Uterine Clear Cell Carcinomas Research Articles

Single-cell transcriptome profiles the heterogeneity of tumor cells and microenvironments for different pathological endometrial cancer and identifies specific sensitive drugs

Endometrial cancer (EC) is a highly heterogeneous malignancy characterized by varied pathology and prognoses, and the heterogeneity of its cancer cells and the tumor microenvironment (TME) remains poorly understood. We conducted single-cell RNA sequencing (scRNA-seq) on 18 EC samples, encompassing various pathological types to delineate their specific unique transcriptional landscapes. Cancer cells from diverse pathological sources displayed distinct hallmarks labeled as immune-modulating, proliferation-modulating, and metabolism-modulating cancer cells in uterine clear cell carcinomas (UCCC), well-differentiated endometrioid endometrial carcinomas (EEC-I), and uterine serous carcinomas (USC), respectively. Cancer cells from the UCCC exhibited the greatest heterogeneity. We also identified potential effective drugs and confirmed their effectiveness using patient-derived EC organoids for each pathological group. Regarding the TME, we observed that prognostically favorable CD8+ Tcyto and NK cells were prominent in normal endometrium, whereas CD4+ Treg, CD4+ Tex, and CD8+ Tex cells dominated the tumors. CXCL3+ macrophages associated with M2 signature and angiogenesis were exclusively found in tumors. Prognostically relevant epithelium-specific cancer-associated fibroblasts (eCAFs) and SOD2+ inflammatory CAFs (iCAFs) predominated in EEC-I and UCCC groups, respectively. We also validated the oncogenic effects of SOD2+ iCAFs in vitro. Our comprehensive study has yielded deeper insights into the pathogenesis of EC, potentially facilitating personalized treatments for its varied pathological types.

Type II endometrial cancer: Incidence, overall and disease-free survival in Martinique.

In Martinique, about 33 new cases of endometrial cancer are diagnosed per year with a high mortality rate (world standardised rate of 4.9/100,000 versus 2.3/100,000 in mainland France). The present study aimed to determine the incidence and mortality of type I and type II endometrial cancers (ECs), their overall survival (OS) and disease-free survival (DFS) between 2012 and 2016. This retrospective observational cohort study used data from the Martinique Cancer Registry (MCR). 191 patients with corpus uterine cancer were extracted between 2012 and 2016. Patients with either endometrioid endometrial carcinoma (EEC), uterine papillary serous carcinomas (UPSC), uterine clear cell carcinomas (UCCC) or uterine carcinosarcomas (UCS) were included. All other uterine cancers were excluded. Among the 163 included patients, 97 (60%) were type I and 66 (40%) were type II. The standardized incidence rate is 4.50/100,000 for type I vs. 2.66/100,000 for type II. Three years DFS for all types, type I and type II was 81.5% [74.2-86.9], 84.9% [75.4-91] and 76.7% [63.8-85.5] respectively. The five-years OS for all types, type I and type II was 47.0% [38.9-54.7] vs. 58.8% [47.3-68.5] vs. 22.8% [15.0-37.7] respectively. In Martinique, we report a high proportion of type II ECs, which has a poor prognosis with few treatment options.

