Significance of progesterone receptors (PR-A and PR-B) expression as predictors for relapse after successful therapy of endometrial hyperplasia: a retrospective cohort study.

OBJECTIVE: After successful progestin therapy for endometrial hyperplasia (EH), the risk of relapse remains. We aimed to assess if immunohistochemical (IHC) expression of progesterone receptor isoforms, PR-A and PR-B, in endometrial glands and stroma in pre-treatment endometrial biopsies was related to relapse of EH. DESIGN AND SETTING: Biopsy material originated from women with low-risk and medium-risk EH recruited to a recent Norwegian multicentre randomised trial. Participants (n = 153) had been treated for 6 months with three different progestin regimens. POPULATION: One hundred and thirty-five of the 153 women achieved therapy response and underwent follow up for 24 months after therapy withdrawal. Fifty-five women relapsed during follow up. Pre-treatment endometrial biopsies from 94 of the 135 responding women were available for IHC staining. METHODS: Immunohistochemical staining was performed separately for PR-A and PR-B and IHC expression was evaluated in endometrial glands and stroma by a histological score (H-score) using light microscopy. MAIN OUTCOME MEASURE: Immunohistochemical expression of PR-A and PR-B in endometrial glands and stroma in women with or without relapse of EH. RESULTS: Low PR-A in endometrial glands (P = 0.013) and stroma (P < 0.001), and high PR-B in endometrial glands (P = 0.001) in pre-treatment endometrial biopsy have a statistically significant association with relapse of EH. Women with a pre-treatment ratio of PR-A:PR-B ≤ 1 have a higher risk of relapse (71%) compared with women with a ratio of PR-A:PR-B > 1 (19%; P < 0.001). CONCLUSION: Immunohistochemical expression of PR-A and PR-B in pre-treatment endometrial biopsy proves valuable as a predictor of relapse in EH. TWEETABLE ABSTRACT: Pre-treatment endometrial expression of PR-A and PR-B is a valuable predictor of relapse in endometrial hyperplasia.

Relapse risk of endometrial hyperplasia after treatment with the levonorgestrel-impregnated intrauterine system or oral progestogens.

OBJECTIVE: To investigate relapse rates after the successful treatment of patients with non-atypical endometrial hyperplasia who were randomised to either a levonorgestrel-impregnated intrauterine system (LNG-IUS; Mirena(®) ) or two regimens of oral medroxyprogesterone acetate (MPA) after primary histological response. DESIGN: A multicentre randomised trial. SETTING: Ten different outpatient clinics localised in hospitals and seven gynaecological private practices in Norway. POPULATION: One hundred and fifty-three women aged 30-70 years with low- or medium-risk endometrial hyperplasia met the inclusion criteria, and 153 completed the therapy. METHODS: Patients were randomly assigned to one of the following three treatment arms: LNG-IUS; 10 mg of oral MPA administered for 10 days per cycle for 6 months; or 10 mg of oral MPA administered daily for 6 months. The women were followed for 24 months after ending therapy. MAIN OUTCOME MEASURES: Histological relapse of endometrial hyperplasia. RESULTS: Histological relapse was observed in 55/135 (41%) women who had an initial complete treatment response. The relapse rates were similar in the three therapy groups (P = 0.66). In the multivariable analyses relapse was dependent on menopausal status (P = 0.0005) and estrogen level (P = 0.0007). CONCLUSIONS: The risk of histological relapse of non-atypical endometrial hyperplasia is high within 24 months of ceasing therapy with either the LNG-IUS or oral MPA. Continued endometrial surveillance and prolonging progestogen therapy should be considered. TWEETABLE ABSTRACT: Relapse of endometrial hyperplasia after successful treatment is independent of therapy regime.

Levonorgestrel-impregnated intrauterine device as treatment for endometrial hyperplasia: a national multicentre randomised trial.

