Uterine Involvement Research Articles

Exploring uterine involvement in hysterectomy samples following conization for adenocarcinoma in situ of the uterine cervix: Insights from a multicenter study by the FRANCOGYN group

BackgroundAdenocarcinoma in situ (AIS) of the cervix can progress to invasive adenocarcinoma. While hysterectomy is standard, conservative management may be considered for women desiring future pregnancies. This study aimed to determine the prevalence of residual disease in hysterectomy specimens following excisional therapy with clear margins for AIS. MethodsA retrospective FRANCOGYN cohort study was conducted on patients who underwent a hysterectomy after conization with clear margins for AIS between 2008 and 2021. The primary goal was to assess the prevalence of residual disease in the hysterectomy specimens. Secondary objectives included identifying preoperative predictors of residual disease and comparing recurrence rates between patients with and without residual disease. ResultsOf 53 hysterectomies performed after conization with negative margins for AIS, 20.8% (11/53) showed residual disease in the final histology. None of the patients had invasive cancer. In the residual disease group, 18% (2/11) had persistent CIN 3, and 82% (9/11) had persistent AIS. These patients tended to have higher BMI (27.5 kg/m² vs. 23.6 kg/m², p=0.04) and shorter endocervical margins (2mm vs. 5mm, p=0.01). No recurrences were observed during follow-up. ConclusionDespite clear margins on the initial conization for AIS, 20% of patients had residual disease in their hysterectomy samples, though no invasive cancer was found. A hysterectomy should be considered after completing childbearing, even if initial margins are clear.

Effect of low uterine segment involvement on prognosis of early stage endometrial cancer.

Our aim is to investigate the effect of uterine lower segment involvement on prognosis of early-stage endometrial cancer cases diagnosed and treated in our clinic. The file records of 316 cases reviewed retrospectively.Only stage I (a and b, n=209) cases were investigated, because they were more homogeneous group. The lymphovascular invasion rate was found to be higher in patients with stage Ia and uterine lower segment involvement (p < 0.001). Adjuvant treatment requirement was higher in patients with stage Ia and uterine lower segment involvement (p < 0.001). Among stage Ia cases, the recurrence rate between 1 and 3 years was found to be higher in cases with uterine lower segment involvement (p = 0.001). Among the stage Ib cases, lymphovascular invasion was found to be higher in cases with uterine lower segment involvement (p < 0.001). The recurrence rate between 1 and 3 years was found to be higher in stage Ib compared to Ia (p = 0.01). Uterine lower segment involvement was found to be associated with high lymphovascular invasion rate in all stage I cases (p < 0.001). It was determined that the need for adjuvant treatment was higher in cases with uterine lower segment involvement (p < 0.001). It was determined that the probability of recurrence between 1 and 3 years was higher in cases with uterine lower segment involvement (p = 0.007). Uterine lower segment involvement is associated with increased lymphovascular invasion even in the early stages. It is an important risk factor for systemic spread such as lymphovascular invasion, myometrial invasion, and lymph node involvement.

Factors Determining Lymph Node Metastasis in Patients with Early Stage Non-Squamous Cell Cervical Carcinoma

Aim: To evaluate the clinical and pathological characteristics of early stage non-squamous cell cervical carcinoma (non-SCCC) patients and identify factors that predict lymph node metastasis.&#x0D; Materials and method: Patients who underwent radical hysterectomy plus lymphadenectomy for stage IB1-IIA2 non-SCCC between 1993 and 2022 in six gynecologic oncology centers were included in this retrospective study. The effects of the risk factors on lymph node metastasis were evaluated by using univariate and multivariate logistic regression analysis.&#x0D; Results: The study involved 126 patients with a median age of 48 years (range, 26-77 years). According to FIGO 2009 staging, 91 patients (72.2%) were at stage IB1, 24 (19%) were at stage IB2, 9 (7.1%) were at stage IIA1, and 2 (1.6%) were at stage IIA2. Tumor subtype were adenocarcinoma in 93 (73.8%) patients and adenosquamous carcinoma in 28 (22.2%) patients. In univariate analysis; age, tumor size, stromal invasion, parametrial invasion, uterine involvement, lymphovascular space invasion (LVSI), vaginal involvement, and surgical border involvement were associated with lymph node metastasis. In multivariate analysis, LVSI (Hazard Ratio: 19.63, 95% Confidence Interval: 3.499-110.166; p=0.001) and uterine involvement (Hazard Ratio: 4.36, 95% Confidence Interval: 1.178-16.165; p=0.027) were identified as independent prognostic factors for lymph node metastasis.&#x0D; Conclusion: LVSI and uterine involvement were independent predictors of lymph node metastasis in early-stage non-SCCC patients. These factors can be identified with high accuracy in biopsy specimens and imaging methods in the preoperative period.

