Pathological factors associated with omental metastases in endometrial cancer.

PURPOSE OF INVESTIGATION: This study aimed to assess the role of omentectomy in the surgical therapy of endometrial cancer. MATERI- ALS AND METHODS: A retrospective study was performed in 98 patients who were pathologically diagnosed with endometrial cancer and had initially undergone surgical therapy at the present institution. This study analyzed the relationship between omental metastasis and clinicopathological factors. RESULTS: Omental metastasis was detected in nine patients (9%). On univariate analysis, significant number of omental metastatic lesions were detected in few cases by positive peritoneal cytology, adnexal metastasis, gross dissemination, and lymphovascular space involvement. On multivariate analysis, adnexal metastasis were a significant risk factor. The sensitivity of the spe- cial histological type and the specificity of the macroscopic peritoneal dissemination and adnexal metastasis were all high. CONCLUSION: Omentectomy plays a significant role in determining the exact surgical staging in cases with non-endometrioid cancer, adnexal metas- tasis, and macroscopic peritoneal dissemination.

Effectiveness of third-line chemotherapy in recurrent ovarian cancer patients.

OBJECTIVE: Despite recent advances in the treatment of recurrent ovarian cancer, little evidence exists describing the benefit of third- line chemotherapy. The present authors previously reported that the treatment-free interval (TFI) after second-line chemotherapy may predict a survival benefit of third-line chemotherapy, however the length of TFI was uncertain due to limited cases. In this study, the authors evaluated the length of TFI, which is correlated with the effectiveness of third-line chemotherapy and a prognostic factor of third-line chemotherapy. MATERIALS AND METHODS: The authors reviewed the medical records of 85 women with recurrent ovarian cancer who received third-line chemotherapy after a paclitaxel/carboplatin (PC) regimen as first-line chemotherapy. RESULTS: The response rate [complete response (CR) + partial response (PR)] and clinical benefit rate [(CBR): CR + PR + stable disease (SD)] during the TFI after second-line chemotherapy for 0-3 months, 3-6 months, and 6-12 months and ≥ 12 months were 9.8%, 0%, 0%, 43.8% and 15.7%, 50%, 66.7%, and 93.8%, respectively. The median overall survival (OS) from the onset of third-line chemotherapy was longer for TFI ≥ 3 months than for TFI 0-3 months (795 days vs. 281 days, p < 0.001). Finally, according to univariate (HR = 0.256; p < 0.001) and multivariate (HR = 0.264; p < 0.001) analyses, TFI was the independent significant prognostic factor for OS. CONCLUSIONS: TFI less than three months after second-line chemotherapy may predict little survival benefit of third-line chemotherapy.

Immunosuppression through constitutively activated NF-κB signalling in human ovarian cancer and its reversal by an NF-κB inhibitor.

BACKGROUND: Although T-cell immunity is thought to be involved in the prognosis of epithelial ovarian cancer (EOC) patients, immunosuppressive conditions hamper antitumour immune responses. Thus, their mechanisms and overcoming strategies need to be investigated. METHODS: The role of NF-κB in human EOC cells and macrophages was evaluated by in vitro production of immunosuppressive IL-6 and IL-8 by EOC cells and in vivo analysis of immune responses in nude mice implanted with human EOC cells using an NF-κB inhibitor DHMEQ. RESULTS: In EOC patients, increased plasma IL-6, IL-8, and arginase were observed. The NF-κB inhibitor DHMEQ inhibited the production of IL-6 and IL-8 by EOC cell lines. Immunosuppression of human DCs and macrophages by culture supernatant of EOC cells was reversed with the pretreatment of DHMEQ. Administration of DHMEQ to nude mice implanted with human EOC resulted in the restoration of T-cell stimulatory activity of murine DCs along with the reduction of tumour accumulation and arginase expression of MDSCs. Nuclear factor-κB inhibition in tumour-bearing mice also enhanced antitumour effects of transferred murine naive T cells. CONCLUSIONS: NF-κB is involved in the immunosuppression induced by human EOC, and its inhibitor may restore antitumour immune responses, indicating that NF-κB is an attractive target for EOC treatment.

Endocervical glandular neoplasia associated with lobular endocervical glandular hyperplasia is HPV-independent and correlates with carbonic anhydrase-IX expression: a Gynaecological Oncology Group Study.

