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.publishedVersio

Lowered expression of tumor suppressor candidate MYO1C stimulates cell proliferation, suppresses cell adhesion and activates AKT

Myosin-1C (MYO1C) is a tumor suppressor candidate located in a region of recurrent losses distal to TP53. Myo1c can tightly and specifically bind to PIP2, the substrate of Phosphoinositide 3-kinase (PI3K), and to Rictor, suggesting a role for MYO1C in the PI3K pathway. This study was designed to examine MYO1C expression status in a panel of wellstratified endometrial carcinomas as well as to assess the biological significance of MYO1C as a tumor suppressor in vitro. We found a significant correlation between the tumor stage and lowered expression of MYO1C in endometrial carcinoma samples. In cell transfection experiments, we found a negative correlation between MYO1C expression and cell proliferation, and MYO1C silencing resulted in diminished cell migration and adhesion. Cells expressing excess of MYO1C had low basal level of phosphorylated protein kinase B (PKB, a.k.a. AKT) and cells with knocked down MYO1C expression showed a quicker phosphorylated AKT (pAKT) response in reaction to serum stimulation. Taken together the present study gives further evidence for tumor suppressor activity of MYO1C and suggests MYO1C mediates its tumor suppressor function through inhibition of PI3K pathway and its involvement in loss of contact inhibition.Royal Physiographic Society in Lund (Nilsson-Ehle Foundation) with grant numbers 30928, 32705 and 36388: KV. Wilhelm and Martina Lundgren Foundation: KV, AB. Assar Gabrielsson Research Foundation for Clinical Cancer Research with grant numbers FB11-15, FB12-26, FB13-05, FB14-46 and FB15-45: KV. Sahlgrenska University Hospital Foundation with grant number 8181: KV. The Knowledge Foundation with grant number HOÈ G12, 20120311: AB.http://www.plosone.orgam2016Physiolog

Incidence of lymphedema in the lower limbs and lymphocyst formation within one year of surgery for endometrial cancer: A prospective longitudinal multicenter study

Objective. The study aimed to determine the incidence of lower limb lymphedema (LLL) after surgery for endometrial cancer (EC) by means of three methods, and to determine the incidence of lymphocysts after one year. Methods. A prospective longitudinal multicenter study was conducted in 14 hospitals in Sweden. Two-hundred-and-thirty-five women with EC were included; 116 underwent surgery that included lymphadenectomy (+LA) and 119 were without lymphadenectomy ( -LA). Lymphedema was assessed objectively on four occasions; preoperatively, at 4-6 weeks, six months and one year postoperatively using systematic measurement of leg circumferences, enabling calculation of leg volumes, and a clinical grading of LLL, and subjectively by the patients perception of lymphedema measured by a lymphedema-specific quality-of-life instrument. Lymphocyst was evaluated by vaginal ultrasonography. Results. After one year the incidence of LLL after increase in leg volume adjusted for body mass index was 15.8% in +LA women and 3.4% in -IA women. The corresponding figures for clinical grading were 24.1% and 11.8%, and for patient-reported perceived LLL 10.7% and 5.1%. The agreement between the modalities revealed fair to moderate correlation between patient-reported LLL and clinical grading, but poor agreement between volume increase and patient-reported LLL or clinical grading. Lymphocysts were found in 43% after one year. Conclusions. Although the incidence of ILL and lymphocysts after surgery for EC including LA seemed to be relatively high the study demonstrated significant variations in incidence depending on the measurement modality. This emphasizes the need for a gold standard of measurement of LLL in clinical practice and research. (C) 2020 Elsevier Inc. All rights reserved.Funding Agencies|Swedish Cancer Society [Cancerfonden]Swedish Cancer Society [CAN2013/620]; Medical Research Council of Southeast Sweden [FORSS-308611, FORSS-391311, FORSS-662141, FORSS-858611]; Uppsala-Orebro Regional Research Council [LUL-349271]; Scientific Council of the Region Halland; County Council of Ostergotland; Linkoping University</p

