Preoperative Diagnosis Of Endometrial Cancer Research Articles

Multiparametric magnetic resonance imaging-based assessment of the effect of adenomyosis on determining the depth of myometrial invasion in endometrial cancer.

Accurate preoperative diagnosis of endometrial cancer (EC) with deep myometrial invasion (DMI) is critical to deciding whether to perform lymphadenectomy. However, the presence of adenomyosis makes distinguishing DMI from superficial myometrial invasion (SMI) on magnetic resonance imaging (MRI) challenging. We aimed to evaluate the accuracy of multiparametric MRI (mpMRI) in diagnosing DMI in EC coexisting with adenomyosis (EC-A) compared with EC without coexisting adenomyosis and to evaluate the effect of different adenomyosis subtypes on myometrial invasion (MI) depth in EC. Patients with histologically confirmed International Federation of Gynecology and Obstetrics (FIGO) stage I EC who underwent preoperative MRI were consecutively included in this 2-center retrospective study. Institution 1 was searched from January 2017 to November 2022 and institution 2 was searched from June 2017 to March 2021. Patients were divided into 2 groups: group A, patients with EC-A; group B, EC patients without coexisting adenomyosis, matched 1:2 according to age ±5 years and tumor grade. A senior radiologist assessed the MRI adenomyosis classification in group A. Then, 2 radiologists (R1/R2) independently interpreted T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), T1-weighted contrast-enhanced (T1CE), and a combination of all images (mpMRI) respectively, and then assessed MI depth. Accuracy, sensitivity, specificity, and the areas under the receiver operating curve (AUC) were calculated. The chi-square test was used to compare the accuracy of diagnosing DMI. Interobserver agreement was evaluated using the Kappa test. A total of 70 cases in group A and 140 cases in group B were included. The accuracy, sensitivity, and specificity of consensus were 94.3% [95% confidence interval (CI): 88.9-99.7%] vs. 92.1% (95% CI: 87.7-96.6%), 60.0% (95% CI: 17-92.7%) vs. 86.7% (95% CI: 68.4-95.6%), and 96.9% (95% CI: 88.4-95.5%) vs. 93.6% (95% CI: 86.8-97.2%) (group A vs. group B, respectively). There was no significant difference in the diagnostic accuracy of DMI on each sequence between the groups (Reviewer 1/Reviewer 2): PT2WI=0.14/0.17, PDWI=0.50/0.33, PT1CE=0.90/0.18, PmpMRI=0.50/0.37. The AUC for T2WI, DWI, T1CE, and mpMRI (Reviewer 1/Reviewer 2), respectively, were 0.54 (95% CI: 0.42-0.66)/0.78 (95% CI: 0.67-0.87), 0.63 (95% CI: 0.50-0.74)/0.77 (95% CI: 0.65-0.86), 0.69 (95% CI: 0.57-0.80)/0.79 (95% CI: 0.68-0.88), and 0.91 (95% CI: 0.82-0.97)/0.89 (95% CI: 0.79-0.95) (group A) and 0.83 (95% CI: 0.76-0.89)/0.85 (95% CI: 0.78-0.90), 0.83 (95% CI: 0.76-0.89)/0.86 (95% CI: 0.79-0.91), 0.88 (95% CI: 0.82-0.93)/0.86 (95% CI: 0.80-0.92), and 0.91 (95% CI: 0.85-0.95)/0.87 (95% CI: 0.80-0.92) (group B). Interobserver agreement was highest with mpMRI [κ=0.387/0.695 (case/control)]. The consensus results of MRI categorization of adenomyosis revealed no significant difference in the accuracy of diagnosing DMI by adenomyosis subtype (Pspatial relationship>0.99, Paffected area=0.52, Paffected pattern=0.58, Paffected size>0.99). The presence of adenomyosis or adenomyosis subtype had no significant effect on the interpretation of the depth of MI. T1CE can increase the contrast between adenomyosis and cancer foci; therefore, the information provided by T1CE should be valued.