BACKGROUND: Lobular endocervical glandular hyperplasia (LEGH) is a rare lesion of the uterine cervix. It has been proposed that LEGH may represent a precursor lesion to a group of mucinous adenocarcinoma with gastric phenotype (GA) that is independent of high-risk human papillomavirus (H-HPV) infection. Carbonic anhydrase-IX (CA-IX) is highly expressed in conventional glandular lesions (CGLs). However, expression of CA-IX in LEGH or GA has not been studied. METHODS: In all, 12 CGLs, 7 LEGHs, 6 LEGHs with coexisting adenocarcinoma in situ (AIS, 3) and GA (3) were identified from Japanese women with a cytological diagnosis of atypical glandular cells of undetermined significance. Immunostaining was used to detect CA-IX and p16(INK)4(a) (hereafter termed p16) protein expression in the tissues and CA-IX protein expression in the Papanicolaou smears (PSs). Polymerase chain reaction was used to detect H-HPV DNA in liquid-based cytology. RESULTS: Out of 12 (83%) CGLs, 10 were positive with H-HPV and high levels of CA-IX expression were seen in all (100%) cases. P16 protein expression was observed in 11 out of 12 (92%) cases. None of the LEGHs, LEGHs with AIS or GA were positive for H-HPV and only 8 out of 13 (62%) showed focal weak (1+) p16 expression. In contrast, all cases (100%) exhibited strong CA-IX protein expression. CONCLUSION: Our study suggests that there are different molecular mechanisms of carcinogenesis resulting in CGLs vs LEGHs associated with AIS or GA. There is also a possible link between LEGHs and GAs. Furthermore, CA-IX expression may serve as a useful biomarker for the detection of GAs in the absence of H-HPV infection.

Retrospective study comparing irinotecan and pegylated liposomal doxorubicin in treatment of recurrent platinum-refractory/resistant epithelial ovarian cancer.

PURPOSE: The standard regimen for platinum-resistant/refractory recurrent epithelial ovarian cancer (EOC) remains to be determined. In this study, we retrospectively compared the effect of irinotecan (CPT-11) and pegylated liposomal doxorubicin (PLD) in the treatment of platinum-resistant recurrent EOC. METHODS: Thirty patients who received salvage chemotherapy with CPT-11 or PLD were included in the study. CPT-11 (100 mg/m2) was administered intravenously on days 1, 8 and 15 every four weeks. PLD (50 mg/m2) was administered on day 1 every four weeks. Treatment was repeated, provided that no disease progression or intolerable toxicity occurred. RESULTS: Response rate in the CPT-11 group and PLD group showed no difference at 26.7% (p = 0.66) in both, while non-PD rate was 73.3% vs. 33.3% (p < 0.05), respectively. Progression-free survival after CPT-11 treatment and PLD treatment was 28.4 weeks and 16.8 weeks (p = 0.07), respectively. Hand-foot syndrome and mucositis were more common in the PLD group than in the CPT-11 group (p < 0.05). CONCLUSIONS: The results indicate that CPT-11 is a promising drug for the treatment of platinum-resistant recurrent EOC.

Carbonic anhydrase IX (CA-IX) and high-risk human papillomavirus (H-HPV) as diagnostic biomarkers of cervical dysplasia/neoplasia in Japanese women with a cytologic diagnosis of atypical glandular cells (AGC): a Gynecologic Oncology Group (GOG) Study.

BACKGROUND: High-risk human papillomavirus (H-HPV) infection is linked to cervical neoplasia but its role in detecting cervical glandular lesions (GLs) is unclear. Carbonic anhydrase IX (CA-IX) is a hypoxic biomarker that is highly expressed in neoplastic cervical GLs. The diagnostic utility of these biomarkers was evaluated by the Gynecologic Oncology Group in Japanese women with a cytological diagnosis of atypical glandular cells. METHODS: Immunostaining was used to detect CA-IX in a conventional Pap smear. Immunoreactivity of CA-IX was interpreted by a panel of pathologists blinded to the histological diagnosis. Polymerase chain reaction was used to detect H-HPV in a liquid-based cytology specimen. RESULTS: Significant cervical lesions (SCLs), defined as cervical intraepithelial neoplasia (CIN2, CIN3), adenocarcinoma in situ or invasive carcinoma, were observed in 37/88 (42%) of women. CA-IX testing alone (n=88) had a sensitivity of 89, 100 or 73% for SCLs, GLs or significant squamous lesions (SLs), respectively, with a false negative rate (FNR) of 14%. Testing for H-HPV (n=84) had a sensitivity of 65, 53 or 80% for SCLs, GLs or SLs, respectively, with a FNR of 22%. The combination of CA-IX and H-HPV testing had a sensitivity of 97, 100 or 93% for SCLs, GLs or SLs, respectively, with a FNR of 5%. Among eight H-HPV-negative GLs, six (75%) had a diagnosis of lobular endocervical glandular hyperplasia (LEGH). CONCLUSION: The combination of CA-IX and HPV testing improved the diagnostic accuracy. The low rate of H-HPV positivity in the GLs was associated with coexisting LEGH independent of H-HPV.