The significance of lower uterine segment involvement in endometrial cancer

BackgroundLimited data suggests lower uterine segment involvement (LUSI) in endometrial cancer may be associated with other poor prognostic factors. We assessed the unclear impact of LUSI on prognosis in endometrial cancer. Methodology: A revision of pathological samples following surgical staging between the years 2002–2022 was performed and clinical data collected from patients’ records. Characteristics and outcomes of women with and without LUSI were compared and analysed. Kaplan Meyer survival curves compared overall survival (OS) and progression-free survival (PFS). Results429 women were included, of which 45 (10.5%) had LUSI. No differences were found between the groups regarding demographic or clinical characteristics. LUSI was significantly associated with lympho-vascular space invasion (40% vs. 22% p = 0.01), lymph node involvement (6.4% vs. 9.1%, p = 0.05), shorter PFS (4 vs. 5.5 years, p = 0.01) and OS (5.6 vs. 11.5 years, p = 0.03). Multivariate analysis showed higher hazard ratios for OS and PFS (1.55 95%CI 0.79–3.04 and 1.29 95%CI 0.66–2.53, respectively) but these were insignificant even in a sub-analysis of endometrioid histology (1.76 95%CI 0.89–3.46 and 1.35 95%CI 0.69–2.65, respectively). A trend towards decreased PFS and OS was demonstrated in the Kaplan Meyer survival curves for all cases (log rank test p = 0.5 and 0.29 respectively), endometrioid histology (log rank test p = 0.06 and 0.51 respectively) and early-stage disease (log rank test p = 0.63 and 0.3 respectively). ConclusionLUSI may be related to poorer outcome of endometrial cancer and may represent an additional factor to consider when contemplating adjuvant treatment, especially in endometrioid-type and early-stage disease.

Retrospective analysis of uterine involvement in low grade serous ovarian carcinoma

ObjectivesLow grade serous ovarian carcinoma (LGSOC) accounts for 2.5% of all ovarian carcinoma more affects younger women than high grade serous ovarian carcinoma. Hysterectomy is performed routinely for LGSOC treatment, but fertility sparring surgery (FSS) is feasible for some early stages. Currently, there is no study about uterine involvement in LGSOC. We evaluate uterine involvement in LGSOC patients and aim to identify pre-operative predictive factors. MethodsRetrospective observational study of LGSOC patients treated between January 2000 and May 2022 in the Hospices Civils de Lyon. All cases were viewed, reviewed or approved by an expert pathologist. ResultsAmong 535 serous ovarian carcinomas, 26 were included. Most patients (73 %) had FIGO III disease. Median OS was 115 months and median PFS was 42 months. Uterine involvement was found in 58 % patients who underwent hysterectomy (14/24), serosal involvement was the most frequent type of involvement (n = 13, 54 %). Myometrial involvement was found in 8 patients (33 %) and was associated with serosal involvement (7/8). Among patients with a macroscopic disease-free uterus during exploratory laparoscopy, 31 % had a microscopic serosal involvement. None patient with presumed early stage (FIGO I) were upstaged due to uterine involvement (serosal or myometrial). In patients with stage FIGO IIII, 72 % of uterine involvement were found.Univariate analysis did not show any predictive factor of myometrial involvement. There was no difference on OS nor PFS between patients with or without myometrial involvement. ConclusionsIn early stages LGSOC, FSS may be considered for selected patients. In advanced stages, hysterectomy should be performed routinely, since no predictive factor for uterine involvement were identified.

