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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 16  |  Issue : 2  |  Page : 367-370

Evaluation of various prognostic factors of endometrial carcinoma


Department of Pathology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India

Date of Submission20-Aug-2020
Date of Decision18-Jan-2021
Date of Acceptance21-Mar-2021
Date of Web Publication18-Oct-2021

Correspondence Address:
Dr. Prachi Rai
Department of Pathology, Jawaharlal Nehru Medical College, DMIMS (DU), Sawangi (M), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_143_20

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  Abstract 


Background: Endometrial carcinoma (EC) is the most common malignancy of the female genital tract that accounts for about 7% of all invasive cancer in women. Therefore, the first step is to find predictive and prognostic factors, then to define clinically relevant risk groups and finally design clinical trials and treatment options. Hence, to improve the treatment and follow-up of EC patients, the importance of various prognostic factors has been extensively studied. The present study is intended to evaluate the various prognostic parameters of EC. Aim: The aim of the study was to evaluate various prognostic factors in patients of diagnosed case of EC at a tertiary health center. Objectives: The objectives of the study were (1).to diagnose EC by routine H and E staining and grade (FIGO) it and (2) and to evaluate various prognostic parameters including clinical, gross, and histopathological factors. Study Design: This was a observational and retrospective study. Materials and Methods: Fifty cases of EC were diagnosed on histopathology, then evaluate various prognostic factors. Results: Most of the cases belonged to the postmenopausal group, endometrioid type, stage I that means confined to the endometrium alone. The most common grade was Grade II accounting to 40.00%, followed by Grade I and Grade III, i.e., 34% and 18%, respectively, and 8% were included in the unknown grade. Conclusion: Knowledge of prognostic factors may enable physicians to find the best appropriate treatment for the prevention of recurrence. Patients at risk for an aggressive or advanced disease could be referred to centers and clinicians with special expertise in managing advanced or recurrent EC.

Keywords: Endometrial carcinoma, Prognostic factors, histopathological factors


How to cite this article:
Rai P, Bhake A, Bahadure S. Evaluation of various prognostic factors of endometrial carcinoma. J Datta Meghe Inst Med Sci Univ 2021;16:367-70

How to cite this URL:
Rai P, Bhake A, Bahadure S. Evaluation of various prognostic factors of endometrial carcinoma. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2021 Dec 4];16:367-70. Available from: http://www.journaldmims.com/text.asp?2021/16/2/367/328449




  Introduction Top


Endometrial carcinoma (EC) is the most common invasive cancer of the female genital tract and accounts for 7% of all invasive cancer in women, excluding skin cancer.[1] The highest incidence rates are in the United States and Canada, but in recent years, there has been a decline in incidence and mortality. It typically occurs in elderly individuals, 80% of the patients being postmenopausal at the time of diagnosis.[2]

Currently, it is believed that ECs can be divided in two distinct types on the basis of their pathogenesis, i.e., one occurring as a result of excess estrogenic stimulation and developing against a background of endometrial hyperplasia which is more common and the other is developing de novo.[3],[4],[5],[6]

Now, ECs are generally thought to have a favorable prognosis due to early detection and the majority of tumors are detected in early stages; however, this is not completely true in all cases. Therefore, the first step is to find predictive and prognostic factors, then to define clinically relevant risk groups and finally to design clinical trials and treatment options for these risk groups.

The risk factors for EC are excess estrogenic stimulation, early menarche and late menopause, nulliparous women, use of an intrauterine device, using birth control pills, family history having close relatives with endometrial cancer, genetic, having been diagnosed with endometrial hyperplasia in the past, obesity, certain type of ovarian tumor, the granulose cell tumor, polycystic ovarian disease, diabetes, dysfunctional bleeding, etc.[7]

Therefore, to improve the treatment and follow-up of EC patients, the importance of various prognostic factors has been extensively studied. The identification of high-risk groups would make it possible to avoid unnecessary adjuvant treatment. Demonstration of various prognostic parameters including lymph node status, histological type of carcinoma, histological grade, stage of disease, depth of myometrial invasion, lymphovascular space involvement, and cervical involvement is important.

The present study is intended to evaluate the various prognostic parameters of EC.


  Materials and Methods Top


The study was observational and retrospective carried out in Histopathology Division of Department of Pathology, Jawaharlal Nehru Medical College (JNMC), DMIMS (DU), Sawangi, Wardha, Maharashtra.

The study was undertaken with the approval of Institutional Ethics Committee. Informed consent was obtained from all the patients who were included in the study.