Expression of hypoxia-inducible 2 (HIG2) protein in uterine cancer.

For both cervical cancer (UCC) and endometrial cancer (EMC) there are no effective prognostic markers. In this study, we evaluated HIG2 protein expression in 332 uterine cancers (186 UCCs and 146 EMCs) and examined the relationship between HIG2 protein expression and clinical factors, including prognosis. Totally, HIG2 expression was detected in 58% of UCC and 66% of EMC. However, there was no significant relationship between HIG2 expression and age, clinical stage and histology in either UCC or EMC. In addition, HIG2 protein expression was not related to prognosis of UCC or EMC. The positivity rate of HIG2 protein was 56% and 61% in early-stage UCC and EMC, respectively and 67% in non-squamous cell carcinoma of UCC. The positivity rate of HIG2 protein was high even in early-stage UCC and EMC

The chemosensitivity of nodal metastases in recurrent epithelial ovarian cancer.

PURPOSE: In this study, we compared second-line chemotherapy effects of nodal metastases with other metastases sites. METHODS: The medical records of 44 women with recurrent ovarian cancer who received second-line chemotherapy were retrospectively reviewed. RESULTS: Median age at the time of second-line chemotherapy was 55 years (range: 31-74). Recurrent sites were as follows: 29 patients had a solitary site (abdominal cavity: 8; lymph node: 3; pelvic cavity: 10; liver: 4; lung: 4) and 15 patients had multiple sites In total, the response rate was 30% (CR: 8, PR: 5). The response rate in sensitive cases was higher than in refractory/resistant cases (50% vs 5% p = 0.002). However, age, chemotherapy regimen, histologic type and number of diseases were not related with chemotherapy effect. In all diseases, response rate tended to be higher in lymph node disease than in the others (44% vs 27%). In both sensitive and refractory/resistant cases, response rate tended to be higher in lymph node disease. CONCLUSION: The response rate for lymph node diseases tended to be relatively high. Further study analyzing survival will be required to conclude the chemotherapy effect.

Effects of third-line chemotherapy for women with recurrent ovarian cancer who received platinum/taxane regimens as first-line chemotherapy.

PURPOSE: At present, it remains unclear whether the third-line chemotherapy has clinical benefit. In this study, we retrospectively evaluated the effect of third-line chemotherapy. METHODS: We reviewed the medical records of 40 women with recurrent epithelial ovarian cancer (EOC) who received third-line chemotherapy after platinum/taxan regimens as first line chemotherapy. RESULTS: In the first recurrence, 23 cases were platinum-sensitive and 17 cases were platinum-resistant. The cases for which the treatment-free interval from second-line chemotherapy (TFI) was a 3 months had a higher non-PD rate than those with TFI < 3 months (86% vs 33%, p = 0.002). In addition, the median overall survival (OS) was longer for TFI > or = 3 months than for TFI < 3 months (1195 days vs 235 days, p = 0.004). Finally, TFI was an independent significant prognostic factor by univariate (HR 3.28, p = 0.006) and multivariate (HR 3.21, p = 0.018) proportional hazard tests. CONCLUSION: TFI from second-line chemotherapy may predict a survival benefit of third-line chemotherapy.

Can ABCF2 protein expression predict the prognosis of uterine cancer?

