Maintained survival outcome after reducing lymphadenectomy rates and optimizing adjuvant treatment in endometrial cancer.

OBJECTIVE: Main controversies in endometrial cancer treatment include the role of lymphadenectomy and optimal adjuvant treatment. We assessed clinical outcome in a population-based endometrial cancer cohort in relation to changes in treatment management over two decades. METHODS: All consenting endometrial cancer patients receiving primary treatment at Haukeland University Hospital from 2001 to 2019 were included (n = 1308). Clinicopathological variables were evaluated for year-to-year changes. Clinical outcome before and after discontinuing adjuvant radiotherapy and individualizing extent of lymphadenectomy was analyzed. RESULTS: The rate of lymphadenectomy was reduced from 78% in 2001-2012 to 53% in 2013-2019. The rate of patients with verified lymph node metastases was maintained (9% vs 8%, p = 0.58) and FIGO stage I patients who did not undergo lymphadenectomy had stable 3-year recurrence-free survival (88% vs 90%, p = 0.67). Adjuvant chemotherapy for completely resected FIGO stage III patients increased from 27% to 97% from 2001 to 2009 to 2010-2019, while adjuvant radiotherapy declined from 57% to 0% (p < 0.001). These patients had improved 5-year overall- and recurrence-free survival; 0.49 [95% CI: 0.37-0.65] in 2001-2009 compared to 0.61 [0.45-0.83] in 2010-2019, p = 0.04 and 0.51 [0.39-0.68] to 0.71 [0.60-0.85], p = 0.03, respectively. For stage I, II and IV, survival rates were unchanged. CONCLUSIONS: Our study demonstrates that preoperative stratification by imaging and histological assessments permits a reduction in lymphadenectomy to around 50%, and is achievable without an increase in recurrences at 3 years. In addition, our findings support that adjuvant chemotherapy alone performs equally to adjuvant radiotherapy with regard to survival, and is likely superior in advanced stage patients.

Lowering of interstitial fluid pressure after neurogenic inflammation is inhibited by mystixin-7 peptide.

Soft tissue injury is accompanied by lowering of interstitial fluid pressure (P(if)), plasma protein extravasation, and edema. Inflammation was produced by electrical stimulation (ES) of the vagus and the effects of the synthetic peptide mystixin-7 (p-anisoyl-Arg-Lys-Leu-Leu-D-Thi-Ile-D-Leu-NH(2)) on P(if) were examined. Micropuncture measurement of P(if) in submucosa, without opening the trachea, was conducted on rats anesthetized with pentobarbital sodium (50 mg/kg) and euthanized with intravenous KCl. P(if) in control (intravenous saline) was -1.2 +/- 0.7 mmHg before ES and decreased to -4.7 +/- 1.0 mmHg (P < 0.01, n = 8) after ES. Mystixin-7 (10 and 20 microg/kg iv) blocked the fall in P(if) after ES (-1.1 +/- 0.3 and -0.8 +/- 0.2 mmHg, P < 0.01, n = 8 and n = 4). The 1 microg/kg dose was without effect. When trachea from animals pretreated with mystixin-7 (20 microg/kg iv) were soaked in phosphate-buffered saline (0.15 M, pH 7.4), the rate of fluid accumulation was significantly reduced. This study suggests that mystixin peptides, which have structural similarity to a fragment from laminin-alpha1 chain, may be useful tools for studying cell adhesion and factors that maintain the structural integrity of connective tissue after injury.

Corticotropin-releasing hormone inhibits lowering of interstitial pressure in rat trachea after neurogenic inflammation.

