surgery started with thoracoscopic resection of a right enlarged paracardiac lymph node of 24 mm and a small wedge of the right lung, which was attached to the lymph node. At laparoscopy, 2 nodules of 3 and 5 mm were excised from the mesosigmoid and 1 nodule of 20 mm was resected from the right hemidiaphragm. Measurements and Main ResultsThe total operative time was 251 minutes, and no intraoperative complication occurred. No conversion to open surgery was necessary. The estimated blood loss was 50 mL. There was no visible residual disease at the end of the surgery. The patient was discharged 4 days after surgery. The final pathology report confirmed the presence of endometrioid adenocarcinoma in all specimens removed. Adjuvant chemotherapy with carboplatin/paclitaxel was started 2 weeks later. At the 60-day follow-up, no complications were recorded. A computed tomographic scan performed after 6 cycles of chemotherapy did not reveal any evidence of relapse. ConclusionsThe combined endoscopic approach might be feasible in selected patients.

Identifiable Risk Factors for Lymph Node Metastases in Grade 1 Endometrial Carcinoma.

The aim of this study was to evaluate the clinicopathological features related to lymph node metastases in grade 1 endometrial carcinomas. Five hundred ninety-nine cases of endometrial carcinoma treated with total hysterectomy bilateral salpingo-oophorectomy and pelvic lyphadenectomy between 2001 and 2015 were retrieved from the pathology files of IASO Women's Hospital, Athens, Greece. Of these, 345 were grade 1 endometrioid carcinomas and were included in the study. Features such as the age of the patients, the stage, the location, and size of the tumors, as well as the existence of microcystic, elongated, and fragmented pattern invasion or lymph vascular space invasion, were estimated. In our cohort of endometrial carcinomas, features related to an increased risk of lymph node metastases were stages IB or higher; the location of the tumor in the lower uterine segment; the identification of microcystic, elongated, and fragmented pattern of invasion; and the existence of lymph vascular emboli. When considering the size of the tumors, only stage IA myoinvasive cancers of larger than 4 cm in diameter were significantly associated with nodal disease. In addition, a statistically significant relationship was found between the number of excised lymph nodes and the possibility to detect nodal disease. Full surgical staging carries a substantial risk of operative complications, and, indeed, it can be avoided in most cases of grade 1 endometrial carcinomas. Nevertheless, even in the low-risk group of patients, there are clinicopathological parameters that should alert the clinician for the possibility of a more disseminated disease.

The Adoption of Single-port Laparoscopy for Full Staging of Endometrial Cancer: Surgical and Oncology Outcomes and Evaluation of the Learning Curve

Study ObjectiveTo study the safety, feasibility, learning curve, and surgical outcome for single-port laparoscopic full staging of endometrial cancer. DesignA retrospective study (Canadian Task Force classification II-3). SettingA university academic hospital. PatientsWomen with endometrial cancer undergoing single-port laparoscopic full surgical staging. InterventionsThis was a single-center, retrospective consecutive study of patients undergoing single-port laparoscopic full staging of endometrial cancer from March 2012 to December 2015. Measurements and Main ResultsOne hundred ten consecutive cases were included in the study. The mean age was 63 years (standard deviation = 14), and the mean body mass index was 34 kg/m2 (standard deviation = 7). Medical comorbidity was noted in 62% (68/110) of patients, and 55% (61/110) of patients had previous abdominal surgery. Preoperative histology included grade 1 (63%), grade 2 (23%), grade 3 (4%), papillary serous (6%), clear cell (3%), and mixed (1%). Postoperatively, 73% of patients were stage I, 2% were stage II, 21% were stage III, and 4% were stage IV. The conversion rate to multiple ports or to laparotomy was 6.3%. The average total surgical time was 186 minutes. Comparing the last 30 cases of our cohort with the first 20, there was a significant improvement in the reduction of the total operative time (191 vs 152 minutes, p = .036), estimated blood loss (389 vs 121 mL, p = .002), conversion rate (20 % vs 0%, p = .02), and rate of surgical complication (10% vs. 0%, p = .03). The readmission rate was 11% (12/110) with 75% of those patients being readmitted for surgical indications and 25% for medical indications. The rate of ventral hernia was 1.8% (2/110) with an average follow-up of 298 days (31–1085 days). ConclusionSingle-port laparoscopic staging of endometrial cancer is a safe and feasible technique to introduce into a gynecologic oncology practice that is compatible with other minimally invasive modalities with similar complication rates, discharge timing, and operative times. Drastic improvement in surgical time can be seen after approximately the first 20 cases.