Uterine cervical and endometrial cancers are common malignant solid neoplasms for which there are no useful prognostic markers. In this study, we evaluate the relationship between ATP-binding cassette superfamily F2 (ABCF2) expression and clinical factors including clinical stage, histologic type, grade and prognosis in uterine cervical and endometrial cancer. Two hundred and sixty seven cervical and 103 endometrial cancers were studied. ATP-binding cassette superfamily F2 cytoplasmic expression was detected by immunohistochemical staining and scored as positive or negative. Among cervical cancer cases, 149 (55.8%) expressed ABCF2. The overall survival was longer in ABCF2-negative than ABCF2-positive cases (P=0.0069). Statistically significant prognostic factors for survival were ABCF2 positivity (risk ratio (rr)=1.437), old age (rr=1.550) and advanced stage (rr=2.577). ATP-binding cassette superfamily F2 positivity was an independent prognostic factor by multivariate proportional hazard test (P=0.0002). Among endometrial cancer cases, 72 (69.9%) were cytoplasmic ABCF2 positive. However, there was no significant relationship between ABCF2 expression and age, clinical stage, histologic type, histologic grade, oestrogen receptor status or prognosis. ATP-binding cassette superfamily F2 expression may be a useful prognostic marker in cervical but not endometrial cancer. The role of ABCF2 protein may differ depending on the type of cancer.

Human monoclonal antibody for ovarian clear cell carcinoma-2, a human monoclonal antibody with antitumor activity against ovarian cancer cells that recognizes CA125-like antigen.

In recent years, antibody therapy employing monoclonal antibodies has become a new approach for treating cancer. This study was performed to establish a human monoclonal antibody recognizing an epitope related to CA125 using KM mice and to assess its reactivity with ovarian cancer cells. A human ovarian clear cell adenocarcinoma cell line (RMG-I) was used to immunize KM mice, and hybridoma supernatant was obtained by a standard method employing enzyme-linked immunosorbent assay screening. Next, selection of hybridomas was performed with two antibodies (MA602-1 and MA602-6) and a sandwich immunoassay for CA125-like antigen, and then the limiting dilution was used to obtain a human monoclonal antibody. Immunohistochemical reactivity of this antibody (human monoclonal antibody for ovarian clear cell carcinoma-2 [HMOCC-2]) with ovarian cancer was assessed, while its specificity was analyzed by Western blotting. Various antibodies were used to identify the epitope targeted by HMOCC-2. Finally, the antitumor effect of HMOCC-2 was assessed by intraperitoneal administration to SCID (severe combined immunodeficiency) mice with heterografts of RMG-I tumors. HMOCC-2 showed a positive reaction with 60% (63/105) of ovarian cancer specimens. Western blotting of the membrane fraction of RMG-I revealed several bands at 120-250 kd. HMOCC-2 recognized the CA125-like antigens identified by several antibodies. HMOCC-2 also exhibited significant antitumor activity (P < 0.01) against ovarian cancer heterografts. HMOCC-2 reacts specifically with ovarian cancer cells via a target epitope analogous to that of CA125 and also exhibits activity against ovarian tumors. These findings suggest that it may have the potential to be employed clinically for molecular-targeting therapy.

8-1A, a human monoclonal antibody that reacts with intact human chorionic gonadotropin.

The incidence of choriocarcinoma has decreased over time and therapeutic results have improved about 90% complete remission in patients without extensive metastasis. However, some choriocarcinomas metastasize to other organs and show resistance to chemotherapy, having a poor prognosis despite multidisciplinary treatment. Better methods of early diagnosis for recurrence or micrometastasis, and treatment against cases with intractable gestational trophoblastic neoplasia (GTN) are needed to improve the prognosis. Human chorionic gonadotropin (hCG) is a glycoprotein hormone composed of two dissimilar subunits and a tumor marker to make a diagnosis and monitor therapeutic effect in GTN. Even when hCG levels in the serum become too low to measure with the hCG beta-CTP system which is the most sensitive assay, there are estimated to be approximately 10,000 trophoblastic cells in the body. Residual trophoblast cells may cause symptoms such as bleeding or undergo malignant transformation to choriocarcinoma. Since most monoclonal antibodies developed so far are murine, administration creates human anti-mouse antibodies, resulting in clinical failure. More recent mouse/human chimeric antibodies or humanized antibodies still possess substantial immunogenicity that makes repeated administration difficult. In the present study, KM mice that can produce completely human monoclonal antibodies were used to prepare hCG-specific human monoclonal antibody. This yielded 8-1A, a human monoclonal antibody capable of reacting with intact hCG. In the future, new diagnostic techniques and treatments for chorionic diseases may be developed using this kind of human monoclonal antibody.

