PIpelle Prospective ENDOmetrial carcinoma (PIPENDO) study, pre-operative recognition of high risk endometrial carcinoma: a multicentre prospective cohort study.

BACKGROUND: Endometrial carcinoma is the most common gynaecologic malignancy in industrialised countries and the incidence is still rising. Primary treatment is based on preoperative risk classification and consists in most cases of hysterectomy with bilateral salpingo-oophorectomy. In patients with serous and clear cell histology a complete surgical staging is mandatory. However, in routine clinical practice final histology regularly does not correspond with the preoperative histological diagnosis. This results in both over and under treatment. METHODS/DESIGN: The aim of this multicentre, prospective cohort study is to select a panel of prognostic biomarkers to improve preoperative diagnosis of endometrial carcinoma in order to identify those patients that need extended surgery and/or additional treatment. Additionally, we will determine whether incorporation of cervical cytology and comorbidity could improve this preoperative risk classification. All patients treated for endometrial carcinoma in the participating hospitals from September 2011 till December 2013 are included. Patient characteristics, as well as comorbidity are registered. Patients without preoperative histology, history of hysterectomy and/or endometrial carcinoma or no surgical treatment including hysterectomy are excluded. The preoperative histology and final pathology will be reviewed and compared by expert pathologists. Additional immunohistochemical analysis of IMP3, p53, ER, PR, MLH1, PTEN, beta-catenin, p16, Ki-67, stathmin, ARID1A and L1CAM will be performed. Preoperative histology will be compared with the final pathology results. Follow-up will be at least 24 months to determine risk factors for recurrence and outcome. DISCUSSION: This study is designed to improve surgical treatment of endometrial carcinoma patients. A total of 432 endometrial carcinoma patients were enrolled between 2011 and 2013. Follow-up will be completed in 2015. Preoperative histology will be evaluated systematically and background endometrium will be classified. This is the first study incorporating immunohistochemistry, cervical cytology and comorbidity to define the optimal panel of prognostic biomarkers that contribute in clinical decision making in the management of endometrial carcinoma. TRIAL REGISTRATION: Netherlands Trial Register number NTR3503.

Synchronous ovarian and endometrial cancer--an international multicenter case-control study.

OBJECTIVES: This study aimed to compare the prognosis of patients with synchronous endometrial and ovarian cancer (SEOC) to matched controls with either endometrial cancer (EC) or ovarian cancer (OC). METHODS: A retrospective case-control study including all patients with SEOC who had been treated at 5 European tertiary gynecologic oncology centers between 1996 and 2011 and patients with either EC or OC matched for age, International Federation of Gynecology and Obstetrics (FIGO) stage, histology, year of diagnosis, and Eastern Cooperative Oncology Group performance score. RESULTS: The study cohort comprised 77, 132, and 126 patients with SEOC, EC, and OC, respectively. The patient characteristics confirmed an equal distribution of matching factors, and the median follow-up did not differ (P = 0.44). 48.1% of the patients with SEOC showed early FIGO stage I for both EC and OC. The 5-year PFS rates differed between SEOC and EC (76.3% vs 86.3%; P = 0.047) but not the 5-year overall survival rates (71.6% vs 79.8%; P = 0.12) and did not differ between SEOC and OC (76.3% vs 63.8%; P = 0.19 and 71.6% vs 69.3%; P = 0.61, respectively). After the adjustment for the FIGO stage of the 2 components of SEOC, neither PFS nor overall survival rates were different. CONCLUSIONS: Prognosis of patients with SEOC tended to be the same in comparison with matched controls with either one EC or OC. Therefore, it could be considered that patients with SEOC may be eligible for clinical trials of the advanced tumor component if no additional therapy is indicated for the other component.

Hormone receptor loss in endometrial carcinoma curettage predicts lymph node metastasis and poor outcome in prospective multicentre trial.

BACKGROUND: Preoperative histologic examination of tumour tissue is essential when deciding if endometrial cancer surgery should include lymph node sampling. We wanted to investigate if biomarkers could improve prediction of lymph node metastasis and outcome. PATIENTS AND METHODS: Curettage specimens from 832 endometrial carcinoma patients prospectively recruited from 10 centres in the MoMaTEC trial (Molecular Markers in Treatment of Endometrial Cancer) were investigated for hormone receptor and p53 status. RESULTS: Eighteen per cent of tumours were double negative for oestrogen- and progesterone receptors (ER/PR loss), 24% overexpressed p53. Pathologic expression of all markers correlated with nodal metastases, high FIGO (Federation International of Gynecology and Obstetrics) stage, non-endometrioid histology, high grade and poor prognosis (all P<0.001). ER/PR loss independently predicted lymph node metastasis (odds ratios (OR) 2.0, 95% confidence interval (CI) 1.1-3.7) adjusted for preoperative curettage histology and predicted poor disease-specific survival adjusted for age, FIGO stage, histologic type, grade and myometrial infiltration (hazard ratio (HR) 2.3, 95% CI 1.4-3.9). For lymph node negative endometrioid tumours, ER/PR loss influenced survival independent of grade. CONCLUSION: Double negative hormone receptor status in endometrial cancer curettage independently predicts lymph node metastasis and poor prognosis in a prospective multicentre setting. Implementing hormone receptor status to improve risk-stratification for selecting patients unlikely to benefit from lymphadenectomy seems justified.