OBJECTIVE: The purpose of this study was to investigate if the levonorgestrel-impregnated intrauterine device (LNG-IUS, Mirena(®) ) is safe and effective as therapy for low-risk and medium-risk endometrial hyperplasia compared with oral medroxyprogesterone (MPA). DESIGN: A multicentre randomised trial. SETTING: Norway. POPULATION: In all, 170 women aged 30-70 years with low- or medium-risk endometrial hyperplasia who met inclusion criteria. METHODS: Patients were randomly assigned to one of three treatment arms: LNG-IUS; oral MPA 10 mg administered for 10 days per cycle, or continuous oral MPA 10 mg daily, for 6 months. MAIN OUTCOME MEASURES: The primary outcome measure was normalisation or persisting hyperplasia. RESULTS: After 6 months all three treatment regimens showed significant effect when the outcome was evaluated as therapy response or not (P < 0.001). Responses were obtained for all the women in the LNG-IUS group (53/53, 95% CI 0.93-1.0) and for 96% of the women in the continuous oral group (46/48, 95% CI 0.86-0.99). Only 69% of the women in the cyclic oral group were responders (36/52, 95% CI 0.55-0.81). Adverse effects were relatively common with minimal differences between therapy groups. CONCLUSION: In the first trial of its kind, women treated with the LNG-IUS showed histologically normal endometrium after 6 months of therapy for endometrial hyperplasia. Cyclical progestogens are found to be less effective compared with continuous oral therapy and LNG-IUS and should not be used for this purpose.

Prognostic markers for detection of coexistent carcinoma in high-risk endometrial hyperplasia.

OBJECTIVES: Reliable predictive uterus-sparing methods are crucial for treatment decisions among women who wish to preserve fertility and for seriously ill patients for whom surgery is hazardous. Thus, prediction of myoinvasive carcinoma by objective histomorphometry (4C-rule) and subjective diagnosis (endometrial intraepithelial neoplasia, EIN) were investigated in high-risk endometrial biopsies. PATIENTS AND METHODS: A total of 45 patients retrospectively diagnosed with high-risk hyperplasia, of whom ten were found to have concurrent carcinoma, were investigated. The histomorphometric 4C-rule and the EIN classification system were used for outcome prediction. RESULTS: Myoinvasive disease was predicted with a sensitivity of 87% and a specificity of 79% by using 4C-rule assessment. The sensitivity and specificity of the EIN classification to predict coexistent carcinoma or not was 50% and 97%, respectively. CONCLUSION: Six out of the seven reported cases with myoinvasion were correctly diagnosed with the 4C-rule assessment. In contrast, only three out of the seven myoinvasive cases were diagnosed as cancer using the EIN approach.

Genetic derangements in the tumor suppressor gene PTEN in endometrial precancers as prognostic markers for cancer development: a population-based study from northern Norway with long-term follow-up.

OBJECTIVES: The purpose of the current study was to characterize the role of PTEN in malignant transformation and to evaluate the significance of mutated PTEN exons as prognostic markers in the carcinogenesis of endometrial hyperplasia. A comparison of PTEN mutations as prognostic markers with former investigated prognosticators was also intended. METHODS: Histological material from 68 patients with endometrial hyperplasia and 10-20 years of follow-up of whom 18 later developed cancer was examined. PCR amplification and DNA sequencing were performed, screening the most frequently mutated exons 5a-8b of the PTEN gene. RESULTS: Mutations were demonstrated in 13.2% of the patients. Of the patients with cancer development, five showed to have PTEN mutations corresponding to 28%. Of the patients remaining without carcinoma, only 8% had PTEN mutations (P = 0.04). In total, there were three missense, three nonsense, and four frameshift mutations, and twice as many mutations leading to a truncated protein (six) than mutations altering one amino acid in the entire protein (three). Mutations were distributed in the following manner: three in exon 5a, two in exon 5b, two in exon 6, two in exon 7, and one in exon 8b. Only mutations in exons 6, 7, and 8a were connected with cancer development or coexisting cancer and six out of seven mutations within these exons were frameshift or nonsense mutations. CONCLUSIONS: Our results showed that mutations in the PTEN gene were statistically more frequent in cases with cancer development or coexisting cancer. Although the specificity was acceptable, the sensitivity of PTEN mutations was too low to make it suitable as a tumor marker (sensitivity of 27% and specificity of 91%) in clinical practice.

