Hum. Reprod. Advance Access originally published online on April 21, 2007
Human Reproduction 2007 22(7):1953-1958; doi:10.1093/humrep/dem088
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Fertility-preserving treatment with progestin, and pathological criteria to predict responses, in young women with endometrial cancer
1 Department of Obstetrics and Gynecology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku, Tokyo 160-0023, Japan 2 Department of Reproductive Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuoku, Chiba 260-8677, Japan 3 Department of Molecular Pathology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuoku, Chiba 260-8677, Japan
4 Correspondence address. Tel: +81-3-3342-5111; Fax: +81-3-3348-5918; E-mail: K3126oji{at}aol.com
 |
Abstract |
|---|
 Top Abstract IntroductionMETHODSResultsDiscussionAcknowledgementReferences |
|---|
BACKGROUND: There are therapeutic dilemmas regarding conservative management of endometrial cancer in young women.
METHODS: We planned a prospective study to conservatively treat women aged under 40 years with clinical stage 1A, grade 1 endometrioid adenocarcinoma from 1999 to 2005. There were nine women (aged 28–40) who fulfilled the criteria, and medroxyprogesterone acetate (400 mg/day) was continued for 6 months. Curettage materials were pathologically evaluated according to our criteria including partial response (PR) (a small amount of cancer tissue with remarkable hormonal effects or atypical hyperplasia). To predict complete response (CR) to progestin, immunohistochemical staining for insulin-like growth factor type 1 receptor, phosphatase and tensin homolog deleted on chromosome ten, progesterone receptor (PgR), estrogen receptor and Ki67 were assessed.
RESULTS: Seven (78%) and two cases presented complete and PRs, respectively. Two patients developed recurrent disease 10 and 22 months after the last dilatation and curettage, and both had synchronous ovarian cancer. However, all nine patients were alive and disease-free for a mean of 39 months. Of eight married patients, four (50%) conceived and three delivered full-term singletons. CR was related to positive expression of PgR (P = 0.008).
CONCLUSIONS: Patients with an initial PR can obtain CR after further treatment, and the PgR may be useful in predicting CR to fertility-preserving treatment in young women with endometrial cancer.
Key words: endometrial cancer/young women/fertility/progestin treament/response prediction
|
Introduction |
|---|
|
TopAbstractIntroductionMETHODSResultsDiscussionAcknowledgementReferences |
|---|
Endometrial cancer is the most common gynecological malignancy diagnosed in women, and is typically a disease of postmenopausal women. However, 20–25% of cases are diagnosed before menopause and
5% of women with this disease are diagnosed before the age of 40 years, during their childbearing years (Crissman et al., 1981
). The occurrence of the disease at a young age can be related to prolonged unopposed estrogen exposure, and the women usually suffer from hormone-related disorders such as obesity, nulliparity and polycystic ovary syndrome (Sherman, 2001).
The standard therapy for endometrial cancer consists of a staging laparotomy with total abdominal hysterectomy and bilateral salpingo-oophorectomy. However, because of the particularly good prognosis for young women with early stage endometrial cancer, the limited myometrial invasion and high-tumor differentiation (Yamazawa et al., 2000), and because most of the women also suffer from subfertility, many attempts have been made to treat such cases conservatively with hormonal therapy rather than with surgery (Kaku et al., 2001; Wang et al., 2002; Gotlieb et al., 2003; Ramirez et al., 2004). Despite this, all studies except one prospective study (Wang et al., 2002) have been based on retrospective case reports, and many questions still remain unanswered regarding the optimal treatment of these patients. Such questions are about (i) the duration and dosage of progestin, (ii) the appropriate pathological evaluation during treatment, (iii) candidates for hysterectomy and (iv) the significance of the presence of synchronous ovarian tumor.