High-throughput interrogation of PIK3CA, PTEN, KRAS, FBXW7 and TP53 mutations in primary endometrial carcinoma.

OBJECTIVE: Endometrial cancer patients may benefit from systemic adjuvant chemotherapy, alone or in combination with targeted therapies. Prognostic and predictive markers are needed, however, to identify patients amenable for these therapies. METHODS: Primary endometrial tumors were genotyped for >100 hot spot mutations in genes potentially acting as prognostic or predictive markers. Mutations were correlated with tumor characteristics in a discovery cohort, replicated in independent cohorts and finally, confirmed in the overall population (n=1063). RESULTS: PIK3CA, PTEN and KRAS mutations were most frequently detected, respectively in 172 (16.2%), 164 (15.4%) and 161 (15.1%) tumors. Binary logistic regression revealed that PIK3CA mutations were more common in high-grade tumors (OR=2.03; P=0.001 for grade 2 and OR=1.89; P=0.012 for grade 3 compared to grade 1), whereas a positive TP53 status correlated with type II tumors (OR=11.92; P<0.001) and PTEN mutations with type I tumors (OR=19.58; P=0.003). Conversely, FBXW7 mutations correlated with positive lymph nodes (OR=3.38; P=0.045). When assessing the effects of individual hot spot mutations, the H1047R mutation in PIK3CA correlated with high tumor grade and reduced relapse-free survival (HR=2.18; P=0.028). CONCLUSIONS: Mutations in PIK3CA, TP53, PTEN and FBXW7 correlate with high tumor grade, endometrial cancer type and lymph node status, whereas PIK3CA H1047R mutations serve as prognostic markers for relapse-free survival in endometrial cancer patients.

Weekly paclitaxel-carboplatin regimen in patients with primary advanced or recurrent endometrial carcinoma.

OBJECTIVE: The objective of the study was to evaluate the response of weekly paclitaxel/carboplatin in patients with primary advanced or recurrent endometrial cancer. METHODS: Eighteen cycles of paclitaxel (60 mg/m²) and carboplatinum (area under the plasma concentration-time curve, 2.7) were administered weekly. Response rates were evaluated according to Response Criteria in Solid Tumors criteria. RESULTS: Paclitaxel/carboplatin weekly was administered to 29 patients. Median age was 62 years (range, 44-80 years). Main histopathologic types were serous/clear cell (n = 16) and endometrioid (n = 9). Patients were divided into a chemonaive group (n = 16) (group 1) and a group with previous chemotherapy (n = 13) (group 2). Response rate for group 1 was as follows: partial remission, n = 8 (50%); stable disease, n = 1 (6%); and progressive disease, n = 7 (44%). Response for group 2: partial remission, n = 5 (39%), and progressive disease, n = 8 (62%). Median progression-free survival and overall survival were 9 months (range, 5-27 months) and 12 months (range, 2-27 months), respectively, for group 1 and 8 months (range, 6-10 months) and 9 months (range, 2-18 months), respectively, for group 2.Overall 411 weekly treatments were administered. Because of grade 4 bone marrow toxicity, treatments needed to be adjusted as follows: dose reduction of 50% to 75%, n = 81 (20%); dose delay, n = 66 (16%); not administered, n = 6 (1%); and changed to paclitaxel/cisplatin, n = 4 (1%). Twenty-three patients (85%) needed treatment adjustment because of toxicity. Neutropenic fever occurred in 1 patient (4%). The most common nonhematologic toxicities were grade 1 to 2 fatigue (89%) and grade 2 nausea (37%). Seven percent had grade 2 neuropathy. No grade 2 alopecia occurred. CONCLUSIONS: Paclitaxel/carboplatin weekly seems effective, however, with a considerable hematologic toxicity. Larger trials are needed to confirm these data.

Progesterone inhibits epithelial-to-mesenchymal transition in endometrial cancer.