Resection margins in conization as prognostic marker for relapse in high-grade dysplasia of the uterine cervix in northern Norway: a retrospective long-term follow-up material.

OBJECTIVE: The main intention of the current study was to evaluate free resection margins in cervical conization specimens as prognostic marker by investigating the statistical association between clear or unclear resection margins of cervical cones and the risk of recurrence. METHODS: In a retrospective material, 459 women with moderate (CIN II) and severe dysplasia (CIN III) were included. Fifty of the patients were diagnosed with CIN II (10.9%) and 409 with CIN III (89.1%). Cold knife conization was performed in 371 (81%) patients, the rest were treated with CO(2) laser (19%). All the patients had been treated with conization between 1980 and 1984, follow-up time being from 19 to 23 years. Mean age of the patients was 35.2 years (range 18-81 years) at operation. The histopathological material and the results of the follow-up biopsies and smears were accessible as archival material. RESULTS: A total of 379 (82.6%) patients had clear margins in the primary operation specimens, in 80 patients margins were unclear (17.4%). There were three recurrences in the CIN II group (6%) and 39 (9.5%) in the CIN III group. Further there were 42 (9.2%) relapses in the total group, 36 relapses in the cold-knife group and 6 in the laser group. When univariate analysis was performed to investigate the statistical relation between the resection margins and recurrences, there was no significant correlation (P = 0.7, P > 0.05). Nor did variables like CIN group, surgical procedure, age at disease, age at recurrence, and years till recurrence prove to be predictors of relapses. CONCLUSION: In our material, the relation between free margins and relapse was not statistically significant. According to the literature-free resection margin is not an optimal prognostic criterion for recurrence. The search for new prognostic markers for high-risk cases are important to give these patients adequate therapy and avoiding over-treatment of the low risk groups.

Nuclear morphometric changes and therapy monitoring in patients with endometrial hyperplasia: a study comparing effects of intrauterine levonorgestrel and systemic medroxyprogesterone.

OBJECTIVE: To show that local application of the levonorgestrel intrauterine device was a better therapy for endometrial hyperplasia (EH) compared to per-oral gestagen treatment based on subjective (WHO criteria) and objective (prognostic data-based morphometric and stereological method/D score, predicting the risk of cancer development for each single patient) evaluation. METHODS: Women between 30 and 70 years with EH and D score > 0 were treated with levonorgestrel intrauterine device (n = 26) and the results compared to a historic group of women treated with per-oral gestagen (n = 31). In both treatment groups only patients with low risk (D score > 1) and uncertain risk (D score = 0-1) of cancer development were included. Endometrial specimens were investigated prior to treatment and after 3 months of therapy. The endometrial samples from the two groups were examined by light microscopy and objective data-based morphometry to assess tissue characteristics and to evaluate nuclear size variation. RESULTS: After 3 months all patients treated with levonorgestrel intrauterine device showed regression of hyperplasia, whereas 14 of 31 patients in the per-oral group still had persisting disease. The objective morphometric analysis showed reduction in nuclear size for both treatment groups, including the D score > 1 as well as the D score 0-1 patients. However, the reduction was most obvious for the levonorgestrel intrauterine device-treated patients with initial D score of 0-1. CONCLUSION: The present study indicates that levonorgestrel intrauterine device is a superior alternative to per oral treatment of endometrial hyperplasia. By using objective morphometric treatment monitoring we have shown that the hyperplasia patients with the highest malignant potential (D score = 0-1) were those taking most benefit from local high-dose levonorgestrel therapy.

Loss of expression of MLH1, MSH2, MSH6, and PTEN related to endometrial cancer in 68 patients with endometrial hyperplasia.