The role of adjuvant treatment for early-stage uterine clear cell carcinomas

BackgroundUterine clear cell carcinoma is a rare and aggressive subtype of endometrial carcinoma. Prospective clinical trials have not been feasible for this rare tumor, and data regarding the optimal adjuvant treatment regimen for early-stage uterine clear cell carcinomas is limited. Our study's objective was to determine if adjuvant chemotherapy or radiation therapy improves patients' outcomes in stage I and II uterine clear cell carcinoma. MethodsPatients with stage I and II uterine clear cell carcinoma were identified at a single institution. All cases were reviewed by a gynecologic pathologist. Both pure and mixed non-serous uterine clear cell carcinomas were included. Primary outcomes were recurrence free survival and overall survival. ResultsA total of 71 patients were identified including 39 (55%) pure and 32 (45%) mixed clear cell carcinoma. Most patients were FIGO stage IA (77.5%). Most patients (n = 58, 82%) received adjuvant therapy, including 43 (61%) receiving chemotherapy, 50 (70%) receiving radiation therapy, and 35 (49%) receiving both. Recurrence free survival was not significantly different among patients receiving no or <6 cycles of chemotherapy versus patients receiving 6 cycles of chemotherapy (p = 0.39). However, median OS was significantly different among patients receiving no or <6 cycles of chemotherapy versus 6 cycles of chemotherapy (p = 0.004). On univariable analysis, 6 cycles of chemotherapy was significantly associated with improved OS (HR 0.1, 95% CI 0.01–0.07). Presence of LVSI, mutated p53, number of pelvic and para-aortic lymph nodes assessed, adjuvant chemotherapy (any number of cycles), and >2 medical co-morbidities were not significant predictors of OS on univariable analysis. On multivariable analysis, 6 cycles of adjuvant chemotherapy remained a significant predictor of improved OS (HR 0.1, 95% CI 0.01–0.8). ConclusionsIn this study, administration of 6 cycles of chemotherapy appears to significantly improve OS. This finding suggests consideration of 6 cycles of adjuvant chemotherapy in patients with early-stage uterine clear cell carcinoma, however clinical trials are needed to confirm these findings.

Executive summary of the American Radium Society appropriate use criteria for management of uterine clear cell and serous carcinomas

BackgroundUterine clear cell and serous carcinomas have a high propensity for locoregional and distant spread, tend to be more advanced at presentation, and carry a higher risk of recurrence and...

Transcriptome Analysis of Ovarian and Uterine Clear Cell Malignancies.

PurposeOvarian and uterine clear cell carcinomas (CCCs) are rare but associated with poor prognosis. This study explored RNA transcription patterns characteristic of these tumors.Experimental DesignRNA sequencing (RNA-seq) of 11 ovarian CCCs and five uterine CCCs was performed and compared to publicly available data from high grade serous ovarian cancers (HGSOCs). Ingenuity Pathway Analyses were performed. CIBERSORT analyses estimated relative fractions of 22 immune cell types in each RNA-seq sample. Sequencing data was correlated with PD-L1 immunohistochemical expression.ResultsRNA-seq revealed 1,613 downregulated and 1,212 upregulated genes (corrected p < 0.05, |FC |≥10) in ovarian CCC versus HGSOC. Two subgroups were identified in the ovarian CCC, characterized by ethnicity and expression differences in ARID1A. There were 3,252 differentially expressed genes between PD-L1+/− ovarian CCCs, revealing immune response, cell death, and DNA repair networks, negatively correlated with PD-L1 expression, whereas cellular proliferation networks positively correlated with expression. In clear cell ovarian versus clear cell uterine cancer, 1,607 genes were significantly upregulated, and 109 genes were significantly downregulated (corrected p < 0.05, |FC|≥10). Comparative pathway analysis of late and early stage ovarian CCCs revealed unique metabolic and PTEN pathways, whereas uterine CCCs had unique Wnt/Ca+, estrogen receptor, and CCR5 signaling. CIBERSORT analysis revealed that activated mast cells and regulatory T cell populations were relatively enriched in uterine CCCs. The PD-L1+ ovarian CCCs had enriched resting NK cells and memory B cell populations, while PD-L1− had enriched CD8 T-cells, monocytes, eosinophils, and activated dendritic cells.ConclusionsUnique transcriptional expression profiles distinguish clear cell uterine and ovarian cancers from each other and from other more common histologic subtypes. These insights may aid in devising novel therapeutics.

Identifying potential therapeutics by molecular profiling of 136 cases of uterine clear cell carcinoma