Primary Endometrial Carcinoma with Signet Ring Cells: A Rare and Unusual Entity

Abstract Introduction/Objective The presence of signet ring cells in an endometrial tumor is suggestive of metastasis, as primary tumors with this morphology are extremely rare. As a result, primary tumors are a diagnosis of exclusion, defined by the presence of signet-ring cells usually associated with mucinous endometrioid carcinoma without clinical or radiographic evidence of metastases from breast, stomach, or colon. Methods/Case Report A 64-year-old woman presented with vaginal bleeding. Ultrasound showed a large, heterogenous uterine mass that was diagnosed as poorly differentiated carcinoma on biopsy. Serum CEA was elevated, and CA-125 was normal. Hysterectomy with salpingo-oophorectomy showed a minor endometrial component of grade 3 endometrioid carcinoma and a predominant component of poorly differentiated carcinoma with signet ring cells. The myoinvasive component consisted of the signet ring cells with pools of acellular mucin. Extensive lymphovascular invasion was noted. Cervix, adnexa, and lymph nodes were free of disease. The signet ring cells were positive for CK7, CK20, and CDX2, and negative for ER and Pax-8. The endometrioid component was positive for ER, Pax-8, and CK7, and negative for CK20 and CDX2. E-cadherin staining was lost in the myoinvasive component of the tumor. Loss of MLH1 and PMS2 nuclear expression was seen, and MLH1 promoter methylation was detected in both components of the tumor. Subsequent colonoscopy and imaging did not reveal any other disease sites. Based on histology, pattern of uterine involvement, and lack of extrauterine disease, a diagnosis of primary poorly-differentiated endometrial adenocarcinoma with signet ring cell features was made. The patient was treated with adjuvant chemotherapy and is currently being followed. Results (if a Case Study enter NA) NA Conclusion We present a rare case of primary signet ring carcinoma of the uterus, a challenging diagnosis made after extensive work-up to rule out metastases. Of the previous 9 reported cases, only one was similar to our tumor with distinct endometrioid and signet ring components. Although these primary endometrial tumors are unified by the presence of signet ring cells, there is considerable immunohistochemical heterogeneity. Some reports suggest the signet ring cells have a Mullerian phenotype, while others, including our case, suggest a gastrointestinal phenotype. In presenting this case, we hope to contribute to this entity’s characterization and bring further awareness that the presence of signet ring cells does not exclude a uterine primary.

Predicting Factors of Uterine Invasion in Early-Stage (FIGO 2014 Stage IB1–IIA2) Cervical Cancer

Objective: Uterine corpus involvement was demonstrated radiologically or diagnosed by endometrial biopsy in the previous reports. Thus, there are few studies that detect uterine corpus involvement in radical hysterectomy specimens. This study was designed to investigate the factors that influence uterine corpus involvement in surgically treated cervical cancer patients.&#x0D; Materials and Methods: A total of 269 patients with clinical early-stage (stageIB1-IIA2) cervical cancer who underwent radical hysterectomy and pelvic-paraaortic lymphadenectomy at Zekai Tahir Burak Women's Health Training and Research Hospital and Ankara Bilkent City Hospital between January 2008 and August 2021 were recruited, and their clinicopathologic data were extracted from their patient files or the hospital's electronic database.&#x0D; Results: Uterine invasion was positive in 102 (37.9%) patients. Tumor size of patients was ≤20 mm in 66 (24.5%) patients and &gt;40 mm in 82 (30.5%). Parametrial invasion was detected in 44 (16.4%) patients. In the multivariate analysis; tumor type (adenocancer vs. other tumor types) (HR: 8.94; 95% CI: 3.569–22.401; p35 mm vs. ≤35 mm) (HR: 2.34; 95% CI: 1.234–4.440; p=0.009) depth of stromal invasion (&gt;1/2 vs. ≤1/2) (HR: 6.63; 95% CI: 2.205–19.952; p

A nomogram prediction model for the TP53mut subtype in endometrial cancer based on preoperative noninvasive parameters