Derangements in the tumor suppressor gene PTEN and the mismatch-repair genes, hMLH1, hMSH2, and hMSH6, have an important role in endometrial carcinogenesis. The purpose of this study was to assess immunohistochemically the pattern of protein expression for these genes in 68 patients with endometrial hyperplasia and to determine the relation of protein expression to cancer development or coexistence of cancers. Loss of expression of these genes also was evaluated as potential tumor markers for clinical use. PTEN and hMLH1 both showed loss of expression in 55% of specimens from 18 patients with subsequent or coexisting carcinoma. D&C specimens from 50 patients who did not develop cancer (10 patients underwent hysterectomy within 2 years; 40 had no hysterectomy; follow-up of 10-20 years), expressed protein at a much higher frequency (92% for PTEN and 98% for hMLH1). The parameter with the strongest independent relation to subsequent or coexisting carcinoma in a stepwise multiple logistic regression analysis was hMLH1. Evaluation of the investigated factors as prognostic markers for tumor development showed high specificity (92% for PTEN, 98% for MLH1) at the expense of sensitivity (56% for PTEN, 56% for MLH1). The results were compared with the results of the computerized image analysis algorithm, the D-score.

Computerised morphometric study of the paraurethral tissue in young and elderly women.

AIM: Changes in structural support of the urethra and bladder neck have been proposed to be among the most important factors in the pathogenesis of stress urinary incontinence. In this context, we histologically investigated the paraurethral area in continent women to quantify the relative distribution of connective tissue, smooth muscle, vessels, nerves, and striated muscle. Previously published literature gives only descriptive evaluations of the relative distribution of these tissue components. METHODS: We used a computerised morphometric method, which allowed us to estimate the paraurethral tissue distribution in a more objective way. The material was obtained by dissection during autopsy in five premenopausal and five postmenopausal women. RESULTS: Paraurethral tissue consisted of 56% connective tissue (SD, 5%), 30% smooth muscle (SD, 5%), 11% blood vessel (SD, 6%), 2% striated muscle (SD, 3%), and 1% nerves (SD, 1%). We also found that the distribution of different tissue components along the length of the urethra did not differ at a statistically significant level. Furthermore, there was a statistically significant difference in the amount of connective tissue and blood vessels in the postmenopausal women compared with the premenopausal women. CONCLUSIONS: The present study shows that the paraurethral area is built of heterogeneous tissue with small changes in its composition along the course of urethra. Increase in connective tissue was found to be the dominating change in the process of ageing.

Significance of morphometric, DNA cytometric features, and other prognostic markers on survival of endometrial cancer patients in northern Norway.

The objective of this study was to evaluate the prognostic value of nuclear morphometric features and DNA ploidy by flow cytometry next to depth of myometrial invasion and vascular invasion in endometrial cancer of all FIGO stages. A total of 123 women (103 FIGO stage I, eight stage II, and 12 stage III and IV) from northern Norway were studied. The follow-up period was between 7 and 19 years. The median age of patients was 62 years. The primary surgery was performed in the University Hospital of Tromso or in the seven different reference hospitals in the northern part of Norway after an endometrial cancer diagnosis. The histologic, morphometric,flow cytometric and immunohistochemical investigations were based on archival paraffin-embedded material. The information regarding the follow-up data and clinical information were obtained from the medical records. Thirteen (10.6%) patients from the entire group (all stages) but only three (2.7%) of the FIGO stage I and II patients died from locally recurrent or metastatic disease. FIGO substage (P = 0.0006; odds ratio [OR] =16.44, 95% confidence interval [CI] = 3.36-80.45), vascular invasion (P =0.01, OR = 6.42, CI = 1.57-26.34) and nuclear size (P = 0.025, OR = 1.3,CI = 1.05-1.61) were independently correlated with recurrence in a multivariate analysis but histologic grade and DNA ploidy were not. Vascular invasion was poorly reproducible both between and within the same observer, however. In this retrospective study of all stages of endometrial carcinoma with long follow-up periods the primary tumor characteristics nuclear perimeter and FIGO stage were of prognostic significance in addition to the poorly reproducible vessel invasion.

A semiautomated test for microsatellite instability and its significance for the prognosis of sporadic endometrial cancer in northern Norway.