A reliable method of identification of patients who can respond to treatment with progestin would provide a better basis for individualized treatment, improved planning of the conservative treatment and potentially reduced morbidity of excessive treatment with progestin. We therefore prospectively planned a study to conservatively treat young women with endometrial cancer with progestin. The main purpose of our study was to evaluate our pathological criteria for determining response to progestin and to predict complete response (CR) to progestin by investigating curettage materials for the expression pattern of five markers: insulin-like growth factor type 1 receptor (IGF1R), phosphatase and tensin homolog deleted on chromosome ten (PTEN), progesterone receptor (PgR), estrogen receptor (ER) and Ki67 nuclear antigen.
|
METHODS |
|---|
|
TopAbstractIntroductionMETHODSResultsDiscussionAcknowledgementReferences |
|---|
Patients
We previously reported that young women treated for endometrioid adenocarcinoma (EA) (between 1989 and 1998) had better outcomes than older patients due to a significantly higher proportion of early stage disease and less myometrial invasion (Yamazawa et al., 2000
). We then planned a prospective study and have conservatively treated young women with endometrial cancer using progestin at the Department of Obstetrics and Gynecology, Chiba University Hospital from January 1999 to December 2005. Relevant clinical and pathological information was obtained from their inpatient, outpatient and oncology records (Table 1).
|
Inclusion criteria were (i) age younger than 40 years, (ii) nulliparous, (iii) confirmed EA of grade 1 differentiation, (iv) absence of myometrial invasion and extrauterine spread by imaging study and (v) possessing a strong desire to preserve fertility. Each patient was extensively counselled regarding the possibility of recurrence or progression.
We have used magnetic resonance imaging and computed tomography to determine the absence of myometrial invasion, tumor spread and associated ovarian cancers, for the pretreatment evaluation. We have also used serum cancer antigen, CA125 levels because we had accumulated data regarding the usefulness of serum CA125 measurements in determining evidence of extrauterine disease (Yamazawa et al., 2005).
Treatment
After approval from the Hospital Ethical Committees and informed patient consent, medroxyprogesterone acetate (MPA, 400 mg/day) was continued for at least 6 months under the following protocol.
Each patient received dilatation and curettage (D&C) three times: before MPA treatment and 3 and 6 months after the beginning of the treatment. During the treatment, all patients were followed up monthly by endometrial cytology and transvaginal ultrasonography. After the documentation of pathological remission, all patients were followed up tri-monthly. If relapse was pathologically noted, each patient underwent image studies to evaluate possible progression and was extensively counseled about receiving surgery or additional MPA treatment. If relapse was not noted, all treatment modalities for endometrial cancer were censored and fertility treatment was initiated.
Pathology
Using the criteria of Kurman and Norris (1982), two pathologists (H.I. and K.Y.) reviewed the histologic slides and independently confirmed the diagnosis of endometrial carcinoma in all patients (Fig. 1). We also attempted to minimize the diagnostic risk by making the diagnosis of cancer and grade based on D&C rather than on endometrial sampling during the treatment, and hormonal response was assessed at every pathological evaluation by the specimens obtained.
|
Although there are no conclusive criteria to pathologically assess the response by progestin, only the complete disappearance of all cancerous tissue is usually regarded as CR. If a small amount of tissue that structurally meets the criteria of EA or atypical hyperplasia (AH) remains in the specimen, regardless of hormonal effects on the tissue, the case is regarded as a non-responder (NR). In the present study, we regarded the case as a NR if there was some amount of cancerous tissue that was not degenerative and showed only partial hormonal effect. We also added a partial response (PR) category. When there was a small amount of degenerative cancer tissue with remarkable hormonal effects, the case was regarded as a partial responder. Improvement from EA to AH was also regarded as PR. Examples of hormonal effects on cancer tissue were as follows: necrotic and eosinophilic changes of cancer tissue (Fig. 2), remarkable decidual change of stroma (Fig. 2) and the presence of multiple stromal nodule (Fig. 3).