BackgroundThe molecular subtypes of endometrial carcinoma are significantly correlated with survival outcomes and can guide surgical methods and postoperative adjuvant therapy. Among them, the TP53mut subtype has the worst prognosis and can only be determined by detection after surgery. Therefore, identifying preoperative noninvasive clinical parameters for early prediction of the TP53mut subtype would provide important guidance in choosing the appropriate surgical method and early warning for clinicians. Our study aimed to establish a model for the early prediction of the TP53mut subtype by using preoperative noninvasive parameters of endometrial cancer and screen out potential TP53mut patients.MethodsInformation and pathological specimens of 376 patients who underwent surgery for FIGO stage I-IV endometrial cancer in the Department of Gynecology, Peking University Cancer Hospital, from June 2011 to July 2020 were collected, and 178 cases were finally included in the study as the training dataset (part A). Thirty-six cases from January 2022 to March 2023 were collected as the validation dataset (part B). Molecular subtyping was performed using a one-stop next-generation sequencing (NGS) approach. Compared with the TP53mut subtype, the POLE EDM, MSI-H and TP53 wild-type subtypes were defined as non-TP53mut subtypes. Univariate Cox regression analysis and multivariate logistic analysis were performed to determine the preoperative clinical parameters associated with the TP53mut subtype. A nomogram prediction model was established using preoperative noninvasive parameters, and its efficacy in predicting TP53mut subtype and survival outcomes was verified.ResultsThe TP53mut subtype was identified in 12.4% of the part A and 13.9% of the part B. Multivariate logistic regression analysis showed that HDL-C/LDL-C level, CA125 level, and cervical or lower uterine involvement were independent influencing factors associated with the TP53mut subtype (p = 0.016, 0.047, <0.001). A TP53mut prognostic model (TPMM) was constructed based on the factors identified in the multivariate analysis, namely, TPMM = -1.385 × HDL-C/LDL-C + 1.068 × CA125 + 1.89 × CI or LUI, with an AUC = 0.768 (95% CI, 0.642 to 0.893) in the part A. The AUC of TPMM for predicting TP53mut subtype in the part B was 0.781(95% CI, 0.581 to 0.980). The progression-free survival (PFS) and overall survival (OS) of patients with the TP53mut subtype were significantly worse than those of patients with the non-TP53mut subtype, as predicted by the model in the part A.ConclusionsTP53mut prediction model (TPMM) had good diagnostic accuracy, and survival analysis showed the model can identify patients with different prognostic risk.

A Case of Progressive Left Leg Weakness and Vision Changes: Focal Inflammatory Cerebral Amyloid Angiopathy Masquerading as a Glioma (P12-5.003)

<h3>Objective:</h3> To emphasize the need to consider tumefactive focal inflammatory cerebral amyloid angiopathy (CAA) in the differential diagnosis of CNS lesions. <h3>Background:</h3> Although classically considered an etiology of cognitive impairment in the elderly, CAA represents a spectrum of disease. CAA-related inflammation (CAA-ri), a distinct CAA phenotype, is characterized by vascular inflammation from amyloid deposition. CAA-ri may rarely appear as a tumefactive lesion, mimicking CNS malignancy. We present a case of biopsy-proven focal CAA-ri initially misidentified as a glioma, with the goal of increasing awareness of this entity. <h3>Design/Methods:</h3> Not applicable <h3>Results:</h3> A 68-year-old man with Parkinson’s disease presented with progressive left lower extremity weakness, word finding difficulty and vision changes. Neurological examination revealed Parkinsonian features, left homonymous superior quadrantanopia and left leg weakness. Brain MRI revealed a non-enhancing FLAIR hyperintensity in the subcortical right parieto-occipital lobe, with numerous susceptibility-weighted foci within this area, consistent with microhemorrhages versus vascular inflammation. Flash frozen pathology was initially suggestive of glioma, prompting lesionectomy. Final pathology revealed inflammation of small and medium sized blood vessels, multinucleated giant cells and positive Congo-red staining, consistent with necrotizing vasculitis and amyloid angiopathy. Treatment with steroids was deferred following risk-benefit analysis. <h3>Conclusions:</h3> We report a unique case of tumefactive CAA-ri, a clinicopathologic variant of CAA, manifesting as a mass-like lesion with distinguishing radiographic features. Our literature review identified only three prior reports of this entity. Clinical presentation depends on lesion size, location, and presence of edema and inflammation. While our patient lacked systemic co-pathologies, uterine involvement and carpal tunnel syndrome have been reported. Management relies on vascular risk modification, and steroids or immunosuppressants for active inflammation. Our case underscores the need to recognize CAA-ri in the differential of mass-like lesions. Recognizing the spectrum of CAA-related disease is key in understanding the natural history of the disease, and potential benefit of future anti-amyloid therapies. <b>Disclosure:</b> Dr. Mohammadi has nothing to disclose. Dr. Lilian has nothing to disclose. Mr. Chen has received research support from National Institues of Health. Michelle Offit, MS has nothing to disclose. Dr. Lin has nothing to disclose. Dr. Streicher has nothing to disclose. Dr. Sabharwal has nothing to disclose.