A total of 50 already diagnosed cases of EC were included in the study and evaluated from various prognostic factors such as age, clinical stage of carcinoma, level of infiltration of myometrial wall, microscopic grading of differentiation, and exogenous estrogen administration.

Inclusion criteria

  1. All cases diagnosed as EC
  2. Taking hysterectomy specimen resected from EC
  3. All aged female patients.


Exclusion criteria

  1. EC diagnosed on D and C
  2. Patients on treatment.


The specimens were received in the histopathology section of the department of pathology (JNMC), and then, tissue processing was done followed by routine hematoxylin and eosin staining on histopathology then evaluate the various prognostic factors.


  Results Top


The present study was an observational and retrospective study which comprised a total of 50 cases who were diagnosed as an EC on histopathology.

When we distribute 50 cases according to the menopausal status, they were classified into three groups: premenopausal, perimenopausal, and postmenopausal groups. Of the 50 cases, 3 (6%) were premenopausal, 20 (40%) were perimenopausal and 27 (54%) were postmenopausal. Most of the cases belonged to the postmenopausal group [Table 1].
Table 1: Distribution of cases according to the menopausal status

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While distributing cases according to the histological type of EC, cases were classified into three groups: endometrioid, nonendometrioid, and unspecified group. Of the 50 cases, 37 (74%) were of endometrioid type, 9 (18%) were of nonendometrioid type, and 4 (08.00%) were of unspecified type. Most of the cases belonged to the endometrioid type of EC [Table 2].

If we analyzed cases according to the histological staging of EC, cases were classified into four groups according to the stage: I, II, III, and IV. Of the 50 cases, 35 (70%) were in Stage I, 7 (14%) were in Stage II, 5 (10%) were in Stage III, and 3 (6%) were in Stage IV. Most of the cases belonged to Stage I of EC [Table 3].
Table 2: Distribution of cases according to the histological type

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Table 3: Distribution of cases according to the histological staging

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If we analyzed cases according to the status of endometrial infiltration, cases were classified into four groups: carcinoma confined to the endometrium only, ≤50% of myometrial infiltration, ≥50% of myometrial infiltration, and unknown. Of the 50 cases, 27 (54%) were confined to endometrium only, 11 (22%) showed ≤50% myometrial infiltration, 3 (06%) showed ≥50% myometrial infiltration, and 9 (18.00%) showed unknown myometrial infiltration. Most of the cases confined to the endometrium alone [Table 4].
Table 4: Distribution of cases according to the status of myometrial infiltration

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While distributing cases according to the status of EC grading, cases were classified into four groups according to the FIGO grading: Grade1, Grade 2, Grade 3, and unknown. Of the 50 cases, 17 (34%) were included in Grade 1, 20 (40.00%) were included in Grade 2, 9 (18%) were included in Grade 3, and 4 (08%) were included in unknown grade. Most of the cases were included in Grade 2 of EC [Table 5].
Table 5: Distribution of cases according to the status of tumor grading (FIGO grade)

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  Discussion Top


EC is the most common cancer of the female genital tract in the world. Although EC is generally considered to have a good prognosis, over 20% of women with EC die of their disease, with a projected increase in both incidence and mortality over the next few decades.

The aim of accurate prognostication is to ensure that patients receive optimal treatment and are neither overtreated nor undertreated, thereby improving patient outcomes overall. Patients with EC can be categorized into prognostic risk groups based on clinicpathologic findings.

Therefore, many studies evaluate the prognostic parameters of endometrial cancer. These factors are important in tailoring proper adjuvant therapy consisting of modalities such as radiation, chemotherapy, and hormonal therapy. Identification of high-risk endometrial cancer cases and referral of moderate- and high-risk patients to physicians with expertise in treating advanced or recurrent disease appear justified.

Before that, no consensus existed with regard to the type of therapy, but the situation has changed and evidence-based knowledge in this field has improved substantially. Various definitions of the risk groups have confused the results and conclusions drawn from the studies the PORTEC-1 study[8] included both low-risk (Grade 2, superficial infiltration) and medium-risk cases and the ASTEC/EN.5 study[9] included both medium-risk and high-risk cases.

The aim of the present study was to evaluate the prognostic value of the various clinical and histopathological factors of endometrial cancer. Five prognostic and predictive factors were analyzed in this study. The single most important factor was the FIGO grade, but it is important to point out that the DNA ploidy, not so commonly used in the international literature, was one of the three most important predictive factors together with myometrial invasion to predict the risk of tumor recurrences, especially distant recurrences. A number of studies from Sweden[10] have pointed out the prognostic importance of DNA ploidy before, but this information does not seem to have been generally accepted and spread worldwide.