Early Diagnosis of Epithelial Ovarian Cancer - Analysis of Novel Biomarkers

Early Diagnosis of Epithelial Ovarian Cancer - Analysis of Novel Biomarkers Björg Kristjánsdóttir Department of Obstetrics & Gynecology, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Sweden ABSTRACT Background: Majority of epithelial ovarian cancer (EOC) is detected in advanced stage with bad prognosis and high mortality. Reliable diagnostic markers are lacking, pre-cancerous lesions in the more aggressive tumors are not clearly defined, vague or unspecific early symptoms, and the localization of the ovaries, deep in the pelvis contributes to late diagnose. Heterogeneity, not only different type of histology, but also different intrinsic biology and behavior characterizes ovarian cancer. Invasive surgery with histological examination is needed to confirm the diagnosis. Less than 25% EOC are diagnosed early, when there is great possibility to cure and 5-year survival >90%, in contrast to 20-30% 5-year survival in late stage EOC. Thus, early detection is of utmost importance. Proximal fluids, like ovarian cyst fluid, are promising in the search for early markers. Cancer antigen 125 (CA125), the most used biomarker since 30 years, and a promising marker human epididymis 4 (HE4) have recently been approved by FDA to be used in the prediction of malignancy in women with a pelvic mass. Aims: To explore ovarian cyst fluid as a source mining for new diagnostic biomarkers for EOC, and to validate the markers found together with CA125 (Paper I-III); and to evaluate the diagnostic performance of HE4 and CA125, to distinguish between benign cysts and EOC, and EOC divided into slow growing type I and the aggressive type II EOC (Paper IV-V). Method: Cross sectional, observational, explorative, and diagnostic clinical studies, with prospective and consecutive collection of cystic fluid, blood and tumor tissue at the time of operation and retrospective analysis. Women with suspicious malignant pelvic cysts, already scheduled for operation at our clinic for tumor surgery were included. High throughput proteomic analyses were used for searching for novel markers, and selected proteins were validated with ELISA or immunoblot. Paper I: The cyst fluid proteome was mined with surfaceenhanced laser desorption/ionization time of flight (SELDI-TOF) mass spectrometry (MS) (n=192). Paper II: Enrichment of a selection of known cancer antigens to overcome high abundant proteins, and with focus on inflammation, was followed by Immunoprecipitation MS (n=38). Significantly differently expressed chemokines were validated (n=256). Paper III: Serous cystadenoma (n=5) and serous adenocarcinoma (n=10) of different stages were analyzed with isobaric tag for relative and absolute quantification (iTRAQ), followed by immunoblot validation (n=68). Paper IV-V: HE4 and CA125 levels in plasma were analyzed with ELISA and Risk of Ovarian Malignancy Algorithm (ROMA) was calculated (n=393). Significant differences, receiver operator characteristics (ROC) area under the curve (AUC), cut-off levels, sensitivity and specificity were estimated with regard to malignancy, grade, stage histologic subtype and type I and type II. Results: Paper I: Combination of Apolipoprotein CIII and Protein C inhibitor had the best AUC (0.91) in cyst fluid, and improved by CA125 (0.94). Abundant proteins were a problem in the cyst fluid analyses. Paper II: Interleukin-8 and Chemoattractant Protein-I were highly significantly increased expressed in cyst fluid. Increased inflammatory response was present in early tumor development and earlier than in blood. Paper III: Two of 87 differentially expressed proteins in cyst fluid, with high significance and fold change, Serum Amyloid A-4 (SAA4) and astacin-like metalloendopeptidase (ASTL) were validated, and SAA4 was significantly increased in cyst fluid, but not in blood. Paper IV: HE4 complemented CA125 in the diagnosis of ovarian cysts, especially in the premenopausal women. Sensitivity for ROMA at set specificity of 75% was highest in the postmenopausal cohort (87%). Paper V: HE4 and CA125 diagnosed the aggressive type II EOC most correctly (AUC 0.93), but the results were not acceptable in early stage type II (AUC 0.85) or in type I EOC (AUC 0.79) respective early type I AUC 0.73). Conclusion: Ovarian cyst fluid is an excellent source for the search of novel biomarkers for early diagnosis of EOC. Early events are found near the tumor in the early phase, like the inflammatory response and later on in the peripheral circulation. HE4 complements CA125 in predicting malignancy in cystic ovarian tumors. The result from this thesis support, that EOC should be looked upon as several different diseases. Finding early markers that are specific for each histology subgroup will be the future challenge. Combination of such markers in a panel could improve the early diagnosis of EOC. Keywords: EOC; ovarian adenocarcinoma; ovarian cyst fluid; pelvic mass; tumor biomarker; mass spectrometry; SELDI-TOF MS; iTRAQ; ISBN 978-91-628-8727-8 http://hdl.handle.net/2077/3309

Risk factors for lymphedema and method of assessment in endometrial cancer : a prospective longitudinal multicenter study