Subcellular localization of blood group Leb carbohydrate antigen (MSN-1-reactive antigen) in endometrial cancer cells.

MSN-1 is a monoclonal antibody, which was raised by immunizing mice with a human endometrial cancer cell line, SNG-II. The MSN-1 specifically recognizes a blood group carbohydrate antigen, Leb. We investigated the subcellular and suborganellar localization of the MSN-1-reactive carbohydrate antigens in the endometrial adenocarcinomas and the normal endometria using immunofluorescence microscopy, confocal laser scanning microscopy, and immunoelectron microscopy. In normal endometrium, the apical plasma membranes of endometrial glandular cells were weekly positive. In contrast, in endometrial adenocarcinoma specimens, the apical plasma membranes, the lateral plasma membranes, intracytoplasmic vesicular structures, and the Golgi apparatus were strongly positive. We also found that there are differences in the manner of the distribution of the MSN-1 antigen within the Golgi apparatus between the normal and tumor samples; namely, in the endometrial adenocarcinoma cells the antigens are found abundantly throughout the Golgi apparatus or tend to be located not only at the trans side but also close to the cis side, while the localization of this antigen in normal counterpart is restricted to the trans-Golgi cisternae. These findings imply that aberrant glycosylation occurs in endometrial adenocarcinomas, presumably as a result of abnormal expression of some glycosyltransferases involving the expression of the Leb carbohydrate antigen in the Golgi apparatus.

Imbalanced expression of TAN-1 and human Notch4 in endometrial cancers.

The development of cancer is a cellular process that reflects and is partly driven by alterations in cell determination. Mutations in various genes responsible for cell determination have been identified as being oncogenic; however, little is known about the involvement of normal cell fate-determining mechanisms in the oncogenic process. The Notch pathway is an evolutionarily conserved, general cell-interaction mechanism that controls fundamental aspects of cell determination during the development of vertebrates and invertebrates. We have explored the roles of the recently cloned human Notch4 gene, which is a homologue of Drosophila Notch, in endometrial tissue, a cellular environment where cell fate changes take place and neoplastic conditions have been characterized. Northern blot analysis, dot blot analysis, and in situ hybridization were performed on samples of normal endometria at different phases of the menstrual cycle and endometrial cancers. Our results showed that: a) Both human Notch4 and translocation-associated Notch homologue-1 (TAN-1), another human homologue of Drosophila Notch, are expressed in the normal endometrium, mainly in the endometrial glandular cells. b) The level of expression of human Notch4, but not TAN-1, changes during the normal menstrual cycle; i.e., the level of Notch4 expression was significantly lower during the secretory phase than during the proliferative phase. c) Endometrial cancers express a significantly lower level of human Notch4 and a significantly higher level of TAN-1 than normal endometria. These results suggest that human Notch4 and/or TAN-1 are involved in the changes of the endometrium during the menstrual cycle, and also in the development of endometrial cancer.

[Hormonal therapy for endometrial adenocarcinoma].

Recently, the number of cases of endometrial cancer has increased in Japan. Most of the increase are accounted for by premenopausal cases, which are frequently positive for ER or PR. Hormonal treatment using progestins such as MPA has been widely applied to endometrial cancer patients under 40 years old under the conditions of grade 1 well-differentiated endometrioid adenocarcinoma without myometrial invasion. In our hospital, we applied high-dose (600 mg/day) MPA for over 8 weeks in 14 cases of endometrial cancer, of which adenocarcinoma disappeared in 12 cases (86%), followed by cyclic administrations of low-dose MPA, with 7 subsequent recurrences. We think that a protocol for improving ovarian function, such as active induction of ovulation, should be established to induce intrinsic progesterone sufficient for the prevention of the recurrence of endometrial cancers. In the 2 cases, in which adenocarcinoma remained even after long administrations of MPA, myometrial invasion was noted in the surgically resected specimens. For advanced or recurrent endometrial cancers, MPA has been reported to be effective in an average of 26% in several reports, and effective in 42% cases when applied with combination chemotherapy, such as CAP, by virtue of the "chemical modulator" effect, which can delay the acquired resistance against ADM or CDDP. Furthermore, MPA has resulted in a significant improvement of 5-year disease-free survival rate when used as adjuvant therapy after complete operations and whole pelvic irradiation, compared with administrations of 5-FU in a randomized controlled study in Japan. Thus, in the future, we consider that hormonal therapy will play a more important role in endometrial cancer treatment.