|
|
Immunohistochemistry
A representative paraffin-embedded tissue block was identified from each of the nine patients, and 4-µm unstained sections were prepared for immunohistochemical staining. Tissue sections were deparaffinized in xylene, then hydrated through a descending series of ethanol and washed in distilled water. Epitope retrieval by microwave was performed for 5 min three times in 0.01 M citrate buffer. An automated system (DAKO Autostainer, Copenhagen, Denmark) was used. Briefly, the sections were washed in phosphate-buffered saline and endogenous peroxidase activity was quenched by incubating in peroxidase blocking solution for 7 min. Then, the sections were incubated for 60 min with each of the mouse monoclonal anti-human antibodies (Table 2) at room temperature in a moist chamber. Antigen–antibody binding was demonstrated using the HRP enzyme labeled polymer conjugated to mouse secondary antibodies by the dextran-polymer technique (Envision+ kit/HRP, DAKO). Peroxidase activity was developed by adding diaminobenzidine as the chromogen for 5 min, resulting in a brown reaction product. The sections were counterstained with Mayer's hematoxylin for 2 min and mounted. The percentage of the cancer area stained in high-power fields was examined. Percentage of positive cells examined was scored as negative (<10%), weakly positive (11–50%), positive (51–80%) and strongly positive (>80%). Ki67 was evaluated in 500 neoplastic cells under the same observation conditions, and only strong nuclear immunostaining was regarded as positive; weak nuclear or cytoplasmic stainings were excluded.
|
Statistical analyses
Immunohistochemical stainings were stratified into two groups on the basis stainings (negative and weakly positive versus positive and strongly positive) and were analysed statistically as categorical covariates. To identify significant differences between CR and NR cases to progestins for each immunohistochemistry, Welch's t-test were performed after equality of variances was tested by using the F-test. SPSS statistical software (version 11.5, SPSS Inc., Chicago, Illinois, USA) was used. A P-value of <0.05 was considered significant.
|
Results |
|---|
|
TopAbstractIntroductionMETHODSResultsDiscussionAcknowledgementReferences |
|---|
Patient characteristics
We encountered 145 endometrial cancers during the study period, and there were 15 (10%) patients aged under 40. Out of the 15 patients, 9 patients with grade 1 EA received progestins as the primary treatment modality for their cancer. The clinical characteristics of the nine patients are presented in Table 1. Age at diagnosis ranged from 28 to 40 years, with a mean age of 36 years. In three women, the diagnosis was made during infertility workup, and workup for irregular bleeding led to the diagnosis of the other six patients. None of the patients had hypertension, diabetes or a family history consistent with hereditary non-polyposis colon cancer. CA 125 levels were all within the normal range (8.2–21 U/ml), and no extension of the disease outside the endometrium was indicated by imaging studies.
Treatment response after 6 months treatment
All patients received progestins for at least 6 months. According to our pathological criteria, three and five patients presented CR and PR already at the time of second D&C (3 months after the beginning of treatment), respectively. At the third D&C (6 months after the beginning of treatment), seven presented CR; however, two patients (Cases 6 and 9) still had only PR. As a result, 78 and 22% presented CR and PR, respectively, and the overall pathological response rate was 100% after MPA treatment for 6 months.
Case 6 presented PR (focal G1 EA with marked hormonal effects) at the third D&C, and therefore, she received a second course of treatment with a higher dose of MPA (600 mg/day for 3 months). Although she still had a focal EA after a total of 9 months of MPA treatment, she refused a hysterectomy and strongly desired to preserve her fertility. We then gave her four cycles of combination chemotherapy (taxol and carboplatin) and achieved CR at the fourth D&C. Case 9 still had AH at the third D&C, and received additional MPA treatment (400 mg/day for 3 months) and also achieved CR.
Recurrence
Eight of nine women with EA all finally achieved CR by MPA treatment (the exception being Case 6 who received chemotherapy), and six patients showed no evidence of recurrence for a mean of 36 months (range: from 24 to 69 months) after the treatment. The other two cases developed recurrent disease 10 and 22 months after the last D&C. Thus, the recurrence rate was 25% in our study.
These last two patients underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy and pelvic lymph node sampling. The tumors were grade 1 EA, which was the same as the pretreatment evaluation, and minimal myometrial invasion was noted in both cases. These two patients surprisingly had right ovarian cancer (grade 1 EA), which were under 1 cm in size and were not detected on preoperative imaging evaluation. Although they were diagnosed to have double cancer (FIGO stage 1B endometrial cancer and FIGO stage 1A ovarian cancer) on the basis of pathological findings, adjuvant chemotherapy in the form of three cycles of taxol and carboplatin was given. All nine patients are alive without recurrent disease at the time of last contact, which was at a mean of 39 months (range: from 24 to 69 months).