• Uterine clear cell carcinoma is a rare subtype of endometrial cancer that accounts for only 1-6% of all uterine malignancies.1-2 • Uterine clear cell carcinomas are considered to be Type-II estrogen-independent and exhibit aggressive behavior with worse clinical outcomes compared Type I tumors.3 • Uterine clear cell carcinomas most often occur in post menopausal women with a median age of 66-68 years.4 • Similar to uterine serous cancers, clear cell carcinoma is more prevalent in African American women.5 • While the pathogenesis of many subtypes of uterine cancer have been well studied, the molecular pathways involved in uterine clear cell carcinoma development are poorly understood. • Broader understanding of the molecular and genomic characteristics of uterine clear cell carcinomas could contribute to the growing body of literature this disease and potentially provide treatment options with targeted therapies. Background: Clear cell carcinoma of the endometrium (CCE) is a rare subtype of endometrial cancer (EC) associated with worse prognosis when compared to other high grade EC subtypes. We aim to evaluate molecular, genomic and protein expression patterns in a large cohort of CCEs in order to direct patients to rational therapeutic strategies and clinical trials. Methods: Out of 3133 EC submitted to Caris Life Sciences from March 2011 to July 2014, 136 CCEs were identified based on reported pathology. Testing was ordered per physician request and included a combination of sequencing (Sanger or next generation sequencing), protein expression (immunohistochemistry), and /or gene amplification (FISH/CISH). Results: Of the samples evaluated by sequencing, the most common genetic mutations were P53 (40%) and BRCA2 (33%). Hormone receptor expression was low: ERα (35%), PR (22%) and AR (7%). ERBB2 was mutated in 8%, while its protein product Her2, a biomarker for HER2-directed therapies, was amplified in 12% and expressed in 5% of patients. Aberrations of the PI3K pathway, including 26% PTEN and 25% PIK3CA mutation rate, with 69% loss of PTEN expression, highlight potential utility with inhibitors of this pathway. DNA repair pathway was altered in our CCE cohort as well: low ERCC1 (6%) and MGMT (34%) expression, and high BRCA2 mutation rate, suggesting sensitivity to alkylating agents. Evaluation of the cMET pathway showed 40% IHC expression. TUBB3, a class III β-tubulin, was infrequently expressed (15%), and TLE3 expression was high (29%) compared to other EC subtypes, implicating sensitivity to microtubule-stabilizing agents. Increased TOPO2A expression, associated with anthracycline efficacy, was seen in over 80% of cases. Loss of RRM1, a DNA synthesis protein known to determine efficacy of gemcitabine, was seen in 78% of cases. Conclusions: Our findings highlight the genetic heterogeneity of CCE, and identified altered cellular pathways with potential diagnostic and predictive values for therapeutic intervention. Drugs targeting the pathways for DNA repair, PI3K, and receptor tyrosine kinases, as well as gemcitabine and taxanes, may warrant consideration in selected patients with CCE. • 136 out of 3133 (4.3%) of endometrial cancers submitted to Caris Life Sciences from March 2011 to July 2014 were identified as clear cell carcinoma. • Specific testing was performed per physician request and included a combination of sequencing (Sanger, NGS or pyrosequencing), protein expression (IHC), gene amplification (CISH or FISH), and/or RNA fragment analysis. • IHC analysis was performed on formalin-fixed paraffin-embedded tumor samples using commercially available detection kits, automated staining techniques (Benchmark XT, Ventana, and AutostainerLink 48, Dako), and commercially available antibodies. • Fluorescent in-situ hybridization (FISH) was used for evaluation of the HER-2/neu [HER-2/CEP17 probe], EGFR [EGFR/CEP7 probe], and cMET [cMET/CEP7 probe] (Abbott Molecular/Vysis). HER-2/neu and cMET status were also evaluated by chromogenic in-situ hybridization (INFORM HER-2 Dual ISH DNA Probe Cocktail; commercially available cMET and chromosome 7 DIG probe; Ventana). The same scoring system was applied as for FISH. • Direct sequence analysis was performed on genomic DNA isolated from formalin-fixed paraffin-embedded tumor samples using the Illumina MiSeq platform. Specific regions of 47 genes of the genome were amplified using the Illumina TruSeq Amplicon Cancer Hotspot panel. • Mutation analysis by Sanger sequencing included selected regions of BRAF, KRAS, NRAS, c-KIT, EGFR, and PIK3CA genes and was performed by using M13-linked PCR primers designed to amplify targeted sequences. • Retrospective data analysis; Statistical analysis (unpaired t-tests used to compare biomarker expression across histologic subtypes) performed using PrismTM v6. Biomarker associations were calculated by two-tailed Fisher Exact tests.

Preoperative CT-based nomogram for predicting overall survival in women with non-endometrioid carcinomas of the uterine corpus.