Is lymph node dissection mandatory among early stage endometrial cancer patients? A retrospective study

BackgroundWhether routine lymph node dissection for early endometrial cancer is beneficial to survival is still controversial. However, surgeons usually perform lymph node dissection on all patients with early endometrial cancer. This study aimed to prove that the risk of lymph node metastasis, as defined by our standard, is very low in such patients and may change the current surgical practice.Methods36 consecutive patients who had staged surgery for endometrial cancer were collected. All eligible patients meet the following very low risk criteria for lymph node metastasis, including: (1) preoperative diagnosis of endometrial cancer (preoperative pathological diagnosis), (2) tumors confined to the uterine cavity and not beyond the uterine body, (3) PET-MRI lymph node metastasis test is negative. PET-MRI and pathological examination were used to assess the extent and size of the tumor, the degree of muscular invasion, and lymph node metastasis.ResultsThe median age at diagnosis was 52 years (range 35–72 years). The median tumor size on PET-MRI was 2.82 cm (range 0.66–6.37 cm). Six patients underwent robotic surgery, 20 underwent laparoscopic surgery, 8 underwent Laparoscopic-assisted vaginal hysterectomy, and 2 underwent vaginal hysterectomy. 23% (63.9%) patients had high-grade (i.e. 2 and 3) tumors. Among the 36 patients who underwent lymph node sampling, the median number of lymph nodes retrieved was 32 (range 9–57 nodules). No patient (0%) was diagnosed with lymph node metastasis. According to the policy of each institution, 8 patients (22.2%) received adjuvant therapy, and half of them also received chemotherapy (4 patients; 50%).ConclusionsNone of the patients who met the criteria had a pathological assessment of lymph node metastasis. Omitting lymph node dissection may be reasonable for patients who meet our criteria.

Disparities in surgical management of endometrial cancers in a public healthcare system: A question of equity

ObjectiveTimely surgery has been shown to impact outcome in endometrial cancer patients. Social determinants of health (SDH) are associated with adverse cancer outcomes. We sought to evaluate the association of SDH with surgical treatment indicators in endometrial cancer patients in a public healthcare system. MethodsEndometrial cancer patients in Ontario, Canada, diagnosed between 2009 and 2017 were identified, and clinical, social and demographic variables were extracted from administrative databases. Validated community marginalization scores that include material deprivation, residential instability and ethnic concentration were used for stratification. Surgical treatment features were compared across marginalization quintiles using chi-square, Fischer exact or Wilcoxon rank sum tests as appropriate. Predictors of timely surgical treatment were evaluated with logistic regression. Results20228 patients were identified of whom 14,423 had primary hysterectomy for a preoperative diagnosis of endometrial cancer. Fewer patients in marginalized communities received surgery (89% vs. 93%, p < 0.001). Surgical delay was longer among marginalized patients and 78% had surgery within 12 weeks compared to 84% of those least marginalized (p < 0.0001). Other quality indicators of surgical treatment were not negatively associated with marginalization. On multivariable analysis adjusted for patient and disease factors, marginalization was independently associated with increased odds of delayed surgery (OR = 0.94/quintile, CI 0.91–0.97, p < 0.001). ConclusionsSocial marginalization is associated with decreased likelihood of having surgery and with delayed surgery among endometrial cancer patients in Ontario. This may be mediated by delayed presentation and real or perceived barriers to access. Reducing surgical wait times among marginalized cancer patients is an important deliverable in public healthcare.

Robotic single-site staging operation for early-stage endometrial cancer: initial experience at a single institution.

ObjectiveThe aims of this study were to introduce surgical guidelines, and to evaluate the feasibility and safety of a robotic single-site staging (RSSS) operation for early-stage endometrial cancer.MethodsPatients with a preoperative diagnosis of endometrial cancer (International Federation of Gynecology and Obstetrics stages IA to IB) from endometrial curettage and preoperative imaging studies were selected at Dongsan Medical Center from March 2014 to November 2015. All surgical procedures, including hysterectomy, salpingo-oophorectomy, bilateral pelvic node dissection, and cytology aspiration, were performed by robotic single-site instruments (da Vinci Si® surgical system; Intuitive Surgical, Sunnyvale, CA, USA).ResultsA total of 15 women with early-stage endometrial cancer underwent the RSSS operation. The median patient age and body mass index were 53 years (range, 37–70 years) and 25.4 kg/m2 (range, 18.3–46.4 kg/m2). The median docking time, console time, and total operative time were 8 minutes (range, 4–15 minutes), 75 minutes (range, 55–115 minutes), and 155 minutes (range, 125–190 minutes), respectively. The median retrieval of both pelvic lymph nodes was 9 (range, 6–15). There were no conversions to laparoscopy or laparotomy.ConclusionThe RSSS operation is feasible and safe in patients with early-stage endometrial cancer. In this study, operative times were reasonable, and the surgical procedure was well-tolerated by the patients. Further evaluation of patients with early-stage endometrial cancer should be performed in large-scale comparative studies using the laparoendoscopic, single-site staging operation to confirm the safety and benefits of the RSSS operation for early-stage endometrial cancer.