Could uterine conservation be an option in presumed early-stage epithelial ovarian cancer?

In early-stage epithelial ovarian cancer (EOC), patients usually undergo a hysterectomy. However, in fertility sparing surgery (FSS), carefully selected patients could conserve their uterus. The aim of our study was to evaluate the incidence and epidemiologic characteristics associated with uterine involvement in patients with early-stage EOC, outside of FSS. We conducted a retrospective, monocentric, study from 2003 to 2019 and included all patients with a presumed early-stage EOC (FIGO I) who underwent a hysterectomy. The incidence of uterine involvement, predictive factors of uterine involvement, and the impact of uterine involvement on survival (recurrence-free survival and overall survival) were analyzed. Eighty-five patients had an early-stage EOC. Of these, six had an uterine involvement (7%). The populations of patients with or without uterine involvement did not differ except for CA 125 at diagnosis (136 ± 138 versus 356 ± 723, p = 0.04, respectively). No patient or tumor characteristics were predictive of uterine involvement. Uterine involvement was not associated with recurrence-free survival (HR = 1.26, IC95% 0.36-4.4, p = 0.72) or overall survival (HR = 0.7, IC95% 0.1-6.1, p = 0.77). Due to the small size of our sample, no conclusion can be drawn, yet it could be hypothesized that, for selected patients, a systematic hysterectomy could be discussed, notably in restaging surgery.

Evaluation of Cervical Cancer Staging Based on Magnetic Resonance Imaging in Comparison with Surgical Staging

Background: Cervical cancer is prevalent cancer among women that correct diagnosis has very important role in its treatment. Objectives: The aim of this study was to evaluate the accuracy of magnetic resonance imaging (MRI) in comparison with surgical staging. Also, we compared the accuracy of physical examination with surgical pathology. Methods: This retrospective cross-sectional study was performed on women who had cervical cancer from the start of 2017 to the end of 2021. Age, tumor pathology report (squamous cell carcinoma, clear cell carcinoma, adenocarcinoma, and small cell carcinoma), stage of the tumor, involvement of vagina, uterine, and parametrium, cervical stroma invasion, mass size, pelvic and abductor lymph node metastasis were extracted from the patient’s data and all were evaluated. The pathology report was considered as the gold standard. Results: Eighty women with cervical cancer were evaluated and the mean age was 47.3 years. There was a statistically significant difference between the different prevalence of disease stages (P-value = 0.035) and also stage diagnosis between the three methods (P-value = 0.0004). The diagnostic accuracy of physical examination and MRI in terms of vaginal involvement, parametrium involvement, and uterine involvement were 97.5% and 98.7%; 98.7% and 96.2%; 94.9% and 93.6%; respectively. Conclusions: Magnetic resonance imaging is a good method for the assessment of the clinical staging of cervical cancer and its accuracy is more than 94% in the diagnosis of different parts of cervical cancer involvement.

Perivascular malignant epithelioid cell tumor (PEComa) of the uterus:

Perivascular epithelioid cell tumors, called PEComas, have a mesenchymal origin with immunoreactivity for melanocytic and smooth muscle markers. Its incidence in the form of uterine involvement is rare, between 1 and 2 cases per million inhabitants, affecting mainly women in their fifth decade of life. The present study was elaborated according to the rules of the CARE case report. The patient's medical record was analyzed, and who authorized access to it and signed the Free and Informed Consent Form, together with those involved in this work. This patient underwent treatment and medical follow-up with the supervisor of this work. Therefore, this study aimed to describe a rare clinical case report of uterine malignant perivascular epithelioid cell tumor (PEComa). Although the literature on this subject is scarce and there are no consistent criteria for diagnosis and treatment, our case in question presented aspects of unfavorable evolution (a large number of cytological atypia and high mitotic index) characterizing a PEComa with uncertain malignant potential, requiring a treatment adjuvant after surgery. The patient evolved well after the surgery and adjuvant treatment, undergoing quarterly follow-ups at the oncology and gynecology outpatient clinic, with a physical examination and nuclear magnetic resonance of the pelvis for control purposes.