To develop a preoperative CT-based nomogram for predicting overall survival (OS) in patients with non-endometrioid carcinomas of the uterine corpus. Waiving informed consent, the institutional review board approved this HIPAA-compliant, retrospective study of 193 women with histopathologically proven uterine papillary serous carcinomas (UPSC), uterine clear cell carcinomas (UCCC), and uterine carcinosarcomas (UCS) who underwent primary surgical resection between May 1998 and December 2011, and had a preoperative CT ≤ 6 weeks before surgery. All CT scans were reviewed for local or/and regional tumor extent, presence of pelvic or/and para-aortic adenopathy, and presence of distant metastases. Univariate survival analysis was performed using log-rank test and Cox regression. Variables shown significant by the univariate analysis were evaluated with the multivariable Cox regression analysis and the results were used to create a nomogram for predicting OS. The predictive accuracy of the nomogram was assessed with the concordance probability index (c-index) and a 3-year calibration plot. Mean patient age was 67.2 years (range 49.0-85.9); histologies included UPSC (n = 116), UCCC (n = 27), and UCS (n = 50). Median follow-up was 38.1 months (0.9-168.5 months). At multivariate analysis, patient age, ascites, and omental implants on CT were significant adverse predictors of OS and were used to build the nomogram. Concordance index for the nomogram was 0.640 ± 0.028. We developed a nomogram with a good concordance probability at predicting OS based on readily available pretreatment clinical and imaging characteristics. This preoperative nomogram has the potential to improve initial treatment planning and patient counseling.

Low expression of miR-449 in gynecologic clear cell carcinoma.

Clinical detection of ovarian clear cell carcinomas is important because of the poor prognosis. To identify microRNA profiles specific for clear cell carcinomas, microRNA expression profiles were compared between clear cell carcinomas and serous carcinomas of the ovary using microRNA microarray. In parallel, clear cell carcinomas were compared with germ cell tumors of the ovary. Six microRNAs differentially expressed between ovarian clear cell and serous carcinomas distinguished uterine clear cell carcinomas from endometrioid carcinomas. MiR-449 was underexpressed in both ovarian and uterine clear cell carcinomas. When germ cell tumors were compared with clear cell carcinomas of the ovary, miR-302d was the most significantly overexpressed microRNA in germ cell tumors. Thus, here we describe microRNA profiles characteristic for clear cell carcinomas of the ovary and uterus.

Loss of BAF250a (ARID1A) is frequent in high‐grade endometrial carcinomas

Mutation of the ARID1A gene and loss of the corresponding protein BAF250a has recently been described as a frequent event in clear cell and endometrioid carcinomas of the ovary. To determine whether BAF250a loss is common in other malignancies, immunohistochemistry (IHC) for BAF250a was performed on tissue microarrays (TMAs) in more than 3000 cancers, including carcinomas of breast, lung, thyroid, endometrium, kidney, stomach, oral cavity, cervix, pancreas, colon and rectum, as well as endometrial stromal sarcomas, gastrointestinal stromal tumours, sex cord-stromal tumours and four major types of lymphoma (diffuse large B cell lymphoma, primary mediastinal B cell lymphoma, mantle cell lymphoma and follicular lymphoma). We found that BAF250a loss is frequent in endometrial carcinomas but infrequent in other types of malignancies, with loss observed in 29% (29/101) of grade 1 or 2 and 39% (44/113) of grade 3 endometrioid carcinomas of the endometrium, 18% (17/95) of uterine serous carcinomas and 26% (6/23) of uterine clear cell carcinomas. Since endometrial cancers showed BAF250a loss, we stained whole tissue sections for BAF250a expression in nine cases of atypical hyperplasia and 10 cases of atypical endometriosis. Of the nine cases of complex atypical endometrial hyperplasia, all showed BAF250a expression; however, of 10 cases of atypical endometriosis (the putative precursor lesion for ovarian clear cell and endometrioid carcinoma), one case showed loss of staining for BAF250a in the atypical areas, with retention of staining in areas of non-atypical endometriosis. This was the sole case that recurred as an endometrioid carcinoma, indicating that BAF250a loss may be an early event in carcinogenesis. Since BAF250a loss is seen in endometrial carcinomas at a rate similar to that seen in ovarian carcinomas of clear cell and endometrioid type, and is uncommon in other malignancies, we conclude that loss of BAF250a is a particular feature of carcinomas arising from endometrial glandular epithelium.