Pregnancy
Fertility treatment was initiated after a 3-month disease-free interval; normal endometrial cytology, normal CA125 level and no evidence of disease by image studies were achieved. Of eight married patients, four conceived (50%). Cases 4, 8 and 9 conceived by IVF-ET, and Case 5 by AIH and Metoformin (Evans et al., 2005). Three women (Cases 5, 8 and 9) delivered full-term singletons by Cesarean section. The other one pregnancy (Case 4) resulted in a spontaneous abortion at 8 weeks of gestation.
Immunohistochemistry
Table 3 shows the results of expression analysis in tumor tissue from the study group patients. The CR frequency differed between PTEN positive cases and negative cases, although there was no statistical significance. In contrast, PgR positivity was significantly related to the CR rate (P = 0.008); 100% CR of PgR positive cases versus 50% CR of PgR negative cases. The frequency of CR was unrelated to staining for the other three markers.
|
|
Discussion |
|---|
|
TopAbstractIntroductionMETHODSResultsDiscussionAcknowledgementReferences |
|---|
Standard therapy for endometrial cancer is total abdominal hysterectomy with bilateral salpingo-oophorectomy. However, young women with endometrial cancer generally have an excellent prognoses (Crissman et al., 1981
; Yamazawa et al., 2000); therefore, there is a therapeutic dilemma regarding conservative management in young women who wish to preserve their fertility. To date, various studies have been published and progestin therapy has been proven effective for well-differentiated endometrial cancer (Kaku et al., 2001; Gotlieb et al., 2003; Ramirez et al., 2004). On the basis of results in these reports, the Japan Society of Gynecologic Oncology Committee (2006) provided guidelines for fertility-preserving treatment in Japanese women with endometrial cancer. However, most of the studies were retrospective, the exception being one prospective study by Wang et al. (2002). To the best of our knowledge, our study is only the second prospective one and is the first to employ the pathological ‘partial’ response and to investigate several immunohistochemical markers in evaluating the response to progestins in young women with endometrial cancer.
Despite the achievement of previous studies, many questions still remain unanswered regarding the optimal treatment of these patients. Regarding the dose of progestin, many clinicians assume that high-dose MPA (600 mg/day) is appropriate. However, a Gynecologic Oncology Group study showed that low-dose MPA (200 mg/day) was more effective than high-dose treatment even for advanced or recurrent endometrial carcinomas (Thigpen et al., 1999). On the basis of this study, we considered that lower MPA doses (400 mg/day) may be sufficient for conservative therapy for grade 1 EA and that they have the advantage of reducing the risk of vascular events. According to our protocol, eight of nine EAs showed PR or more after 3 months of MPA treatment, and all patients presented CR or PR after 6 months of the treatment. Furthermore, even in the two women with AH who received smaller doses (200 mg/day), we detected remarkable hormonal effects in tumor tissue after 3 months of treatment. They had no residual disease after 6 months of treatment and did not require a further treatment to achieve resolution (data not shown). Thus, a smaller dose of MPA may be sufficient for conservative treatments.
There is also currently no standard recommendation for the appropriate timing to pathologically evaluate response by progestins. The morphologic appearance of endometrial cancer cells following progestin therapy becomes apparent as early as 10 weeks after the start of treatment (Saegusa et al., 1998). Reifenstein et al. (1974) noted that an initial period of exposure of at least 12 weeks should elapse before response is evaluated. Given these results, we thought that a D&C, which may have therapeutic as well as diagnostic purposes, after 3 months treatment by MPA should be the standard method for evaluating the initial response.
Another major difficulty is the interpretation of pathological specimens obtained during the treatment course. Most previous reports have not explained strict pathological criteria to assess response by progestin and considered only the absence of EA and AH tissue as a CR regardless of hormonal effects. Therefore, all other patients were regarded as treatment failures and generally underwent a hysterectomy. However, we observed that four partial responders who still had a small amount of endometrial cancer tissue or AH after 3 months of MPA obtained CR after an additional 3 months of MPA, whereas one NR after 3 months achieved PR after an additional 3 more months of MPA (Table 1). Thus, on the basis of our criteria, in most cases, CR could be achieved after 6 months MPA treatment in the present report, and all patients finally reached CR after an additional treatment. Therefore, we believe that our pathological criteria including PR are appropriate to evaluate the response on the specimen. Again, our criteria are as follows. If there was a disappearance of cancer tissue (CR) or a favorable change from grade 1 adenocarcinoma to AH (PR) at second D&C (3 months after the beginning of MPA treatment), we considered that the case had a therapeutic response and continued the treatment. If a small amount of degenerative cancer tissue, which structurally met the criteria of endometrial cancer, remained in the specimen, and if we could detect remarkable hormonal effects on the cancer tissue (Figs. 2 and 3), we diagnosed PR and continued the treatment.
