Endometrial carcinoma; can biomarkers aid in the prediction of aggressive disease? A study with focus on preoperative tumour markers

Background: Although endometrial cancer in general has a good prognosis, 15-20% recurs. Surgery is the main treatment with lymph node sampling increasingly advocated as compulsory for adequate staging. In metastatic disease, there is limited effect from systemic therapies including chemotherapy or antihormonal treatment. No other targeted therapies are yet available in a routine clinical setting. To improve and individualise therapy for this patient group, improved tools for identification of highrisk patients, to tailor surgery in particular, and identification of targetable molecular alterations for development of more effective systemic therapies, are urgently needed. Several biomarkers including hormone receptor status, TP53 and Stathmin expression have been found to be of prognostic importance in retrospective studies. The PI3Kinase signalling pathway is over-expressed in aggressive endometrial carcinomas and PI3kinase inhibitors are entering clinical trials for treatment of metastatic disease. Main objectives: The main objective was to evaluate if biomarkers, particularly examined in a preoperative setting, could identify aggressive endometrial carcinomas, especially those with lymph node metastasis. An additional aim was to evaluate immunohistochemical markers potentially applicable as markers for response to antihormonal therapy and PI3Kinase-inhibitors. Also, we wanted to study changes in treatment strategy in relation to survival for endometrial carcinoma patients during a 30-year period in a population based setting. Materials and methods: To evaluate potential biomarkers related to PI3Kinase signalling, a population based cohort was investigated for immunohistochemical expression of AKT, Phospho-AKT and Stathmin in hysterectomy specimens. These markers were also related to level of PI3Kinase signalling based on mRNA expression score in a prospective series of 76 patients (Paper I). The prospective international multicenter study MoMaTEC; Molecular Markers in Treatment of Endometrial Cancer, recruited clinical data, tissue and blood samples from 1192 endometrial cancer patients treated at 10 different centres during 2001-2010. Preoperative curettage specimens and blood samples have been investigated for expression of a panel of potential biomarkers; Stathmin, Estrogen Receptor (ER), Progesterone Receptor (PR), TP53 and GDF-15 (Paper II, III and IV). Changes in clinicopathological features and treatment were related to survival in a population based cohort of endometrial cancer patients from Hordaland County, Norway over the last 30 years (Paper V). Results: Stathmin overexpression in hysterectomy specimens was strongly correlated with characteristics for aggressive disease and poor survival. PI3Kinase signalling activation was significantly associated with overexpression of Stathmin. Neither AKT nor phospho-AKT expression showed any significant correlations with clinicopathological factors nor PI3Kinase signalling levels (Paper I). Overexpression of Stathmin validated to be correlated with aggressive disease in the large prospective multicentre setting (Paper II). Stathmin staining in curettage specimens was an independent predictor of lymph node metastases and overexpression of Stathmin estimated in curettage and hysterectomy specimens were both independent predictors of poor survival. High preoperative plasma GDF-15 level was significantly associated with aggressive disease. Adjusting for age and histological risk factors detected in preoperative biopsies, plasma GDF-15 independently predicted risk of lymph node metastasis. GDF-15 level also independently predicted poor prognosis (Paper III). Pathologic expression of ER, PR and TP53 in preoperative curettage specimen correlated significantly with high age at diagnosis, high FIGO stage, nonendometrioid histology, high grade, metastatic nodes and poor prognosis in a large prospective multicenter setting. Double negative ER-PR independently predicted lymph node metastasis and poor survival. Even for the most favourable group of lymph node negative endometrioid tumours, ER-PR negative status influenced survival independent of tumour grade (Paper IV). The number of endometrial cancer patients from Hordaland County increased significantly from 1981 through 2010 (Paper V), with a simultaneous increase in body mass index and decrease in disease stage at diagnosis. Routinely performed pelvic lymph node sampling increased, adjuvant radiotherapy was reduced and survival increased significantly during the same period. Conclusions: Stathmin immunohistochemical staining is superior to AKT and phospho-AKT staining in detecting PI3Kinase signalling activation and endometrial carcinomas with poor outcome (Paper I). Stathmin staining has been validated to identify endometrial carcinomas with aggressive clinic-pathological features in a large multicenter setting. Immunohistochemical staining for Stathmin in preoperative biopsies (curettage) independently predicts lymph node metastasis and poor survival (Paper II). Plasma GDF-15 has been documented as elevated in two independent patient cohorts of endometrial cancer patients compared to controls. High preoperative GDF-15 plasma level was significantly correlated with aggressive subtypes and a significant and independent predictor for lymph node metastasis and poor survival (Paper III). Double negative hormone receptor status (ER and PR negative) in preoperative endometrial cancer curettage has been validated to identify patients with poor prognosis in a prospective multicenter setting. ER-PR status independently predicts lymph node metastasis (Paper IV). During the 30-year period 1981 through 2010, a reduction in adjuvant radiotherapy and increase in routine pelvic lymphadenectomy and curative surgery with advanced disease, are associated with improved disease-specific- and overall survival in a population-based study of endometrial carcinoma patients with steadily increasing body mass index (Paper V)