Three versus six cycles of adjuvant platinum-based chemotherapy in early stage clear cell ovarian carcinoma – A multi-institutional cohort

ObjectivesTo determine if 6 versus 3cycles of adjuvant platinum-based chemotherapy with or without taxane impacts survival in early stage ovarian clear cell carcinoma (OCCC). MethodsWe retrospectively identified all cases of stage I and II OCCC treated at 5 institutions from January 1994 through December 2011. Patients were divided into 2 groups: those who received 3 versus 6cycles of adjuvant chemotherapy. Our cohort consisted of 210 patients with stage IA-II disease, 116 of whom underwent full surgical staging. Cox proportional hazards regression and Kaplan-Meier analyses were performed to evaluate progression-free (PFS) and overall survival (OS) between groups. ResultsAmong 210 eligible patients, the median age was 53years (range 30–88). The majority of patients were Caucasian (83.8%). All patients received adjuvant chemotherapy with 90% receiving carboplatin and paclitaxel. Thirty-eight (18.1%) patients received 3cycles, and 172 (81.9%) patients received 6cycles of adjuvant treatment. Recurrence rate was comparable between groups (18.4% vs. 27.3% for 3 vs. 6cycles, p=0.4). There was no impact of 3 versus 6cycles of chemotherapy on PFS (hazard ratio [HR] 1.4; 95% confidence interval [CI] 0.63–3.12, p=0.4) or OS (HR 1.65; 95% CI 0.59–4.65, p=0.3) on univariate analysis. There was no benefit to more chemotherapy in stratified analysis by stage nor on multivariate analysis adjusting for the impact of stage. Subgroup analysis of surgically staged patients also showed no difference in survival between 3 versus 6cycles of chemotherapy. ConclusionsThree cycles of platinum with or without taxane adjuvant chemotherapy were comparable to 6cycles with respect to recurrence and survival in patients diagnosed with early stage ovarian clear cell carcinoma in this retrospective multi-institutional cohort. CondensationThree cycles of platinum with or without taxane adjuvant chemotherapy are comparable to 6 cycles with respect to recurrence and survival in patients diagnosed with early stage ovarian clear cell carcinoma in this retrospective multi-institutional cohort.

Studying CA-125 tumor marker level in different stages, histopathological types, and grades of endometrial cancer

Objective The aim of this study was to correlate the level of CA125 in different stages, histopathological types, and grades of endometrial cancer. Patients and methods Prospective study was conducted on 120 endometrial cancer patients who underwent full surgical staging, preoperative measurement of CA125, histopathological examination, and grading of uterus and pelvic lymph nodes. Results Histopathology of the cases revealed the following: 102 cases were endometrioid adenocarcinoma, 17 cases were serous papillary adenocarcinoma, and one case was clear cell carcinoma. All 25 (100%) cases with advanced-stage disease had a CA-125 level of at least 35 U\ml, compared with 52 of 95 (54.7%) cases with early-stage disease (P<0.001). In relation to histopathological type and CA-125 serum level, all the 18 (100%) nonendometrioid-type cases had a CA-125 level of greater than or equal to 35 U\ml in comparison with 59 of 102 (57.8%) endometriod cases (P=0.001). In contrast to histopathological grading, there was no positive correlation (P=0.36). Conclusion Preoperative CA125 serum levels of at least 35 U\ml in uterine adenocarcinoma can predict advanced disease stages (III or IV), regional lymph nodes metastasis, and high risk patients who need regional lymphadenectomy and complete surgical staging.