A rare case of parasitic fibroid presenting as abdominopelvic mass – A surgical dilemma

Parasitic fibroids (PFs) are rare extrauterine fibroids classified as Type 8 leiomyomas as per The International Federation of Gynecology and Obstetrics (FIGO) classification, without uterine myometrial involvement or attachment. Due to its very low incidence, unusual locations, and atypical presentations, these fibroids cause lot of clinical dilemmas to treating physicians. Hereby, we are presenting an interesting case of PF which is presented to us as a case of abdominopelvic mass. Here, we learned that whenever female patients with abdominal mass and prior surgical history, PF should be considered possibilities to avoid on-table intraoperative surprises where a multidisciplinary surgical team may be required depending upon location and organ involved. We were fortunate that our PF was attached to the omentum and sigmoid colon by connective tissue and feeding vessels and could be removed without much deliberation.

Oncologic outcome in patients with 2018 FIGO stage IB cervical cancer: Is tumor size important?

To evaluate the prognostic factors and oncologic outcome in patients with 2018 International Federation of Gynecology and Obstetrics (FIGO) stage IB cervical cancer (CC) after radical hysterectomy and lymphadenectomy. This study included 290 patients with type II or III radical hysterectomy + pelvic ± para-aortic lymphadenectomy and 2018 FIGO stage IB1-3 epithelial CC. Disease-free survival (DFS) estimates were determinate by using the Kaplan-Meier method. Survival curves were compared using the log-rank test. Multivariate analysis was performed using a Cox proportional hazards models. The mean age of study cohort was 52 ± 10.25 years. Five-year DFS was 93% in entire cohort. On univariate analysis, surgical border involvement (p=0.007), lymphovascular space invasion (LVSI) (p=0.040), uterine involvement (p=0.040), and depth of cervical stromal invasion (p=0.007) were found to have statistical significance for DFS. However, none of them were independent prognostic factors for the risk of recurrence. Tumor size according to 2018 FIGO staging criteria was not related with recurrence. Surgical border involvement, LVSI, depth of cervical stromal invasion, and uterine involvement were predictors for DFS on univariate analysis. Tumor size was not predicting to recurrence in patient with 2018 FIGO stage IB1-3 CC.

Association between gene polymorphisms of IL-12, IL-12 receptor and IL-27 and organ involvement in Iranian endometriosis patients.

Endometriosis is an inflammatory disease characterized by the presence of ectopic endometrial tissue, immune cell dysfunction and abnormal cytokine secretion. In addition to immunological factors, genetic variations that influence endometriosis severity and cytokine expression levels play important roles in the pathogenesis of this disease. Interleukin-12 (IL-12), specifically its p40 subunit encoded by IL-12B gene and the interleukin-12 receptor β1 (IL-12Rβ2) chain of its receptor, as well as interleukin-27 (IL-27) are important in the establishment of endometriosis. So, in this study, we measured IL-12 and IL-27 serum levels and investigated the possible links between IL-12B rs3212227, IL-12Rβ2 rs3790565 and IL-27 rs153109 polymorphisms and the risk of developing endometriosis in a group of Iranian women. In this case-control study, 162 endometriosis patients and 151 healthy women were included and tested for the aforementioned polymorphisms using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique. The enzyme-linked immunosorbent assay (ELISA) method was also used to measure IL-12 and IL-27 serum levels. Although there was no statistically significant association between the genotypes and alleles of the studied polymorphisms and the development of endometriosis in general, the AA genotype of IL-12B rs3212227 showed a significant association with uterine endometriosis when compared to AC+CC genotypes (p=.04, CI=0.270-0.988, OR=0.517). Indeed, the AA genotype of the IL-12B rs3212227 single nucleotide polymorphism (SNP) may be linked with a lower risk of developing uterine endometriosis. There was no significant difference in IL-27 levels between the two studied groups (p=.49), and IL-12 levels were undetectable in both groups. In conclusion, the AA genotype of IL-12B rs3212227 might be associated with a decreased risk of uterine involvement in endometriosis patients.