Increased negativity of interstitial fluid pressure (Pif) is a key determinant of edema formation after tissue injury. In this study, we addressed the question of whether the anti-inflammatory effects of corticotropin-releasing hormone (CRH) shown by others are mediated by changes in interstitial fluid pressure. CRH, 25 to 50, but not 5 and 11 microg/kg s.c., administered 45 min before antidromic stimulation of the vagal nerve inhibited the lowering of interstitial fluid pressure in rat trachea produced by nerve stimulation. This inhibitory effect of CRH was blocked by pretreatment with the CRH receptor antagonist, alpha-helical CRH-(9-41), 0.15 mg/kg i.v., administered 5 min before CRH. These results suggest that CRH receptors modulate the structural integrity of the extracellular matrix in rat trachea for its response to inflammatory stimuli.

CGRP, but not substance P, induces an increased negativity of the interstitial fluid pressure in rat trachea.

Neurogenic inflammation is mediated by neuropeptides released from sensory nerves following electrical stimulation of the vagal nerve or by capsaicin. The released neuropeptides are, among others, calcitonin gene-related peptide and substance P, which both induce vasodilation, while only substance P induces plasma extravasation. Electrical stimulation of the vagal nerve induces increased negativity of interstitial fluid pressure (Pif), which will contribute to enhance oedema formation. Pif was measured, on the abluminal side of the surgically exposed trachea, with sharpened glass capillaries (4-10 microns) connected to a servo-controlled counterpressure system. Measurements were performed after circulatory arrest, since the oedema formation associated with acute inflammation will increase Pif in a positive direction, which may potentially underestimate the increased negativity of Pif. Experiments were carried out in pentobarbital anaesthetized (50 mg kg-1) Wistar-Møller rats. Pif in control rats averaged -1.2 +/- 0.9 (SD) mmHg (n = 9). Intravenous injection of capsaicin (65.0 nmol) and calcitonin gene-related peptide (1.3 nmol) increased the negativity of Pif to -4.0 +/- 1.2 mmHg (n = 8) (P < 0.01) and -4.7 +/- 2.0 mmHg (n = 9) (P < 0.01), respectively. Intravenous injection of substance P (7.4 nmol, n = 9; and 37.0 nmol, n = 8) did not affect Pif compared to control (P > 0.05). Similarly, potentiation of the available substance P with thiorphan or captopril did not increase the negative Pif, nor did injection of stable substance P analogues. Thus, the present study seems to support the theory that, in rat trachea, the increased negativity of Pif after intravenous injection of capsaicin and after vagal stimulation is caused by calcitonin gene-related peptide.

Alloxan diabetes abolishes the increased negativity of interstitial fluid pressure in rat trachea induced by vagal nerve stimulation.

Increased negativity of interstitial fluid pressure (Pif) occurs concomitantly with oedema formation in acute airway inflammation. This observation is principally important because the loose connective tissues become 'active' and provide the driving force for the rapid oedema formation via Pif. The present study reports Pif in acute airway inflammation in alloxan diabetic rats. The basis for the study was, firstly, that inflammation is important in the pathogenesis of asthma. Secondly, that clinically there is almost a mutual exclusion between diabetes and asthma and, lastly, that the inflammatory response is attenuated in alloxan diabetic rats. Pif was measured on the ventral side of the trachea with sharpened glass capillaries (3-6 microns) connected to a servocontrolled counterpressure system. Measurements and nerve stimulation were performed after circulatory arrest, since oedema formation associated with inflammation will increase Pif, causing an underestimation of a potentially increased negativity of Pif. Control or diabetic rats (alloxan 45 mg kg-1 i.v. 5 days earlier) received either the mast cell degranulating substance compound 48/80 (100 micrograms), dextran 70 (60 mg) i.v. or vagal nerve stimulation. After dextran, Pif was -4.7 +/- 0.9 (SD) mmHg (n = 6) and -1.3 +/- 0.3 mmHg (n = 6) (P < 0.01) in normal and diabetic rats, respectively. Corresponding values after vagal nerve stimulation were -5.3 +/- 1.8 mmHg (n = 5) and -0.7 +/- 0.2 mmHg (P < 0.01). Insulin treatment restored the Pif response to dextran and vagal stimulation. Pif after Compound 48/80 did not differ between control and diabetic rats. Interstitial volume, total tissue water and transcapillary albumin extravasation increased significantly in controls after vagal nerve stimulation, but was attenuated in diabetic rats.