Two (Cases 1 and 3) of the eight CR cases developed an intrauterine relapse 10 and 22 months after a histological CR and the completion of their progestin treatment in the present study. Both patients underwent abdominal hysterectomy and bilateral salpingo-oophorectomy combined with pelvic lymphadenectomy or sampling. Surprisingly, both cases had synchronous ovarian cancer (grade 1 EA). Although their histology and tumor grade were the same as intrauterine recurrent disease, they were categorized as double cancer based on other pathological findings (Young and Scully, 1987). The risk of adnexal metastasis has been shown by the Gynecologic Oncology Group to be 5% for disease apparently localized to the uterus in general; however, Gitsch et al. (1995) reported synchronous ovarian malignancies in 29% of women younger than 45 years. Taken together, although our results indicate that the conservative treatment may not worsen the prognosis or tumor grade, one should be aware that a refractory case may indicate the presence of synchronous ovarian tumor during or after conservative management.
The identification of reliable markers in curettage specimens that can predict CR to progestin would facilitate treatment decisions. We therefore performed immunohistochemistical analyses for several established carcinogenic markers in endometrial cancer in curettage material from a series of young patients with endometrial cancer. Previous studies of PgR expressions in tumor tissues have demonstrated a usefulness in predicting response to progestin (Thigpen et al., 1999). However, to the best of our knowledge, no previous study has investigated the prognostic impact of IGF1R, PTEN or Ki67 expression in young patients with endometrial cancer. The results of our study seemed to agree with those of several previous studies because pathologic PgR expression was significantly related with CR rate (P = 0.008), and this study is the first to confirm the prognostic importance of PgR expression in a prospective study.
In conclusion, combined with the results previously reported in the literature (Table 4) (Kim et al., 1997; Niwa et al., 2005; Randall and Kurman, 1997; Duska et al., 2001), the present study indicates that primary treatment with progestin may be an effective and relatively safe choice of treatment for women with well-differentiated endometrial adenocarcinoma who wish to preserve fertility. Our criteria were appropriate to evaluate response to progestins on the specimen, and we found that the patients with samples positive for PR had a therapeutic response. The presence of PgR may be useful in predicting CR in fertility-preserving treatment in young women with endometrial cancer.
|
|
|
Acknowledgement |
|---|
|
TopAbstractIntroductionMETHODSResultsDiscussionAcknowledgementReferences |
|---|
The authors are indebted to Prof. Patrick Barron of the International Medical Communications Center of Tokyo Medical University for his review of this manuscript.
|
References |
|---|
|
TopAbstractIntroductionMETHODSResultsDiscussionAcknowledgementReferences |
|---|
Crissman JD, Azoury RS, Barnes AE, et al. Endometrial carcinoma in women 40 years of age or younger. Obstet Gynecol (1981) 57:699–704.[Web of Science][Medline]
Duska LR, Garrett A, Rueda BR, et al. Endometrial cancer in women 40 years old or younger. Gynecol Oncol (2001) 83:388–393.[CrossRef][Web of Science][Medline]
Evans JM, Donnelly LA, Emslie-Smith AM, et al. Metformin and reduced risk of cancer in diabetic patients. Brit Med J (2005) 330:1304–1305.
Gitsch G, Hanzal E, Jensen D, et al. Endometrial cancer in premenopausal women 45 years and younger. Obstet Gynecol (1995) 85:504–508.[CrossRef][Web of Science][Medline]
Gotlieb WH, Beiner ME, Shalmon B, et al. Outcome of fertility-sparing treatment with progestins in young patients with endometrial cancer. Obstet Gynecol (2003) 102.