[Preclinical and clinical studies on a tumor marker, galactosyltransferase associated with tumor (GAT), in ovarian cancer (first report)--preclinical study of GAT assay kit and clinical study of normal level].

We conducted preclinical and clinical studies on GAT: Galactosyltransferase Associated with Tumor, a newly developed tumor marker of ovarian carcinoma. This paper presents the results of evaluation of a GAT assay kit, the normal range of its values, and analysis of its value relative to age, menstrual cycle, and stage of pregnancy. Calibration curve, reproducibility, analytical recovery test, and dilution test all yielded favorable results, and the assay system was proved to be reliable in both precision and reproducibility. However, special attention must be paid to highly hemolytic samples because of a positive error in GAT value for samples with a high concentration of hemoglobin. The cut-off value was set at 16U/ml based on the mean+2SD of healthy females. A uniform cut-off value could be employed since neither age nor stage of menstrual cycle had any observable influence on the level. The positive rate for healthy subjects was 3.1%, when the cut-off value of 16 U/ml was used. On the other hand, elevation of the GAT value was observed during the progression of pregnancy.

[Preclinical and clinical studies on a tumor marker, galactosyltransferase associated with tumor (GAT), in ovarian cancer (second report)--clinical significance of GAT and comparison with other tumor markers].

Galactosyltransferase Associated with Tumor (GAT) was clinically studied in cases of ovarian cancer. When two cut-off levels of GAT were compared, the cut-off level of 16 U/ml (which corresponds to mean + 2SD among healthy females) was found to be more suitable than the cut-off level of 14 U/ml (the level maximizing the diagnostic efficiency between malignant and benign ovarian tumors). When the GAT positive rate was examined for gynecologic tumors, the rate was 5.7% for benign ovarian cyst, 6.6% for endometriosis, 20.5% for cervical cancer, 19.5% for endometrial cancer, and 52.9% for ovarian cancer. The GAT positive rate for different histologic types of ovarian carcinoma was relatively high for each type, e.g., 55.0% for clear cell adenocarcinoma and 66.7% for endometrioid adenocarcinoma. The GAT positive rate increased gradually with the stage of ovarian cancer. In patients with benign diseases, in particular endometriosis, the GAT positive rate was lower than the positive rate with any other simultaneously determined marker (CA602, CA125, CA54/61, CA72-4, STN, and SLX). The GAT level most weakly correlated with the level of any of the other markers assessed. An assay combining GAT with CA602 or CA54/61 resulted in a higher positive rate and a higher diagnostic efficiency, when compared with the assay for GAT alone. The lower positive rate of GAT in endometriosis, when compared with the positive rate of other markers, suggests the usefulness of GAT in distinguishing malignant ovarian tumors from benign ovarian tumors. The use of GAT in a combination assay is expected to overcome the disadvantages of CA602 or CA125.

Sensitivity to cisplatin determined by the histoculture drug response assay and clinical response of endometrial cancer.

This study investigated the value of the in vitro histoculture drug response assay (HDRA) for predicting the efficacy of chemotherapy in patients with endometrial cancer. Specimens were obtained from 115 patients with endometrial cancer treated at Keio University Hospital between 1994 and 2002. Tumor fragments were cultured on collagen sponge gel with cisplatin for 7 days, and cell viability was assessed. The cutoff value of the 50% inhibitory concentration of cisplatin was set at 23 microg/mL. Sensitivity of stage III or IV disease to chemotherapy was investigated, and differences of 5-year progression-free survival between patients with sensitive and resistant tumors were evaluated by the Kaplan-Meier method. Tumors were evaluable in 93.0% of patients (107/115). Among 38 patients in stages III or IV, 23 received chemotherapy containing cisplatin. Seven sensitive tumors did not recur, while recurrence/progression occurred within 6 months in 8/16 patients with tumors showing low sensitivity. Among stages III and IV patients, there was a significant difference of 5-year progression-free survival (P < 0.05) between those with tumors showing high or low sensitivity. Accordingly, the HDRA may predict the efficacy of chemotherapy for endometrial cancer.