Lowering of interstitial fluid pressure will enhance edema in trachea of albumin-sensitized rats.

Interstitial fluid pressure (Pif) has recently been found to play an important role in edema formation in acute airway inflammation. Because airway inflammation is important in the pathogenesis of asthma, Pif was measured in rat trachea after albumin challenge to rats previously sensitized to chicken egg albumin. In pentobarbital anesthesia (50 mg/kg intraperitoneally) sensitized rats received an intravenous infusion of either saline or albumin, which circulated for 4 min. Circulatory arrest was then induced with saturated KCl intravenously to prevent further edema formation, which will increase Pif and thereby possibly cause an underestimation of an increased negativity of Pif. Pif was measured with sharpened glass capillaries (diameter 3-6 micrometer) connected to a servo-controlled counter pressure system. Pif was -1.3 +/- 0.4 mm Hg in controls and -5.8 +/- 0.5 mm Hg in sensitized rats (p < 0.01) after allergen challenge. Airway resistance was measured to verify the occurrence of airway narrowing and increased significantly in sensitized rats after allergen challenge but did not change in controls. The experimental anti-inflammatory drug, alpha-trinositol (D-myo-inositol-1,2,6-trisphosphate, 10 mg), given before or after allergen challenge abolished the increased negativity of Pif (p < 0.05), while hydrocortisone (6.25 mg) had no effect. Thus, allergen challenge is associated with a lowering of Pif, which was abolished by alpha-trinositol.

The relationship between interstitial fluid pressure and volume in rat trachea.

A change of interstitial fluid volume (IFV) will normally change the interstitial fluid pressure (Pif) so as to counteract further fluid movement across the capillaries and changes in IFV. Contrary to this, several acute inflammatory reactions in the trachea are associated with increased negativity of Pif, which will 'actively' generate oedema. To outline further the role of Pif in interstitial fluid balance in the trachea, interstitial compliance (delta IFV/delta Pif) was measured in pentobarbital anaesthetized rats. IFV was measured as the plasma equivalent extravascular distribution space of [51Cr]EDTA. Pif was measured in the same animal with sharpened glass pipettes (diameter 3-6 microns) connected to a servocontrolled counterpressure system. In dehydration (30 mL saline i.v., n = 10) interstitial compliance was 0.083 mL g dry wt-1 mmHg-1. Since control IFV was 1.046 mL g dry wt-1 (n = 10) the interstitial compliance is 8% of IFV per mmHg. In overhydration (30 mL NaCl, n = 10) and dextran anaphylaxis (1 mL dextran 70, n = 10) compliance remained the same for the first 15% increase in IFV and then increased several-fold since Pif did not increase more than 2 mmHg above control level. The increased negativity of Pif by -10 mmHg associated with acute inflammation will require a reduction of IFV by 80% when interstitial compliance is 8% per mmHg. A more likely explanation is therefore that structural rearrangements are responsible for the events leading to increased negativity of Pif in acute inflammation.

Neurogenic inflammation and lowering of interstitial fluid pressure in rat trachea is inhibited by alpha-trinositol.