Handheld transabdominal ultrasound, after limited training, may confirm first trimester viable intrauterine pregnancy: a prospective cohort study

Objectives Handheld point-of-care abdominal ultrasound (POCUS) may be used by primary care physicians while vaginal ultrasound is limited to use in specialist care. We aimed to compare abdominal handheld ultrasound to vaginal ultrasound in determining first trimester viable intrauterine pregnancy and estimate gestational length. Design Prospective cohort study. Setting Gynaecologic outpatient clinic; women referred from GPs during early pregnancy. Handheld ultrasound using VscanExtend® was performed by fourth-year medical students with limited training. Transvaginal ultrasound using high-end devices was performed by ordinary hospital staff. Subjects Women in the first trimester of pregnancy referred for termination of pregnancy or with symptoms of early pregnancy complications. Main outcome measures Rate of confirming vital intrauterine pregnancy (visualizing foetal heart beats) and measurement of crown-rump length (CRL) using handheld abdominal versus vaginal ultrasound. Results In all 100 women were included; 86 confirmed as viable intrauterine pregnancies and 14 pathological pregnancies (miscarriages/extrauterine pregnancies). Handheld abdominal ultrasound detected fetal heartbeats in 63/86 (73% sensitivity) of healthy pregnancies and confirmed lack of fetal heartbeats in all pathological pregnancies, total positive predictive value (PPV) 100% and total negative predictive value (NPV) 38%. From gestational week 7, handheld abdominal ultrasound confirmed vitality in 51/54 patients: PPV 100% and NPV 79%. CRL (n = 62) was median 1 mm shorter (95% confidence interval 1–2 mm) measured by handheld abdominal versus vaginal ultrasound. Conclusion Handheld ultrasound has an excellent prediction confirming viable intrauterine pregnancy from gestational week 7. Validation studies are needed to confirm whether the method is suitable in primary care assessing early pregnancy complications.publishedVersio

Antiemetic treatment of hyperemesis gravidarum in 1,064 Norwegian women and the impact of European warning on metoclopramide: a retrospective cohort study 2002–2019

Background: Women suffering from severe nausea and vomiting during pregnancy, hyperemesis gravidarum, have poor quality of life and increased risk of potentially fatal maternal and fetal complications. There is increasing and reassuring knowledge about safety of antiemetics in pregnancy. In 2013, the European Medical Agency (EMA) issued a warning on metoclopramide limiting treatment to maximum five days. Metoclopramide was the most used antiemetic in pregnancy at the time the warning was implemented in the Norwegian hyperemesis guidelines (2014). We aimed at describing changes in the treatment of hyperemesis over time, including changes associated with the EMA warning. Methods: Retrospective chart review of all women hospitalized for hyperemesis gravidarum with metabolic disturbances between 01/Jan/2002 and 31/Dec/2019 at a university hospital serving nearly 10% of the pregnant population in Norway. Time-series analysis described changes over time and interrupted time series analysis quantified changes in treatment and clinical outcomes related to the EMA warning. Results: In total, 1,064 women (1.2% of the birthing population) were included. The use of meclizine, prochlorperazine, and ondansetron increased during 2002–2019. This led to a yearly increase in the percentage of women using any antiemetic of 1.5% (95%CI 0.6; 2.4) pre-hospital, 0.6% (95%CI 0.2; 1.1) during hospitalization, and 2.6% (95%CI 1.3; 3.8) at discharge. Overall, only 50% of the women received antiemetics pre-hospital. Following the EMA warning, prehospital use of metoclopramide dropped by 30% (95%CI 25; 36), while use of any antiemetic pre-hospital dropped by 20% (95%CI 5.7; 34). In timely association, we observed a decrease in gestational age (-3.8 days, 98.75%CI 0.6; 7.1) at first admission, as well as indication of increased rate of termination of pregnancy with an absolute increase of 4.8% (98.75%CI 0.9; 8.7) in 2014. Conclusion: During 2002–2019, the overall use of antiemetics in treatment of hyperemesis increased. The EMA-warning on metoclopramide in 2013 temporarily limited pre-hospital antiemetic provision associated with hospitalization at lower gestational length and indication of an increase in termination of pregnancy.publishedVersio