BACKGROUND: Every year approximately 74,000 women die of endometrial cancer, mainly due to recurrent or metastatic disease. The presence of tumor infiltrating lymphocytes (TILs) as well as progesterone receptor (PR) positivity has been correlated with improved prognosis. This study describes two mechanisms by which progesterone inhibits metastatic spread of endometrial cancer: by stimulating T-cell infiltration and by inhibiting epithelial-to-mesenchymal cell transition (EMT). METHODOLOGY AND PRINCIPAL FINDINGS: Paraffin sections from patients with (n = 9) or without (n = 9) progressive endometrial cancer (recurrent or metastatic disease) were assessed for the presence of CD4+ (helper), CD8+ (cytotoxic) and Foxp3+ (regulatory) T-lymphocytes and PR expression. Progressive disease was observed to be associated with significant loss of TILs and loss of PR expression. Frozen tumor samples, used for genome-wide expression analysis, showed significant regulation of pathways involved in immunesurveillance, EMT and metastasis. For a number of genes, such as CXCL14, DKK1, DKK4, PEG10 and WIF1, quantitive RT-PCR was performed to verify up- or downregulation in progressive disease. To corroborate the role of progesterone in regulating invasion, Ishikawa (IK) endometrial cancer cell lines stably transfected with PRA (IKPRA), PRB (IKPRB) and PRA+PRB (IKPRAB) were cultured in presence/absence of progesterone (MPA) and used for genome-wide expression analysis, Boyden- and wound healing migration assays, and IHC for known EMT markers. IKPRB and IKPRAB cell lines showed MPA induced inhibition of migration and loss of the mesenchymal marker vimentin at the invasive front of the wound healing assay. Furthermore, pathway analysis of significantly MPA regulated genes showed significant down regulation of important pathways involved in EMT, immunesuppression and metastasis: such as IL6-, TGF-ß and Wnt/ß-catenin signaling. CONCLUSION: Intact progesterone signaling in non-progressive endometrial cancer seems to be an important factor stimulating immunosurveilance and inhibiting transition from an epithelial to a more mesenchymal, more invasive phenotype.

Evolution in endometrial cancer: evidence from an immunohistochemical study.

BACKGROUND: It is poorly described how endometrial cancer biology changes during tumor evolution. We hypothesize that characterization of molecular targets in recurrent lesions is more relevant for targeting treatment. METHODS: Paired biopsies from primary and recurrent endometrial cancer tumors (n = 85) were stained immunohistochemically for the following proteins: estrogen receptor (ER), progesterone receptor (PR), stathmin (correlating with phosphatidylinositol 3-kinase activity), HER-2/neu, WT1 (Wilms tumor gene 1), phospho-mammalian target of rapamycin (p-mTOR), and p53. Each tumor was scored, using a semiquantitative and subjective grading system. Discordance, a change in expression between primary and recurrent tumor, was defined as ≥ 2 step change; concordance was ≤ 1 step change. The frequency of change was correlated with established prognostic markers in endometrial cancer. RESULTS: Fifty-six patients (67%) were diagnosed with endometrioid carcinoma, 23 (27%) with serous/clear cell carcinoma. A change in expression between primary and recurrent tumor was noted in 7% to 31% of patients for ER, PR, stathmin, HER-2/neu, WT1, p-mTOR, and p53. Concordant-positive cases for PR were significantly correlated with stage, tumor grade, and histological subtype. Expression of ER, p53, and p-mTOR in cytoplasm in the recurrent tumor correlated significantly with survival. CONCLUSIONS: Endometrial cancer biology changes over time. The decision on targeted treatment should preferably be based on recurrent tumor characteristics.

Expression of ERCC1, p53, and class III ß-tubulin do not reveal chemoresistance in endometrial cancer: results from an immunohistochemical study.