The effect of alpha-trinositol (D-myoinositol-1,2,6-triphosphate) on edema formation and capillary permeability in neurogenically induced inflammatory edema was investigated in rat trachea. Interstitial fluid pressure (Pif) was studied, since increased negativity of Pif contributes to edema formation in this situation. alpha-Trinositol was used because it inhibits edema formation, capillary leakage, and increased negativity of Pif in burn-injured skin. Pif was measured with sharpened glass capillaries (3 to 7 microns) connected to a servocontrolled counterpressure system after circulatory arrest (induced by intracardiac injection of saturated potassium chloride in pentobarbital anesthesia). This was done in order to avoid the edema formation associated with inflammatory reactions, which will raise interstitial fluid volume and Pif, causing the underestimation of an increased negativity of Pif. Neurogenic inflammation induced by electrical-field stimulation of the left vagal nerve (10 V, 20 Hz, 0.5 ms) lowered Pif from -1.4 +/- 0.6 mm Hg to -8.4 +/- 2.1 mm Hg (p < 0.01). Corresponding numbers after the intravenous administration of alpha-trinositol (40 mg/kg) before stimulation were -1.2 +/- 0.4 and -1.4 +/- 0.4 mm Hg, respectively (p > 0.05). Another series of animals with intact circulation was used to study the effect of vagal nerve stimulation and alpha-trinositol on edema formation (total tissue water and extravascular 51Cr-ethylenediamine tetraacetic acid-[EDTA] space) and albumin extravasation. These parameters increased significantly after vagal nerve stimulation, while intravenous alpha-trinositol (40 and 120 mg/kg), as given above, significantly attenuated this increase. Thus, alpha-trinositol prevented a lowering of Pif and the edema formation accompanying neurogenic inflammation in rat trachea.

Neurogenic inflammation in rat trachea is accompanied by increased negativity of interstitial fluid pressure.

The present experiments were performed to investigate whether neurogenic inflammation in rat trachea (with edema formation and protein extravasation when the circulation is intact) induced by electrical field stimulation of neuropeptide-containing C fibers in the vagal nerve is accompanied by increased negativity of interstitial fluid pressure (P(if)). Increased negativity of P(if) in the trachea occurs in dextran anaphylaxis and mast cell degranulation and facilitates edema formation under these circumstances. Experiments were performed after circulatory arrest had been induced in pentobarbital anesthesia to prevent edema formation, which will raise P(if) and potentially cause underestimation of an increased negativity of P(if). After induction of circulatory arrest, the vagal nerve was isolated and placed in a stimulating electrode. The trachea was then exposed and covered with mineral oil, and measurement of P(if) was started as soon as possible thereafter. P(if) was measured with sharpened glass capillaries (tip diameter, 3 to 7 microns) connected to a servocontrolled counterpressure system. P(if) in the control group (n = 12) did not change throughout the observation period. Electrical stimulation of the left vagal nerve caused P(if) to fall in all experiments, from -1.1 +/- 1.1 mm Hg in the control condition to an average of -10.6 +/- 3.4 mm Hg (n = 9, P < .01). In some experiments, a continuous recording of P(if) was obtained, showing that the reduction of P(if) started within 30 seconds after onset of stimulation to reach and later remain at a stable level within a few minutes. The experimental protocol was repeated after the C fibers had been nearly depleted of neuropeptides with capsaicin.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased negativity of interstitial fluid pressure in rat trachea after mast cell degranulation.

The present study was performed to investigate whether the increased negativity of interstitial fluid pressure (Pif) observed after intravenous injection of dextran could be mediated via mast cell degranulation induced by C48/80 and polymyxin B sulfate. Increased negativity of Pif, concomitant with edema formation and increased albumin extravasation, was seen with both substances. However, the two substances differed in that polymyxin B sulfate induced less negativity in Pif and a larger but transient increase in capillary albumin extravasation and interstitial fluid volume. Total tissue water (TTW) increased from 2.11 to 2.71 ml/g dry wt 10 min after polymyxin B and returned to control level at 30 and 60 min. Injection of C48/80 increased TTW to 2.68 ml/g dry wt at 30 min, and TTW was still elevated at 60 min. Albumin extravasation followed a similar pattern; polymyxin B sulfate increased albumin extravasation from < 0.08 to 1.18 ml/g dry wt during the first 5 min after administration. C48/80 was less potent, and maximal albumin leakage was seen after 10-25 min (0.25 ml/g dry wt). The observations demonstrate the importance of the interstitium and the loose connective tissues as "active" participants in the edema-generating process and suggest an interaction with the structural components of the interstitium, as well as an important role for the mast cells in the chain of events creating increased negativity of Pif.