Sensitivity of the intraoperative assessment of myometrial invasion in patients undergoing hysterectomy for endometrial cancer

Objective: The objective of this study was to determine the ability of the surgeon to distinguish between deep and superficial myometrial invasion on gross inspection as compared to frozen section. Methods: All patients undergoing hysterectomy for endometrial cancer were eligible for this prospective study carried out at a single institution. After removal of the uterus, the specimen was bi-valved and the depth of myometrial invasion was determined grossly by the attending surgeon (gross). The depth of myometrial invasion by visible tumor was measured in millimeters and then described as “superficial” or “deep” if the invasion did not or did extend into the outer half of the myometrial thickness, respectively. The specimen was sent for frozen section evaluation of tumor grade and depth of invasion (frozen). We calculated the sensitivity of each method, gross and frozen, to correctly identify deep myometrial invasion, the specificity to correctly identify superficial or no invasion, and the accuracy, defined as the number of true positives plus true negatives divided by the total number of cases. The final pathologic assessment of myometrial invasion (final) was considered the gold standard for comparison. Results: Between 4/4/2011 and 4/9/2014, a total of 220 patients underwent hysterectomy by the division of gynecologic oncology in the San Diego area of Kaiser Permanente for a preoperative diagnosis of endometrial cancer. Of these, 196 had complete specimen information (gross, frozen, and final). On final, 35 specimens had deep invasion (17.9%). The sensitivity of gross to detect deep invasion was 54.3% and 77.1% for frozen. Specificity for gross and frozen was 93.8% and 98.8%, respectively. Gross inspection failed to identify deep myometrial invasion in 16 (45.7%) of the cases, frozen failed to identify deep myometrial invasion in 8 (22.9%) of the cases, and both gross and frozen failed to identify deep myometrial invasion in 7 (20.0%) of the cases. Conclusions: Frozen section demonstrates greater accuracy and sensitivity in the intraoperative determination of deep myometrial invasion. This should be considered if intraoperative assessment is used to determine staging or treatment decisions.

Choosing the Right Patient: Planning for Laparotomy or Laparoscopy in the Patient With Endometrial Cancer

Endometrial cancer remains the most commonly diagnosed gynaecologic cancer in North America. The staging and initial treatment of endometrial cancer involves surgery. Laparoscopic surgery is increasingly used as an alternative to laparotomy. Patient selection for laparoscopy can be optimized by examining factors involved in both the choice of surgical approach and the ultimate procedure performed. We wished to identify factors that might be barriers to laparoscopic surgery in women with endometrial cancer who had surgery performed by the gynaecologic oncology group at the Capital District Health Authority (CDHA) in Halifax, Nova Scotia. We conducted a retrospective review of the records of women with endometrial cancer, histologically confirmed preoperatively between 2005 and 2007, who underwent surgery at the CDHA. Between 2005 and 2007 in Nova Scotia, 428 cases of endometrial cancer were diagnosed, and 289 women with a preoperative diagnosis of endometrial cancer underwent surgery at the CDHA. Of these, 66.1% (191/289) underwent a planned laparotomy, and 33.9% (98/289) had a planned laparoscopy. The proportion of attempted laparoscopies increased from 21.9% to 57.1% (P = 0.002) over time, while there was no change in the conversion rate (P = 0.23). Patients with abnormal findings on pelvic examination were more likely to have a laparotomy (RR = 1.5; 95% CI 1.34 to 1.68). Independent predictors of laparoscopic conversion to laparotomy were age 75 years or over (P = 0.03) and non-endometrioid histology (P = 0.002). Our data identify age and non-endometrioid histology as independent factors for conversion of surgery for endometrial cancer from laparoscopy to laparotomy. With this information we can optimize patient selection for laparoscopic surgery. Patients undergoing a conversion to laparotomy do not have a significant increase in surgery time or perioperative morbidity.

Surgical staging of endometrial cancer: robotic versus open technique outcomes in a contemporary single surgeon series.