Endometrial ablation; less is more? Historical cohort study comparing long-term outcomes from two time periods and two treatment modalities for 854 women

Background: Abnormal uterine bleeding needs surgical treatment if medical therapy fails. After introduction of non-hysteroscopic endometrial ablation as alternative to hysteroscopic endometrial resection, we aimed to compare short and long-term outcomes for women treated with these two minimally-invasive procedures. A secondary goal was comparing the present cohort to a previous cohort of women treated with hysteroscopic resection only. Materials and methods: Historical cohort study of women treated for abnormal uterine bleeding with hysteroscopic resection or endometrial ablation at Haukeland University Hospital during 2006–2014. Similar patient file and patient-reported outcome data were collected from 386 hysteroscopic resections in a previous cohort (1992–1998). Categorical variables were compared by Chi-square or Fisher´s Exact-test, linear variables by Mann-Whitney U-test and time to hysterectomy by the Kaplan-Meier method. Results: During 2006–2014, 772 women were treated with endometrial resection or ablation, 468 women (61%) consented to study-inclusion; 333 women (71%) were treated with hysteroscopic resection and 135 (29%) with endometrial ablation. Preoperative characteristics were significantly different for women treated with hysteroscopic resection compared to endometrial ablation in the 2006-2014-cohort and between the two time-cohorts regarding menopausal, sterilization and myoma status (p≤0.036). The endometrial ablation group had significantly shorter operation time, median 13 minutes (95% Confidence Interval (CI) 12–14) and a lower complication rate (2%) versus operation time, median 25 minutes (95% CI 23–26) and complication rate (13%) in the hysteroscopy group, all p ≤0.001. The patient-reported rate of satisfaction with treatment was equivalent in both groups (85%, p = 0.955). The endometrial ablation group had lower hysterectomy rate (8% vs 16%, p = 0.024). Patient-reported satisfaction rate was higher (85%) in the 2006-2014-cohort compared with the 1992-1998-cohort (73%), p<0.001. Conclusions: Endometrial ablation has similar patient satisfaction rate, but shorter operation time and lower complication rate and may be a good alternative to hysteroscopic resection for treatment of abnormal uterine bleeding.publishedVersio

Preoperative 18F-FDG PET/CT tumor markers outperform MRI-based markers for the prediction of lymph node metastases in primary endometrial cancer

Objectives To compare the diagnostic accuracy of preoperative 18F-FDG PET/CT and MRI tumor markers for prediction of lymph node metastases (LNM) and aggressive disease in endometrial cancer (EC). Methods Preoperative whole-body 18F-FDG PET/CT and pelvic MRI were performed in 215 consecutive patients with histologically confirmed EC. PET/CT-based tumor standardized uptake value (SUVmax and SUVmean), metabolic tumor volume (MTV), and PET-positive lymph nodes (LNs) (SUVmax > 2.5) were analyzed together with the MRI-based tumor volume (VMRI), mean apparent diffusion coefficient (ADCmean), and MRI-positive LN (maximum short-axis diameter ≥ 10 mm). Imaging parameters were explored in relation to surgicopathological stage and tumor grade. Receiver operating characteristic (ROC) curves were generated yielding optimal cutoff values for imaging parameters, and regression analyses were used to assess their diagnostic performance for prediction of LNM and progression-free survival. Results For prediction of LNM, MTV yielded the largest area under the ROC curve (AUC) (AUC = 0.80), whereas VMRI had lower AUC (AUC = 0.72) (p = 0.03). Furthermore, MTV > 27 ml yielded significantly higher specificity (74%, p  10 ml (58%, 62%, and 9.7, respectively). MTV > 27 ml also tended to yield higher sensitivity than PET-positive LN (81% vs 50%, p = 0.13). Both VMRI > 10 ml and MTV > 27 ml were significantly associated with reduced progression-free survival. Conclusions Tumor markers from 18F-FDG PET/CT outperform MRI markers for the prediction of LNM. MTV > 27 ml yields a high diagnostic performance for predicting aggressive disease and represents a promising supplement to conventional PET/CT reading in EC.publishedVersio