Microsatellite instability and oncological outcomes in Thai patients with endometrial cancer

Here, we determined the frequency of microsatellite instability (MSI) and the impact of MSI-high (MSI-H) on clinical outcomes of Thai patients with endometrial cancer (EC). Tissue samples of 110 Thai patients with EC, who had undergone surgical staging, were tested for mismatch repair (MMR) gene deficiency, and the patients were grouped into MSI-H and MSI-stable (MSI-S) groups; 24.5% had MSI-H. Unlike MSI-S group patients, MSI-H group patients had synchronous and metachronous cancer. They showed better 3-year disease-free survival (DFS) than those in the MSI-S group (p=.182; 92.3% vs. 82.6%). The 3-year overall survival was 96.2% in MSI-H and 86.4% in MSI-S groups (p=.163). Multivariate analyses showed lower uterine involvement (p=.004), myometrial invasion ≥50% (p=.032), lymphovascular space invasion (p<.001) and MSI-S (p=.006) as prognostic factors for DFS. Our study showed that the prevalence of MMR gene deficiency in Thai patients with EC is common and associated with better outcomes. Impact Statement What is already known on this subject? Microsatellite instability (MSI) occurs in approximately 20–40% of endometrial cancer (EC) cases. MSI analysis in EC can identify patients at higher risk of hereditary nonpolyposis colorectal cancer and those having prognostic factors. Additionally, it is predictive of immune checkpoint inhibitor treatment. However, current evidence shows a correlation between clinicopathological characteristics and EC prognosis. Studies on EC and MSI status effect on survival outcome have yielded inconsistent results regarding the pathological significance of MSI in such malignancies. What do the results of this study add? The prevalence of mismatch repair (MMR) gene deficiency in Thai patients with EC is common (24.5%) and associated with better outcomes. What are the implications of these findings for clinical practice and/or further research? This study highlights the prevalence and impact of MSI on oncological outcomes in patients with EC in a low-incidence country. Future studies should focus on the detection of germline mutation to understand the accurate prevalence of Lynch syndrome in Thai patients with EC.

Giant uterus in a patient with Klippel-Trenaunay syndrome. Report of a case.

IntroductionKlippel-Trenaunay syndrome is an uncommon congenital disease also called angio-osteodystrophy syndrome for its typical disorders characterized by abnormal growth of the soft tissues and bones and vascular malformations.Case reportIn this report, we present a rare case of a 46-year-old nulliparous woman with Klippel-Trenaunay syndrome. She suffered from an abnormal uterine bleeding accompanied by severe anemia with need for multiple blood transfusions. At the time of admission, physical examination revealed port-wine stains and varicose veins on her lower limbs and hypertrophy of left lower extremity. We carried out an open bilateral hysteroannexectomy. Histopathology examination revealed a uterus weighing 6300 g with diffuse abnormal vasculature, leiomyomatosis and diffuse venous malformation.DiscussionKlippel-Trenaunay syndrome is considered a rare disease as it has an incidence of 2–5 on 100,000 with no differences between the both sexes. The clinical manifestations are related to the organs involved in the pathological angiogenesis therefore patients may also present cerebral, retinal, gastrointestinal and genitourinary anomalies with consequent occult or significant bleeding. Uterine involvement is very rare. The main clinical manifestations are represented by irregular episodes of hematuria and/or menometrorrhagia associated with important anatomical anomalies of the female reproductive system.ConclusionUterine involvement in patients with Klippel-Trenaunay syndrome, althought rare and with extremely variable clinical manifestations, is actually a relevant event that not only significantly affects the reproductive capacity of the woman but which potentially puts patients' lives at risk because of an unpredictable bleeding.

Improving locoregional outcome in high-intermediate-risk and high-risk stage I endometrial cancer with surgical staging followed by brachytherapy.