BACKGROUND: In non-small cell lung cancer, expression of excision repair cross-complementation group 1 (ERCC1) and p53 correlates with platinum resistance and class III ß-tubulin with resistance to taxanes. The potential to personalize treatment in endometrial cancer remains uninvestigated. METHODS: Patients received platinum-based chemotherapy, with or without paclitaxel. Patients were divided into 2 groups: group A (n = 33) consisted of patients with early-stage endometrial cancer treated with adjuvant chemotherapy. Group B (n = 116) included cases with primary advanced or recurrent disease. Immunohistochemistry was performed to analyze the expression of ERCC1 and p53, for all cases, and class III ß-tubulin for cases treated with paclitaxel. The findings were correlated with response according to Response Criteria in Solid Tumors; recurrence-free, disease-specific survival; and established prognostic markers. RESULTS: The mean age of 149 patients was 64 years (range, 31-84 years). Distribution of histopathologic subtypes was as follows: 44 endometrioid (30%), 92 serous/clear cell (62%), and 13 carcinosarcomas (8%).In group A, 11 (33%) and 19 patients (58%) showed expression for ERCC1 and p53, respectively. Seven (78%) of nine patients receiving paclitaxel were positive for class III ß-tubulin. There was no correlation between expression of ERCC1, p53, or class III ß-tubulin and recurrence or survival. In group B, 25 (22%) and 61 patients (64%) were positive for ERCC1 and p53, respectively. Fifty-two (74%) of seventy patients receiving paclitaxel were positive for class III ß-tubulin. Only p53 expression correlated with survival (P = 0.01). CONCLUSIONS: In contrast to theoretical assumptions, the current study did not reveal evidence that the expression of ERCC1 and class III ß-tubulin predicts response to cytotoxic treatment and patient outcome in endometrial cancer.

Kit gene in endometrial carcinoma: an immunohistochemical and mutational analysis.

OBJECTIVE: : Because the outcome of recurrent disease of endometrial carcinoma is cumbersome, the development of target treatment strategies is critical. We evaluated KIT, a receptor tyrosine kinase, to determine a potential role for imatinib mesylate in the treatment of endometrial carcinoma. MATERIALS AND METHODS: : Immunohistochemical analysis for KIT expression was performed on paraffin sections from 45 patients: 30 primary and 15 recurrent tumors. Fifteen primary cases were available for mutation analysis. RESULTS: : Histopathological distribution of paraffin-embedded tissue was as follows: 30 type I and 15 type II endometrial carcinoma. Histopathological distribution of fresh-frozen tissue was as follows: 8 type I and 7 type II. Cases did not show KIT expression or mutations in mutational hotspot exons of KIT gene. CONCLUSIONS: : On the basis of the absence of KIT expression or mutations, endometrial carcinoma is unlikely to respond to imatinib mesylate.

The role of adjuvant chemotherapy in surgical stages I-II serous and clear cell carcinomas and carcinosarcoma of the endometrium: a collaborative study.

OBJECTIVE: To assess the impact of adjuvant chemotherapy in early surgically staged type II endometrial cancer (serous [S], clear cell carcinoma [CC]) and carcinosarcomas (CS) on recurrence and survival. MATERIALS AND METHODS: Patients diagnosed with stages I-II S-CC and CS after comprehensive surgical staging were retrospectively collected. Surgical staging was defined as pelvic lymphadenectomy of more than 11 nodes harvested and exploration of the upper abdomen, with our without omentectomy. Groups with (group A) and without (group B) platinum-based chemotherapy were compared. RESULTS: We identified 69 patients with a mean age of 66 years (range, 48-88 years). Both groups showed similar baseline characteristics. Group A consisted of 34 patients (23 S-CC, 11 CS) with 10 (29%) recurrences outside the pelvis (7 S-CC, 3 CS). Group B included 35 patients (28 S-CC, 7 CS) of which 10 (29%) developed recurrence outside the pelvis (7 S-CC, 3 CS). The median recurrence-free survival was 22 months (range, 13-51 months) for group A versus 10 months (range, 1-59 months) for group B (P = 0.437). Five patients (15%) of group A and 9 (26%) of group B died of disease after a median follow-up of 29 months (range, 20-59 months) and 17 months (range, 4-64 months), respectively (P = 0.168). CONCLUSION: Recurrences in early-stage type II endometrial cancer and carcinosarcomas occur irrespective of adjuvant chemotherapy, but recurrence-free survival is prolonged when adjuvant chemotherapy is administered. Only prospective randomized intergroup trials can address the benefit of adjuvant chemotherapy in early-stage high-risk endometrial cancer.

Stathmin overexpression identifies high-risk patients and lymph node metastasis in endometrial cancer.