An mri-based radiomic prognostic index predicts poor outcome and specific genetic alterations in endometrial cancer

Integrative tumor characterization linking radiomic profiles to corresponding gene expression profiles has the potential to identify specific genetic alterations based on non-invasive radiomic profiling in cancer. The aim of this study was to develop and validate a radiomic prognostic index (RPI) based on preoperative magnetic resonance imaging (MRI) and assess possible associations between the RPI and gene expression profiles in endometrial cancer patients. Tumor texture features were extracted from preoperative 2D MRI in 177 endometrial cancer patients. The RPI was developed using least absolute shrinkage and selection operator (LASSO) Cox regression in a study cohort (n = 95) and validated in an MRI validation cohort (n = 82). Transcriptional alterations associated with the RPI were investigated in the study cohort. Potential prognostic markers were further explored for validation in an mRNA validation cohort (n = 161). The RPI included four tumor texture features, and a high RPI was significantly associated with poor disease-specific survival in both the study cohort (p < 0.001) and the MRI validation cohort (p = 0.030). The association between RPI and gene expression profiles revealed 46 significantly differentially expressed genes in patients with a high RPI versus a low RPI (p < 0.001). The most differentially expressed genes, COMP and DMBT1, were significantly associated with disease-specific survival in both the study cohort and the mRNA validation cohort. In conclusion, a high RPI score predicts poor outcome and is associated with specific gene expression profiles in endometrial cancer patients. The promising link between radiomic tumor profiles and molecular alterations may aid in developing refined prognostication and targeted treatment strategies in endometrial cancer.publishedVersio

L1CAM expression in uterine carcinosarcoma is limited to the epithelial component and may be involved in epithelial–mesenchymal transition

Uterine carcinosarcoma (UCS) has been proposed as a model for epithelial–mesenchymal transition (EMT), a process characterized by a functional change facilitating migration and metastasis in many types of cancer. L1CAMis an adhesion molecule that has been involved in EMT as a marker for mesenchymal phenotype.We examined expression of L1CAM in UCS in a cohort of 90 cases from four different centers. Slides were immunohistochemically stained for L1CAMand scored in four categories (0%, 50%). A score of more than 10% was considered positive for L1CAM. The median age at presentation was 68.6 years, and half of the patients (53.3%) presented with FIGO stage 1 disease. Membranous L1CAM expression was positive in the epithelial component in 65.4% of cases. Remarkably, expression was negative in the mesenchymal component. In cases where both components were intermingled, expression limited to the epithelial component was confirmed by a double stain for L1CAMand keratin. Expression of L1CAMdid not relate to overall or disease-free survival. Our findings suggest L1CAMis either not a marker for the mesenchymal phenotype in EMT, or UCS is not a good model for EMT

MRI-assessed tumor-free distance to serosa predicts deep myometrial invasion and poor outcome in endometrial cancer

Objectives To explore the diagnostic accuracy of preoperative magnetic resonance imaging (MRI)-derived tumor measurements for the prediction of histopathological deep (≥ 50%) myometrial invasion (pDMI) and prognostication in endometrial cancer (EC). Methods Preoperative pelvic MRI of 357 included patients with histologically confirmed EC were read independently by three radiologists blinded to clinical information. The radiologists recorded imaging findings (T1 post-contrast sequence) suggesting deep (≥ 50%) myometrial invasion (iDMI) and measured anteroposterior tumor diameter (APD), depth of myometrial tumor invasion (DOI) and tumor-free distance to serosa (iTFD). Receiver operating characteristic (ROC) curves for the prediction of pDMI were plotted for the different MRI measurements. The predictive and prognostic value of the MRI measurements was analyzed using logistic regression and Cox proportional hazard model. Results iTFD yielded highest area under the ROC curve (AUC) for the prediction of pDMI with an AUC of 0.82, whereas DOI, APD and iDMI yielded AUCs of 0.74, 0.81 and 0.74, respectively. Multivariate analysis for predicting pDMI yielded highest predictive value of iTFD <  6 mm with OR of 5.8 (p < 0.001) and lower figures for DOI ≥ 5 mm (OR = 2.8, p = 0.01), APD ≥ 17 mm (OR = 2.8, p < 0.001) and iDMI (OR = 1.1, p = 0.82). Patients with iTFD < 6 mm also had significantly reduced progression-free survival with hazard ratio of 2.4 (p < 0.001). Conclusion For predicting pDMI, iTFD yielded best diagnostic performance and iTFD < 6 mm outperformed other cutoff-based imaging markers and conventional subjective assessment of deep myometrial invasion (iDMI) for diagnosing pDMI. Thus, iTFD at MRI represents a promising preoperative imaging biomarker that may aid in predicting pDMI and high-risk disease in EC.publishedVersio