CA 125 and Grade 1 Endometrial Cancer

INTRODUCTION: The purpose of this article was to relate pre-operative serum CA 125 to risk of nodal metastases in women with grade 1 endometrial cancer that were fully surgically staged. METHODS: Charts were reviewed to determine all patients with pre-operative grade 1 endometrial carcinoma and a serum CA 125 undergoing complete surgical staging. Charts were also reviewed for final stage, grade, and site of metastases. All serum CA 125s were drawn within 3 weeks of definitive surgery. RESULTS: Analysis was completed on 737 patients with grade 1 endometrial cancer. The mean age of the population was 61.9 years (95% CI 61.3–62.4). Extra uterine disease was found in 14.7% of patients and nodal disease in 12.6%. A significant difference in BMI was seen between those not having lymph node metastases (mean 38.7 kg/m2; 95% CI 38.1–39.3) and those having positive nodes (mean 35.3 kg/m2; 95% CI 34.3–36.3) (P<.001). The mean CA 125 for the cohort was 25.6 mIU/mL (95% CI 22.0–29.2). No patients with pre-operative grade 1 disease and a CA 125 <15 mIU/mL (0/239) had nodal disease at surgical staging while 18.7% (93/498) with a CA 125 >15 mIU/mL had nodal metastases (P<.001). CONCLUSION: In patients with grade 1 endometrial adenocarcinomas, CA 125 can be used to determine who needs full surgical staging with minimal risk of missing nodal positive patients.

Intraoperative frozen section analysis for the diagnosis of early stage ovarian cancer in suspicious pelvic masses.

Intraoperative frozen section analysis for the diagnosis of early stage ovarian cancer in suspicious pelvic masses.

Cancer of the corpus uteri.

Cancer of the corpus uteri.

Surgical treatment for apparent early stage endometrial cancer

Most experts would agree that the standard surgical treatment for endometrial cancer includes a hysterectomy and bilateral salpingo-oophorectomy; however, the benefit of full surgical staging with lymph node dissection in patients with apparent early stage disease remains a topic of debate. Recent prospective data and advances in laparoscopic techniques have transformed this disease into one that can be successfully managed with minimally invasive surgery. This review will discuss the current surgical management of apparent early stage endometrial cancer and some of the new techniques that are being incorporated.

Association between tumor diameter and lymphovascular space invasion among women with early-stage endometrial cancer

ObjectiveTo investigate the association between tumor diameter and intratumoral risk factors that might predict the need for full surgical staging among women with endometrial cancer (EC). MethodsData from patients with early-stage EC treated at the Istituto Nazionale dei Tumori, Milan, Italy, between January 2004 and December 2012 were retrospectively analyzed. Associations between tumor diameter and tumor grade, myometrial invasion, risk group, lymphovascular space invasion (LVSI), and lower uterine segment (LUS) involvement were assessed by bivariate and multivariate analysis. ResultsIn total, 181 patients met the inclusion criteria. The tumor diameter was 2cm or less in 110 women (60%). χ2 analysis showed that tumor grading, myometrial invasion, risk group, and LVSI were significantly associated with tumor size (P<0.001), whereas LUS involvement was marginally associated (P=0.051). By multivariate analysis, LVSI and myometrial invasion had an independent association with tumor size greater than 2cm (P<0.018). ConclusionTumor size greater than 2cm was significantly and independently associated with LVSI and myometrial invasion among patients with early-stage EC. Given the difficulty of obtaining reliable LVSI data from frozen sections, tumor size might be used as a surrogate at the time of surgery to provide additional information to triage patients for full surgical staging.

A prospective phase II study of chemoradiation followed by adjuvant chemotherapy for FIGO stage I–IIIA (1988) uterine papillary serous carcinoma of the endometrium