Patients prefer robotic surgery due to perceived cosmetic advantages and quicker resumption of regular activity. We compared the results of hysterectomy and surgical staging for endometrial cancer using robotic versus open techniques in patients operated on by a single surgeon. A retrospective clinical data analysis was performed of all patients who underwent surgical staging for endometrial cancer. Patients selected for open techniques underwent surgery between January 2003 and December 2005, whereas patients selected for da Vinci robotic surgery were operated on between June 2006 and June 2008. The study was approved by the Institutional Review Board (IRB). The preoperative diagnosis of endometrial cancer was confirmed using endometrial biopsy. Data were collected and comparative analyses were made using mean or chi-squared test or other appropriate statistical techniques. The study population consisted of 97 patients (open, N=38; robotic, N=59). Mean age was 66.5±1.97 versus 59.5±1.43years, mean parity was 2.11 versus 1.93, and mean body mass index (BMI) was 32.2±2.03 versus 39.3±2.03 (P=0.02) for open versus robotic surgery, respectively. Operating time and lymph node (LN) yield was 175.24±4.6 versus 185.27±4.4min, number of pelvic LNs were 8.6 versus 11.34, and aortic LNs were 3.5 versus 1.9 in the open versus robotic groups, respectively. Although mean BMI was higher, blood loss, complications, and hospital stay were significantly lower for patients undergoing robotic surgery. Overall, complications occurred in 5/38 (13%) patients in the open group and 2/59 (3%) patients in the robotic group. Of the two complications in the robotic group, there was one injury to the external iliac vein requiring open surgical management with blood transfusion resulting in a hospital stay of 7days; however, no other patient required blood transfusion in either surgical group. Robotic surgery results in less blood loss and shorter hospital stay and yields comparable number of lymph nodes, which are adequate for staging. It also results in reduced surgical risks in patients with higher BMI who are prone to higher co-morbidities. Robotic surgery is a useful minimally invasive tool for the comprehensive surgical staging of patients with endometrial cancer.

Sentinel lymph node mapping for grade 1 endometrial cancer: Is it the answer to the surgical staging dilemma?

Objective To describe the accuracy of SLN mapping in patients with a preoperative diagnosis of grade 1 endometrial cancer. Methods A prospective, non-randomized study of women with a preoperative diagnosis of endometrial cancer and clinical stage I disease was conducted. A subset analysis of patients with a preoperative diagnosis of grade 1 endometrial endometrioid cancer was performed. All patients had preoperative lymphoscintigraphy with Tc99m on the day of or day before surgery followed by an intraoperative injection of 2 cm 3 of isosulfan or methylene blue dye deep into the cervix or both cervix and fundus. All patients underwent hysterectomy, bilateral salpingo-oophorectomy, and regional nodal dissection. Hot and/or blue nodes were labeled as SLNs and sent for histopathological analysis. Results Forty-two patients with a preoperative diagnosis of grade 1 endometrial carcinoma treated from 3/06 to 8/08 were identified. Twenty-five (60%) had laparoscopic surgery; 17 (40%) were treated by laparotomy. Preoperative lymphoscintigraphy visualized SLNs in 30 patients (71%); intraoperative localization of the SLN was possible in 36 patients (86%). A median of 3 SLNs (range, 1–14) and 14.5 non-SLNs (range, 4–55) were examined. In all, 4/36 (11%) had positive SLNs—3 seen on H&E and 1 as cytokeratin-positive cells on IHC. All node-positive cases were picked up by the SLN; there were no false-negative cases. The sensitivity of the SLN procedure in the 36 patients who had an SLN identified was 100%. Conclusion Sentinel lymph node mapping using a cervical injection with combined Tc and blue dye is feasible and accurate in patients with grade 1 endometrial cancer and may be a reasonable option for this select group of patients. Regional lymphadenectomy remains the gold standard in many practices, particularly for the approximately 15% of cases with failed SLN mapping.

Progesterone receptor isoform identification and subcellular localization in endometrial cancer

Objective These studies were undertaken to characterize the subcellular localization of the two major isoforms of progesterone receptors (PR), PRA and PRB, in endometrial cancer. Methods Immunohistochemistry, immunoprecipitation, and confocal microscopy were performed using Hec50co and KLE endometrial cancer cell models expressing PRA or PRB as a consequence of transduction. The location of PRB compared to PRA was determined, and antibodies were tested for specificity with respect to PR isoform recognition. Immunohistochemical analyses of PR expression and subcellular compartmentalization were also performed on 20 formalin-fixed endometrial cancer tumors. Results Morphological and biochemical evaluations demonstrated that PRA is localized to the nucleus, even in the absence of progesterone. In contrast, a large proportion of PRB is cytoplasmic in the absence of ligand, but is rapidly translocated to the nucleus in the presence of progesterone. The differential distribution of PRA and PRB proved to be a hallmark of malignant and nonmalignant epithelia in 20 samples of archival endometrial tissue from women with the pre-operative diagnosis of endometrial cancer. All endometrial cancer specimens demonstrated cytoplasmic PRB in 50% or more of the cells, and five of the seven tumors that were moderately to poorly differentiated demonstrated no PRB staining in the nuclei. Nuclear PRB was significantly associated with increasing tumor differentiation ( P = 0.031). Conclusion In the absence of ligand, PRA is nuclear and PRB is largely cytoplasmic. This suggests that PRA may exert ligand-independent nuclear effects, while PRB may have nongenomic cytoplasmic actions in endometrial cancer cells.