Uterine Papillary Serous, Clear Cell, and Poorly Differentiated Endometrioid Carcinomas: A Comparative Study

Uterine papillary serous and clear cell carcinomas (UPSCs/CCs) show a different spreading from that of poorly differentiated endometrioid carcinomas (PDECs) and are usually thought to be prognostically more aggressive than PDECs. On the contrary, it has been recently claimed that UPSC/CC and PDEC have a similar prognosis. In this retrospective study on 2 institutional databases, the surgical-pathological data and survival have been compared in patients with UPSC/CC and PDEC. A total of 139 surgically staged consecutive patients, 63 with UPSC/CC (37 UPSC; 26 CC) and 76 with PDEC clinically limited to the uterine corpus, have been compared for nuclear ploidy, myometrial invasion, (occult) cervical extension, peritoneal, and lymph node metastasis. Prognostic factors have been correlated through multivariate analysis with survival (disease-specific [DSS] and disease-free [DFS]). Peritoneal metastases and aneuploidy were found to be the only parameters significantly different in the 2 groups: peritoneal metastases 28.6% in UPSC/CC (extrapelvic 19%) and 7.9% in PDEC (extrapelvic 2.6%) (P = 0.001), aneuploidy 48.6% in UPSC/CC and 30.6% in PDEC (P = 0.05). Five-year DSS was 57.9% versus 75.2% (P = 0.02), and DFS was 52.3% versus 71.4% (P = 0.04) for UPSC/CC and PDEC, respectively. All but cervical and lymph node involvement were significant predictors of survival. After multivariate analysis, histotype (DSS: hazard ratio [HR], 1.98; 95% confidence interval [CI], 1.02-3.86; P = 0.04; DFS: HR, 1.94; 95% CI, 1.04-3.63; P = 0.04), stage (DSS: HR, 2.26; 95% CI, 1.10-4.65; P = 0.03; DFS: HR, 2.21; 95% CI, 1.12-4.38; P = 0.02), and myometrial invasion (DSS: HR, 2.86; 95% CI, 1.22-6.69; P = 0.01; DFS: HR, 3.96; 95% CI, 1.63-9.62; P = 0.002) were independent risk factors for survival. Uterine papillary serous and clear cell carcinomas spread to abdominal peritoneum more frequently than PDEC; multivariate analysis confirms UPSC/CC as an independent, unfavorable predictor of outcome.

The diagnostic utility of inhibin staining in ovarian neoplasms.

Previous immunohistologic studies have suggested that the antibody to the alpha subunit of inhibin is a sensitive marker of sex cord-stromal differentiation. However, detection has also been reported within both ovarian epithelial and germ cell tumors. To further study the normal tissue distribution of inhibin and the utility of its detection for the differential diagnosis of ovarian sex cord-stromal neoplasms, normal tissues and 225 lesions including sex cord-stromal lesions, ovarian epithelial and stromal cancers, ovarian and testicular germ cell tumors, metastases to the ovary, and non-ovarian cancers were analyzed using semi-automated immunohistochemistry. In normal tissues, immunostaining was found in cell subsets of the ovary, testis, adrenal gland, placenta, and kidney. All sex cord-stromal tumors were inhibin-positive and 37 of 50 (74%) cases exhibited at least moderate to strong immunostaining. Two cases originally diagnosed as adult granulosa cell tumors that were inhibin-negative were reassessed; diagnoses of endometrioid stromal sarcoma and endometrioid carcinoma with sertoliform features were rendered. In other primary or metastatic ovarian lesions or metastases to the ovary, weak to moderate immunostaining was found in only 4 of 84 (4.8%) cases, including ovarian clear cell carcinoma (2/2), uterine clear cell carcinomas metastatic to the ovary (1/3), and serous papillary carcinoma (1/2). Similarly, only 4 of 66 (6.1%) non-ovarian neoplasms exhibited weak immunostaining, including melanoma (1/5), uterine endometrioid carcinoma (1/2), transitional cell carcinoma (1/3), and breast adenocarcinoma (1/8). Only one case of a non-sex cord-stromal tumor had moderate or strong immunostaining. Based on these results, immunohistologic detection of the alpha subunit of inhibin is a useful adjunct in the differential diagnosis of sex cord-stromal neoplasms.