PurposeThis study aims to assess the locoregional efficacy of postoperative vaginal brachytherapy (VBT) alone in patients undergoing surgical staging for early-stage high-intermediate-risk (HIR) and high-risk (HR) endometrial cancer. Materials and MethodsOne hundred and four patients with early-stage HIR and HR endometrial cancer who underwent surgical staging were treated with adjuvant VBT alone. The patients with stage Ib, grade I–III, stage Ia, grade III, lower uterine segment involvement, and lymphovascular invasion (LVI) were included to study. ResultsThe 5- and 10-year overall survival (OS) rates were 87% and 76%, respectively. The 5- and 10-year DFS rates were 86% and 86%, respectively. Among the patients, 92% had endometrioid adenocarcinoma, 2% had undifferentiated carcinoma, 2% had serous papillary carcinoma, and 4% had clear-cell carcinoma. Of the patients, 63% had stage Ib disease, while 37% had stage Ia disease. None of the patients had vaginal or pelvic lymph node recurrence, whereas two had para-aortic lymph node metastasis, one had surgical scar recurrence, one had para-aortic lymph node and brain metastasis, and one had lung metastasis. The presence of lymphatic invasion was found to be a statistically significant prognostic factor for increased distant metastasis rates (p = 0.020). Lymphatic invasion was also regarded as an independent prognostic factor for metastasis-free survival (p = 0.044). ConclusionOur study results suggest that postoperative VBT alone is an effective and safe treatment modality with low complication in patients undergoing surgical staging for HIR and HR endometrial cancer.

Uterine Involvement in Klippel-Trenaunay Syndrome: A Rare But Relevant Event. Review of the Literature.

IntroductionKlippel–Trenaunay syndrome (KTS) is a rare vascular congenital disorder characterized by the classical triad of port-wine stains, abnormal growth of soft tissues and bones, and vascular malformations. The involvement of the genitourinary tract and of the uterus in particular is extremely infrequent but relevant for possible consequences.MethodsWe performed an extensive review of the literature using the Pubmed, Scopus and ISI web of knowledge database to identify all cases of KTS with uterine involvement. The search was done using the MeSH term “Klippel–Trenaunay syndrome” AND “uterine” OR “uterus.” We considered publications only in the English language with no limits of time. We selected a total of 11 records of KTS with uterine involvement, including those affecting pregnant women.ResultsKlippel–Trenaunay syndrome was described for the first time in the year 1900 in two patients with hemangiomatous lesions of the skin associated with varicose veins and asymmetric soft tissue and bone hypertrophy. Uterine involvement is a rare condition and can cause severe menorrhagia. Diagnosis is based on physical signs and symptoms. CT scans and MRI are first-choice test procedures to evaluate both the extension of the lesion and the infiltration of deeper tissues before treatment. The management of Klippel–Trenaunay syndrome should be personalized using careful diagnosis, prevention and treatment of complications.ConclusionKlippel–Trenaunay syndrome is a rare vascular malformation with a wide variability of manifestations. There are no univocal and clear guidelines that suggest the most adequate monitoring of the possible complications of the disease. Treatment is generally conservative, but in case of recurrent bleeding, surgery may be needed.

HE4 is a Beneficial Biomarker in Endometrial Adenocarcinoma

Background: Endometrial carcinoma ranks second among the most common gynecological malignancy in developing countries. Biomarkers are needed to aid in screening the disease and predicting the clinical as well as the therapeutic outcome. Human Epididymis Protein 4 (HE4) is a protein that was first isolated from human epididymis cells. HE4 levels are elevated in various types of cancers, such as ovarian and gastric cancer. Objectives: We aim to assess the association of serum and tissue, HE4, and endometrial adenocarcinoma in 77 Egyptian patients divided into two groups: 37 patients in the endometrial cancer group and 40 patients in the control group. Results: We found that HE4 levels were significantly increased in both serum and tissue of the endometrial cancer group compared to the negative control group. Moreover, higher expression levels were significantly associated with high-grade tumors. HE4 showed excellent diagnostic and prognostic value with a sensitivity and specificity of over 90 percent. Conclusion: We conclude that both serum and tissue expression of HE4 are sensitive, specific diagnostic and prognostic biomarkers in endometrial adenocarcinoma. In addition, they can predict extra- uterine involvement and staging of the disease. Clinical Trial Registration No:: PRS-NCT03456791.