Interobserver agreement and prognostic impact for MRI–based 2018 FIGO staging parameters in uterine cervical cancer

Objectives To evaluate the interobserver agreement for MRI–based 2018 International Federation of Gynecology and Obstetrics (FIGO) staging parameters in patients with cervical cancer and assess the prognostic value of these MRI parameters in relation to other clinicopathological markers. Methods This retrospective study included 416 women with histologically confirmed cervical cancer who underwent pretreatment pelvic MRI from May 2002 to December 2017. Three radiologists independently recorded MRI–derived staging parameters incorporated in the 2018 FIGO staging system. Kappa coefficients (κ) for interobserver agreement were calculated. The predictive and prognostic values of the MRI parameters were explored using ROC analyses and Kaplan–Meier with log-rank tests, and analyzed in relation to clinicopathological patient characteristics. Results Overall agreement was substantial for the staging parameters: tumor size > 2 cm (κ = 0.80), tumor size > 4 cm (κ = 0.76), tumor size categories (≤ 2 cm; > 2 and ≤ 4 cm; > 4 cm) (κ = 0.78), parametrial invasion (κ = 0.63), vaginal invasion (κ = 0.61), and enlarged lymph nodes (κ = 0.63). Higher MRI–derived tumor size category (≤ 2 cm; > 2 and ≤ 4 cm; > 4 cm) was associated with a stepwise reduction in survival (p ≤ 0.001 for all). Tumor size > 4 cm and parametrial invasion at MRI were associated with aggressive clinicopathological features, and the incorporation of these MRI–based staging parameters improved risk stratification when compared to corresponding clinical assessments alone. Conclusion The interobserver agreement for central MRI–derived 2018 FIGO staging parameters was substantial. MRI improved the identification of patients with aggressive clinicopathological features and poor survival, demonstrating the potential impact of MRI enabling better prognostication and treatment tailoring in cervical cancer.publishedVersio

What MRI-based tumor size measurement is best for predicting long-term survival in uterine cervical cancer?

Background: Tumor size assessment by MRI is central for staging uterine cervical cancer. However, the optimal role of MRI-derived tumor measurements for prognostication is still unclear. Material and methods: This retrospective cohort study included 416 women (median age: 43 years) diagnosed with cervical cancer during 2002–2017 who underwent pretreatment pelvic MRI. The MRIs were independently read by three radiologists, measuring maximum tumor diameters in three orthogonal planes and maximum diameter irrespective of plane (MAXimaging). Inter-reader agreement for tumor size measurements was assessed by intraclass correlation coefficients (ICCs). Size was analyzed in relation to age, International Federation of Gynecology and Obstetrics (FIGO) (2018) stage, histopathological markers, and disease-specific survival using Kaplan–Meier-, Cox regression-, and time-dependent receiver operating characteristics (tdROC) analyses. Results: All MRI tumor size variables (cm) yielded high areas under the tdROC curves (AUCs) for predicting survival (AUC 0.81–0.84) at 5 years after diagnosis and predicted outcome (hazard ratios [HRs] of 1.42–1.76, p < 0.001 for all). Only MAXimaging independently predicted survival (HR = 1.51, p = 0.03) in the model including all size variables. The optimal cutoff for maximum tumor diameter (≥ 4.0 cm) yielded sensitivity (specificity) of 83% (73%) for predicting disease-specific death after 5 years. Inter-reader agreement for MRI-based primary tumor size measurements was excellent, with ICCs of 0.83–0.85. Conclusion: Among all MRI-derived tumor size measurements, MAXimaging was the only independent predictor of survival. MAXimaging ≥ 4.0 cm represents the optimal cutoff for predicting long-term disease-specific survival in cervical cancer. Inter-reader agreement for MRI-based tumor size measurements was excellent.publishedVersio