Archival histologic material from 105 women (median age 62 years) treated for endometrial cancer was investigated for the replication error phenotype indicated by the observation of widespread microsatellite instability (MSI). Polymerase chain reaction (PCR) of DNA isolated from paraffin-embedded tissue was analyzed for MSI using six microsatellite loci with a fluorescent-based detection system. Flow cytometry and morphometric investigation were performed in the same material for each of the patients. Twenty percent (21 of 105) of screened endometrial cancers were found to have high MSI at two or more of the loci tested. The mean detection frequency per marker was highest in the dinucleotide repeat sequence, D2S123, and the mononucleotide repeat sequences amplified by Bat 25 and Bat 26. Death from endometrial cancer was not related to the occurrence of MSI (p=0.6). There was no significant association between MSI and FIGO stage (p=0.5), myometrial invasion depth (p=0.8), histological grade (p=0.3), or vessel invasion (p=0.5). There were, however, more MSI cases among the group of diploid cases compared with the aneuploid and tetraploid group. MSI is not a valuable prognosticator for survival of sporadic endometrial cancer, and diploid cases are significantly more often MSI positive than aneuploid and tetraploid cases.

Prospective multicenter evaluation of the morphometric D-score for prediction of the outcome of endometrial hyperplasias.

Prospective multicenter evaluation of the WHO classification and the morphometric D-score to predict endometrial hyperplasia cancer progression. In 132 endometrial hyperplasias WHO classification was performed by two experienced gynecologic pathologists. The D-score was assessed blindly by technicians in a routine diagnostic setting. Development of endometrial carcinoma during a 1-10-year follow-up was used as the end point. Eleven of 132 patients (8%), 10 of 61 (16%) atypical hyperplasias, and 1 of 71 (1%) nonatypical hyperplasias developed cancer. Twenty-six curettings had a D-score < or = 0 ("unfavorable" or endometrial intraepithelial neoplasia) of which 10 (38%) developed cancer. None of the 86 cases with a D-score > 1 ("favorable") and one of the 20 (5%) cases with 0 < D-score < or = 1 ("uncertain") developed cancer. Sensitivity of the D-score was 100%, specificity 82%, the positive and negative predictive values were 38% and 100%, respectively. These values are similar to those in three prior retrospective D-score studies but higher than the WHO values (which are 91%, 58%, 16%, and 99%, respectively). The D-score in endometrial hyperplasias is a more sensitive and specific marker for cancer prediction than the WHO classification, can be assessed in a routine clinical setting on standard hematoxylin and eosin sections (15-30 minutes per case), and is highly reproducible and cost-effective (U.S. $50 per case).

Computerised morphometrical analysis in endometrial hyperplasia for the prediction of cancer development. A long-term retrospective study from northern Norway.

AIMS: To evaluate and compare the long term prognostic value of the WHO classification and the computerised multivariate morphometrical D score in endometrial hyperplasia. To test the reproducibility of the D score in two different centres. METHODS: Histopathological WHO classification and computerised morphometrical analysis using the D score (< 0, high risk; > 1, low risk; 0-1, uncertain) in a population based study from northern Norway of archival dilatation and curettage material from 68 women with 10-20 years of follow up. RESULTS: Of the 68 patients included in the study, 18 developed cancer. The sensitivity and specificity of the D score (< 0 v > 1) were 100% and 78%, respectively, which was better than the WHO classification (89% and 60%, respectively). The negative and positive predictive values for the D score were 100% and 58% and of the WHO classification 94% and 44%, respectively. This study found a slightly higher specificity for the D score than former retrospective studies, but otherwise the results were comparable. The D score results were reproducible between the two centres (R = 0.91; slope = 0.98; intercept = 0.3). CONCLUSIONS: D score assessment is a reproducible and more accurate predictor of outcome of endometrial hyperplasia than the WHO classification assessed by an experienced gynaecological pathologist. Routine application of the D score might reduce over and undertreatment of endometrial hyperplasia.

[Computer-based morphometric image analysis of endometrial hyperplasia]. / Databasert morfometrisk bildeanalyse ved endometriehyperplasi.