ObjectiveTo prospectively evaluate tumor control, survival, and toxic effects in patients with International Federation of Gynecology and Obstetrics (1988) stage I–IIIA papillary serous carcinoma of the endometrium treated with concurrent chemoradiation and adjuvant chemotherapy. MethodsThirty-two patients were enrolled from October 2001 through July 2009. Patients underwent full surgical disease staging and postoperative concurrent weekly paclitaxel (50mg/m2) and pelvic RT to 45Gy plus a vaginal cuff boost followed by 4cycles of adjuvant paclitaxel (135mg/m2). ResultsThirty patients (94%) were evaluable (3 with stage IA disease, 11 IB, 3 IC, 1 IIB, and 12 IIIA). Eighteen patients (60%) received all 5 planned courses of concurrent chemotherapy, 10 (33%) received 4 courses, and 2 (7%) received 3 courses. All 30 patients received RT; 27 (90%) received the full dose, 2 received 43.2Gy, and 1 received 39.6Gy owing to toxic effects. Twenty-three patients (77%) completed all 4cycles of adjuvant paclitaxel, 3 (10%) completed 3cycles, 2 (7%) completed 2cycles, and 2 received no adjuvant therapy. Overall survival (OS), progression-free survival (PFS), and local control rates for all patients were 93%, 87%, and 87%, respectively, at 2years and 85%, 83%, and 87%, respectively, at 5years. Six patients developed (20%) grade 3/4 toxicities from the treatment. Four patients (13%) had grade 3 or more severe bowel complications and two patients developed symptomatic pelvic fractures. ConclusionsTreatment with concurrent paclitaxel and pelvic RT followed by 4 courses of systemic paclitaxel produced favorable results in patients with surgically staged I–III UPSC.

Predictive value of preoperative serum CA-125 levels in patients with uterine cancer: The Asian experience 2000 to 2012

ObjectiveMuch of the early investigative work on the usefulness of preoperative serum CA-125 levels in identifying patients with early-stage endometrial carcinoma who have occult metastases were carried out in Europe and the United States. This article reviews CA-125 as a possible index for determining the need for full surgical staging, from the results of large medical centers in Asia, particularly Taiwan and Korea.MethodsA Medline search was performed using CA-125 and endometrial cancer as index words from 1981 to 2012. Those publications felt to be the most important especially from institutions from Asia since 2000 were identified in this review.ResultsMost articles that analyzed the utility of serum CA-125 levels as predictive marker for disease extent or prognosis in uterine cancer used univariate and multivariable logistic regression analysis, and performed receiver operative curves to find the best cut-off values. The main factor of interest was whether clinicians can stratify patients that need lymphadenectomy in early stage disease. Suggested optimal cut-off value ranged from 20 to 210 U/mL. Not only preoperative CA-125 level, but myometrial invasion status by magnetic resonance imaging was the most significant combined parameter for predicting disease extent.ConclusionElevated CA-125 in patients with apparent early-stage disease is clearly a risk factor for the presence of extra-uterine disease although the optimal cut-off levels vary. The evolution of clinical investigations over the past decade, particularly in Asia, suggests employment of the test in a more focused manner to identify high risk patients preoperatively.

Diagnostic Accuracy of Magnetic Resonance Imaging in Endometrial Cancer

The objectives of this study were to investigate the accuracy of magnetic resonance imaging (MRI) in predicting the depth of myometrial invasion in the preoperative assessment of women with endometrial cancer and to quantify the impact of MRI as an adjunct to predicting patients requiring full surgical staging. This was a diagnostic accuracy study of prospective cases in conjunction with STARD guidelines using collected data from a tumor board within a cancer network. Consecutive series of all endometrial cancers in Northern Ireland over a 21-month period was discussed at the Gynaecological Oncology Multidisciplinary Team/tumor board meeting. This study concerns 183 women who met all the inclusion criteria. Main outcome measure was the correlation between the depth of myometrial invasion suggested by preoperative MRI study and the subsequent histopathological findings following examination of the hysterectomy specimen. Secondary end point was how MRI changed management of women who required surgery to be performed at a central cancer center. For the detection of outer-half myometrial invasion, overall sensitivity of MRI was 0.73 (95% confidence interval [CI], 0.59-0.83), and specificity was 0.83 (95% CI, 0.76-0.89). The positive predictive value was 0.63 (95% CI, 0.50-0.74), and negative predictive value was 0.89 (95% CI, 0.82-0.93). Positive likelihood ratio was 4.35 (95% CI, 2.87-6.61), and negative likelihood ratio was 0.33 (95% CI, 0.21-0.52). Magnetic resonance imaging improved the sensitivity and negative predictive value of endometrial biopsy alone in predicting women with endometrial cancer who require full surgical staging (0.73 vs 0.65 and 0.80 vs 0.78, respectively). Preoperative pelvic MRI is a moderately sensitive and specific method of identifying invasion to the outer half of myometrium in endometrial cancer. Addition of MRI to preoperative assessment leads to improved preoperative assessment, triage, and treatment.