Imai M, Jobo T, Sato R, et al. Medroxyprogesterone acetate therapy for patients with adenocarcinoma of the endometrium who wish to preserve the uterus—usefulness and limitations. Eur J Gynaecol Oncol (2001) 22:217–220.[Web of Science][Medline]
Udagawa Y, et al. Japan Society of Gynecologic Oncology (in Japanese). Fertility-preserving Treatment. In: Endometrial Cancer Treatment Guidelines 2006 (2006) Tokyo: Kanehara & Co. Ltd. 109–118.
Kaku T, Yoshikawa H, Tsuda H, et al. Conservative therapy for adenocarcinoma and atypical endometrial hyperplasia of the endometrium in young women: central pathologic review and treatment outcome. Cancer Lett (2001) 167:39–48.[CrossRef][Web of Science][Medline]
Kim YB, Holschneider CH, Ghosh K, et al. Progestin alone as primary treatment of endometrial carcinoma in premenopausal women. Report of seven cases and review of the literature. Cancer (1997) 79:320–327.[CrossRef][Web of Science][Medline]
Kurman RJ, Norris HJ. Evaluation of criteria for distinguishing atypical endometrial hyperplasia from well-differentiated carcinoma. Cancer (1982) 49:2547–2559.[CrossRef][Web of Science][Medline]
Niwa K, Tagami K, Lian Z, et al. Outcome of fertility-preserving treatment in young women with endometrial carcinomas. BJOG (2005) 112:317–320.[CrossRef][Web of Science][Medline]
Ramirez PT, Frumovitz M, Bodurka DC, et al. Hormonal therapy for the management of grade 1 endometrial adenocarcinoma: a literature review. Gynecol Oncol (2004) 95:133–138.[CrossRef][Web of Science][Medline]
Randall TC, Kurman RJ. Progestin treatment of atypical hyperplasia and well-differentiated carcinoma of the endometrium in women under age 40. Obstet Gynecol (1997) 90:434–440.[CrossRef][Web of Science][Medline]
Reifenstein EC Jr. The treatment of advanced endometrial cancer with hydroxyprogesterone caproate. Gynecol Oncol (1974) 2:377–414.[CrossRef][Medline]
Saegusa M, Okayasu I. Progesterone therapy for endometrial carcinoma reduces cell proliferation but does not alter apoptosis. Cancer (1998) 83:111–121.[CrossRef][Web of Science][Medline]
Sherman ME. Theories of endometrial carcinogenesis: a multidisciplinary approach. Mod Pathol (2001) 13:295–308.[CrossRef][Web of Science]
Thigpen JT, Brandy MF, Alvarez RD, et al. Oral medroxyprogesterone acetate in the treatment of advanced or recurrent endometrial carcinoma: a dose–response study by the Gynecologic Oncology Group. J Clin Oncol (1999) 17:1736–1744.
Wang CB, Wang CJ, Huang HJ, et al. Fertility-preserving treatment in young patients with endometrial adenocarcinoma. Cancer (2002) 94:2192–2198.[CrossRef][Web of Science][Medline]
Yamazawa K, Seki K, Matsui H, et al. Prognostic factors in young women with endometrial carcinoma: a report of 20 cases and review of literature. Int J Gynecol Cancer (2000) 10:212–222.[CrossRef][Web of Science][Medline]
Yamazawa K, Hirashiki K, Usui H, et al. Discordance between serum level and tissue immunohistochemical staining of CA125 in endometrioid adenocarcinoma of the uterine corpus. Int J Gynecol Pathol (2005) 24:254–259.[CrossRef][Web of Science][Medline]
Young RH, Scully RE. Metastatic tumors of the ovary. In: Blaustein's Pathology of the Female Genital Tract—Kurman RJ, ed. (1987) 3rd edn. New York: Springer-Verlag. 742–768.
Submitted on December 25, 2006; resubmitted on March 1, 2007; accepted on March 6, 2007.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  P. S. Steeg, C. E. Horak, and K. D. Miller Clinical-Translational Approaches to the Nm23-H1 Metastasis Suppressor Clin. Cancer Res., August 15, 2008; 14(16): 5006 - 5012. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||