Advanced versus early tumor stage was the single most important factor. FIGO grade was the second most important with a risk factor. Interesting findings were that the nuclear grade was significant and independent of the FIGO grade and the DNA ploidy than myometrial invasion.

Tumor size and lymphovascular space invasion (LVSI) were not included in the present analyses. Tumor size with a cutoff level of 2 cm has been reported to be an important predictive factor in preoperative risk classification to define a low-risk group where lymph node dissection is not required. In another study, tumor size was not an independent predictor of recurrence. In a number of studies, LVSI has been pointed out as an important predictive factor associated with lymph node metastases and distant tumor spread.[11]

Myometrial invasion is an important predictive and prognostic factor but difficult to assess preoperatively in a reliable way.

In an Italian study, preoperative risk classification was made using histology, tumor grade, myometrial invasion, cervical spread, and abdominal spread and correctly identified the postoperative risk classification in 96% with high sensitivity and specificity. This may help the surgeon in the decision to perform limited or extended surgery.

It is important to analyze large samples of ECs to sort out the most important and significant predictive and prognostic factors that should be used in future risk group classifications.


  Conclusion Top


Poor histologic differentiation, deep myometrial invasion, nonendometrioid histologic subtype, lymphovascular invasion, lymph node status, cervical involvement, and the presence and extent of the extrauterine disease have been described as significant histopathologic predictors of distant recurrence. Knowledge of prognostic factors may enable physicians to find the best appropriate treatment for the prevention of recurrence. Patients at risk for aggressive or advanced disease could be referred to centers and clinicians with special expertise in managing advanced or recurrent EC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Robbins P, Pinder S, de Klerk N, Dawkins H, Harvey J, Sterrett G, et al. Histological grading of breast carcinomas: A study of interobserver agreement. Human Pathol 1995;26:873-9.  Back to cited text no. 1
    
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Rose PG. Endometrial carcinoma. N Engl J Med 1996;335:640-9.  Back to cited text no. 2
    
3.
Beckner ME, Mori T, Silverberg SG. Endometrial carcinoma: Nontumor factors in prognosis. Int J Gynecol Pathol 1985;4:131-45.  Back to cited text no. 3
    
4.
Deligdisch L, Cohen CJ. Histologic correlates and virulence implications of endometrial carcinoma associated with adenomatous hyperplasia. Cancer 1985;56:1452-5.  Back to cited text no. 4
    
5.
Gusberg SB. Current concepts in cancer: The changing nature of endometrial cancer. N Engl J Med 1980;302:729-31.  Back to cited text no. 5
    
6.
Deligdisch L, Kalir T, Cohen CJ, de Latour M, Le Bouedec G, Penault-Llorca F. Endometrial histopathology in 700 patients treated with tamoxifen for breast cancer. Gynecol Oncol 2000;78:181-6.  Back to cited text no. 6
    
7.
Rosai J. Rosai and Ackerman's Surgical Pathology E-Book. Michigan: Elsevier Health Sciences; 2011. p. 1787-876.  Back to cited text no. 7
    
8.
Creutzberg CL, van Putten WL, Koper PC, Lybeert ML, Jobsen JJ, Wárlám-Rodenhuis CC, et al. Surgery and postoperative radiotherapy versus surgery alone for patients with stage-1 endometrial carcinoma: Multicentre randomised trial. PORTEC Study Group. Postoperative Radiation Therapy in Endometrial Carcinoma. Lancet 2000;355:1404-11.  Back to cited text no. 8
    
9.
Blake P, Swart AM, Orton J, Kitchener H, Whelan T, Lukka H, et al. “Adjuvant external beam radiotherapy in the treatment of endometrial cancer (MRC ASTEC and NCIC CTG EN. 5 randomised trials): Pooled trial results, systematic review, and metaanalysis,” Lancet 2009;373:137-46.  Back to cited text no. 9
    
10.
Nordstrom B, Strang P, Lindgren A, Bergstrom R, Tribukait B. “Carcinoma of the endometrium: Do the nuclear grade and DNA ploidy provide more prognostic information than do the FIGO and WHO classifications?” Int J Gynecol Pathol 1996;15:191-201.  Back to cited text no. 10
    
11.
Singh N, Hirschowitz L, Zaino R, Alvarado-Cabrero I, Duggan MA, Ali-Fehmi R, et al. Pathologic Prognostic Factors in Endometrial Carcinoma (Other Than Tumor Type and Grade). Int J Gynecol Pathol 2019;38:S93-113.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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