PURPOSE: Overexpression of the oncogen Stathmin has been linked to aggressive endometrial carcinoma and a potential for PI3Kinase inhibitors in this disease. We wanted to validate the prognostic value of Stathmin expression in a large prospective multicenter setting. As lymph node sampling is part of current surgical staging, we also aimed to test if Stathmin expression in endometrial curettage specimens could predict lymph node metastasis. EXPERIMENTAL DESIGN: A total of 1,076 endometrial cancer patients have been recruited from 10 centers to investigate the biological tumor marker Stathmin in relation to clinicopathologic variables, including lymph node status and survival. Stathmin immunohistochemical staining was carried out in 477 hysterectomy and 818 curettage specimens. RESULTS: Seventy-one percent of the patients (n = 763) were subjected to lymph node sampling, of which 12% had metastatic nodes (n = 94). Overexpression of Stathmin was detected in 37% (302 of 818) of the curettage and in 18% (84 of 477) of the hysterectomy specimens investigated. Stathmin overexpression in curettage and hysterectomy specimens were highly correlated and significantly associated with nonendometrioid histology, high grade, and aneuploidy. Stathmin analysis in preoperative curettage samples significantly correlated with, and was an independent predictor of, lymph node metastases. High Stathmin expression was associated with poor disease-specific survival (P ≤ 0.002) both in curettage and hysterectomy specimens. CONCLUSIONS: Stathmin immunohistochemical staining identifies endometrial carcinomas with lymph node metastases and poor survival. The value, as a predictive marker for response to PI3Kinase inhibition and as a tool to stratify patients for lymph node sampling in endometrial carcinomas, remains to be determined.

The use of lymph vessel markers to predict endometrial cancer outcome.

OBJECTIVE: To evaluate lymphangiogenesis and lymph vessel space involvement in different subsets of endometrial cancer using podoplanin, a specific marker for lymphatic endothelium. METHODS: Sixty-two patients undergoing a hysterectomy with lymphadenectomy were included. Distribution of histopathologic subtypes was as follows: 30 endometrioid (48%), 18 serous (29%), 9 clear cell carcinoma (15%), and 5 carcinosarcomas (8%). Distribution of surgical stage according to the International Federation of Gynecology and Obstetrics 2009 criteria was as follows: 33 stage I (53%), 7 stage II (11%), 1 stage IIIA (2%), 15 stage IIIC1 (24%), and 6 stage IIIC2 (10%). Tumor samples were immunostained for podoplanin and the panendothelial marker, CD31. Peritumoral and intratumoral blood vessel density and lymph vessel density were assessed using an image analysis system that calculated mean vessel cross-sectional area (in micrometer squared) and vessel density (per millimeter squared). Presence of blood vessel space involvement and lymph vessel space involvement was screened for. The findings were linked with clinical outcome using Cox regression. RESULTS: Twenty-one patients (34%) experienced recurrence, and 13 (21%) died of disease. Univariate analysis showed that blood vessel space involvement was related to worse overall survival (hazard ratio, 6.59; 95% confidence interval, 1.30-120). Multivariate analyses confirmed the prognostic importance of this variable for overall survival (hazard ratio, 7.52; 95% confidence interval, 1.32-144). CONCLUSION: Blood vessel space involvement is a prognostic marker for worse survival. Although lymph vessels were stained with the most reliable marker, podoplanin, lymph vessel density and lymphovascular space involvement do not seem to be of prognostic importance.

Leuven dose-dense paclitaxel/carboplatin regimen in patients with primary advanced or recurrent endometrial carcinoma.

OBJECTIVE: To evaluate the response of dose-dense paclitaxel/carboplatin (TC) patients with primarily advanced or recurrent endometrial cancer. METHODS: Six courses of paclitaxel (90 mg/m2) and carboplatinum (area under the curve, 4) on days 1 and 8 every 3 weeks were administered. Response rates were evaluated according to the response evaluation criteria in solid tumors. RESULTS: Dose-dense TC was administered to 42 patients. The median age was 63.9 years (range, 41-81 years). The main histopathologic types were serous/clear cell (n = 27) and endometrioid (n = 13). The patients were divided in 2 groups: chemotherapy-naive group (n = 28, group 1) and a group with previous chemotherapy (n = 14, group 2).The responses for group 1 were as follows: 11 (39 %) complete response, 9 (32%) partial response, and 2 (7%) stable disease. The responses for group 2 were 1 (7%) complete response, 2 (14%) partial response, and 6 (43%) stable disease. Treatment-related death occurred in 1 patient (7%) because of neutropenia and nephrotoxicity.Progression-free survival for group 1 was 10 months (range, 4-19 months). At time of analysis, 57% of the patients were still alive after a median follow-up of 10 months (range, 4-21 months). Progression-free survival for group 2 was 11 months (range, 4-19 months).Because of grades 3 and 4 hematologic toxicity, treatment adjustments were as follows: 49 (18%) and 18 (19%) dose reductions (carboplatin area under the curve, 2-3), 35 (13%) and 14 (15%) dose delays, and 8 (3%) and 6 (6%) treatments were not administered on day 8 for groups 1 and 2, respectively. CONCLUSIONS: Administration of dose-dense TC resulted in a response rate of 71% in chemotherapy-naive patients. Treatment modifications due to toxicity were frequent, but severe complications such as neutropenic fever occurred in a similar incidence as other reported 3-weekly regimens.