Former studies have shown that only 20% of endometrial hyperplasias progress to carcinoma. Objective criteria for predicting the outcome of hyperplasias have been lacking. Because hysterectomy has been the therapy of choice to avoid malignant development, overtreatment of these patients is still a clinical problem. A computer-based morphometric image analysis system has proved to be a considerable improvement for the pathologist in assessing which patients will develop cancer. The system is based on ten nuclear and twelve glandular architectural features. The three parameters with the best statistical power of discriminating between patients developing malignancy and those remaining healthy were combined into a morphometric classification rule (D-score or discriminating score). We give a brief description of this method and its background.

Urinary levels of cyclic guanosine monophosphate (cGMP) in patients with cancer of the uterine cervix: a valuable prognostic factor of clinical outcome?

Changes in urinary cyclic nucleotide levels have been reported in patients with various types of cancers. The present study was conducted to relate changes in urinary levels of cyclic guanosine monophosphate (cGMP) and cyclic adenosine monophosphate (cAMP) to the clinical outcome of 11 patients treated for cancer of the uterine cervix. Urine was sampled for 24 h before and 3 months after primary treatment. The levels of cGMP increased in all the patients (n = 5) who relapsed within the observation period of 39 months. 4 of these patients showed an increased cGMP/cAMP ratio. In the patients without relapse (n = 6), the cGMP levels decreased, whereas the cGMP/cAMP ratios were unchanged. No marked changes in the levels of cAMP were observed for either of the groups. The measurement of urinary cGMP levels seems to be a valuable tool in the follow-up of patients with cancer of the uterine cervix.

[How hazardous is the use of female steroid hormones?]. / Hvor farlig er bruk av kvinnelige steroidhormoner?

The development of female steroid hormone-related neoplasms such as gynaecologic and mammary cancers is influenced by hormones administered exogenously. Hormonal contraceptives and hormone replacement therapy both affect the risk of developing cancers in the endometrium, cervix, ovarium, and mammary glands. The authors refer to the recent literature and discuss the findings for the different types of cancers individually. Oestrogens promote development of cancers of the uterine corpus, but women who take progestins combined with oestrogens run no greater risk than women who do not take hormones. Female steroid hormones appear to increase the risk of developing cancer of the uterine cervix slightly, but protect against the development of ovarian cancer. An higher risk of developing mammary cancer is seen after taking oral contraceptive pills.

[Tumor markers in gynecological cancer]. / Tumormarkører ved gynekologisk cancer.

Tumour markers can be defined as biological changes indicating the existence of malignancy in the organism. After the development of monoclonal antibodies, an array of new tumor markers have been discovered over the last two decades. General guidelines are given for the use of tumour markers in practice. Finally, the markers of special relevance for gynecological oncology, and some other recently discovered markers are described.

Export of guanosine 3',5'-cyclic monophosphate (cGMP) from human erythrocytes characterized by inside-out membrane vesicles.

The present study was undertaken to characterize the export of cGMP from human erythrocytes at 37 degrees C. Inside-out membrane vesicles were exposed to cGMP and [3H]-cGMP in the presence and absence of 2 mmol l-1 ATP. In the absence of ATP, an equilibrium was reached within 15 min for the lowest tested concentration (0.65 mumol l-1), and the amount of cGMP in the vesicles was linearly correlated to the cGMP concentrations in the incubate. These observations suggest that the ATP-independent process represents passive diffusion or non-saturated binding to membrane components. In the presence of ATP, cGMP accumulated linearly during the test period (up to 120 min) and the transport into the inside-out vesicles was dependent on both low- and high-Km transport. The kinetic parameters for the low-Km process were determined after 5 and 120 min, the Km values being 4.6 (SD 1.9) and 4.7 (SD 1.1) mumol l-1 (n = 3), respectively. The corresponding Vmax values were 400 (SD 50) and 440 (SD 70) fmol mg-1 min-1. The high-Km process was characterized by Km = 170 (SD 50) mumol-1 and Vmax = 1610 (SD 280) fmol mg-1 min-1 (n = 5). The present data demonstrate an ATP-requiring saturable transport system for cGMP in human erythrocytes.