OBJECTIVE: The aim of the study was to determine risk factors for lymphedema of the lower limbs, assessed by four methods, 1 year after surgery for endometrial cancer. METHODS: A prospective longitudinal multicenter study was conducted in 14 Swedish hospitals. 235 women with endometrial cancer were included; 116 underwent surgery including lymphadenectomy, and 119 had surgery without lymphadenectomy. Lymphedema was assessed preoperatively and 1 year postoperatively objectively by systematic circumferential measurements of the legs, enabling volume estimation addressed as (1) crude volume and (2) body mass index-standardized volume, or (3) clinical grading, and (4) subjectively by patient-reported perception of leg swelling. In volume estimation, lymphedema was defined as a volume increase ≥10%. Risk factors were analyzed using forward stepwise logistic regression models and presented as adjusted odds ratio (aOR) and 95% confidence interval (95% CI). RESULTS: Risk factors varied substantially, depending on the method of determining lymphedema. Lymphadenectomy was a risk factor for lymphedema when assessed by body mass index-standardized volume (aOR 14.42, 95% CI 3.49 to 59.62), clinical grading (aOR 2.11, 95% CI 1.04 to 4.29), and patient-perceived swelling (aOR 2.51, 95% CI 1.33 to 4.73), but not when evaluated by crude volume. Adjuvant radiotherapy was only a risk factor for lymphedema when assessed by body mass index-standardized volume (aOR 15.02, 95% CI 2.34 to 96.57). Aging was a risk factor for lymphedema when assessed by body mass index-standardized volume (aOR 1.07, 95% CI 1.00 to 1.15) and patient-perceived swelling (aOR 1.06, 95% CI 1.02 to 1.10), but not when assessed by crude volume or clinical grading. Increase in body mass index was a risk factor for lymphedema when estimated by crude volume (aOR 1.92, 95% CI 1.36 to 2.71) and patient-perceived swelling (aOR 1.36, 95% CI 1.11 to 1.66), but not by body mass index-standardized volume or clinical grading. The extent of lymphadenectomy was strongly predictive for the development of lymphedema when assessed by body mass index-standardized volume and patient-perceived swelling, but not by crude volume or clinical grading. CONCLUSION: Apparent risk factors for lymphedema differed considerably depending on the method used to determine lymphedema. This highlights the need for a 'gold standard' method when addressing lymphedema for determining risk factors.Funding: Swedish Cancer Society (Cancerfonden)Swedish Cancer Society [CAN2013/620]; Medical Research Council of Southeast SwedenUK Research &amp; Innovation (UKRI)Medical Research Council UK (MRC) [FORSS-308611, FORSS-391311, FORSS-662141, FORSS-858611]; Uppsala-Orebro Regional Research Council [LUL-349271]; Scientific Council of the Region Halland; County Council of Ostergotland; Linkoping University</p

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

Lowered Expression of Tumor Suppressor Candidate MYO1C Stimulates Cell Proliferation, Suppresses Cell Adhesion and Activates AKT.

Myosin-1C (MYO1C) is a tumor suppressor candidate located in a region of recurrent losses distal to TP53. Myo1c can tightly and specifically bind to PIP2, the substrate of Phosphoinositide 3-kinase (PI3K), and to Rictor, suggesting a role for MYO1C in the PI3K pathway. This study was designed to examine MYO1C expression status in a panel of well-stratified endometrial carcinomas as well as to assess the biological significance of MYO1C as a tumor suppressor in vitro. We found a significant correlation between the tumor stage and lowered expression of MYO1C in endometrial carcinoma samples. In cell transfection experiments, we found a negative correlation between MYO1C expression and cell proliferation, and MYO1C silencing resulted in diminished cell migration and adhesion. Cells expressing excess of MYO1C had low basal level of phosphorylated protein kinase B (PKB, a.k.a. AKT) and cells with knocked down MYO1C expression showed a quicker phosphorylated AKT (pAKT) response in reaction to serum stimulation. Taken together the present study gives further evidence for tumor suppressor activity of MYO1C and suggests MYO1C mediates its tumor suppressor function through inhibition of PI3K pathway and its involvement in loss of contact inhibition

Long-term incidence of endometrial cancer after endometrial resection and ablation : A population based Swedish gynecologic cancer group (SweGCG) study

Introduction Minimally invasive methods to reduce menorrhagia were introduced in the 1980s and 1990s. Transcervical endometrial resection (TCRE) and endometrial ablation (EA) are two of the most frequently used methods. As none of them can guarantee a complete removal of the endometrium, there are concerns that the remaining endometrium may develop to endometrial cancer (EC) later in life. The primary aim was to analyze the long-term incidence of EC after TCRE and EA in a nationwide population. The secondary aim was to assess the two treatment modalities separately. Material and Methods The Swedish National Patient Registry and National Quality Registry for Gynecological Surgery were used for identification of women who had TCRE or EA performed between 1997-2017. The cohort was followed from the first TCRE or EA until hysterectomy, diagnosis of EC, or death. Follow-up data were retrieved from the National Cancer Registry and the National Death Registry. Expected incidence for EC in Swedish women was calculated using Swedish data retrieved from the NORDCAN project after having taken into account differences of age and follow-up time. Cumulative incidence of EC after TCRE and EA, was calculated. A standardized incidence ratio was calculated based on the expected and observed incidence, stratified by age and year of diagnosis. Results In total, 17 296 women (mean age 45.1 years) underwent TCRE (n = 8626) or EA (n = 8670). Excluded were 3121 who had a hysterectomy for benign causes during follow up. During a median follow-up time of 7.1 years (interquartile range 3.1-13.3 years) the numbers of EC were 25 (0.3%) after TCRE and 2 (0.02%) after EA, respectively. The observed incidence was significantly lower than expected (population-based estimate) after EA but not after TCRE, giving a standardized incidence ratio of 0.13 (95% confidence interval [CI] 0.03-0.53) after EA and 1.27 (95% CI 0.86-1.88) after TCRE. Median times to EC were 3.0 and 8.3 years after TCRE and EA, respectively. Conclusions There was a significant reduction of EC after EA, suggesting a protective effect, whereas endometrial resection showed an incidence within the expected rate