Abstract Objective The aim of this study is to develop a risk-scoring system for predicting lymph node and distant metastasis in endometrial carcinoma. Methods A total of 1166 patients, treated at a ...single institution between 1-2007 and 12-2013, were included in the study. The association of stage IIIC–IV disease with demographic factors (age, body mass index), biochemical factors (complete blood count, serum CA125), preoperative histology and tumor size was examined in unadjusted analyses. Logistic regression analysis was used for the identification of variables that independently predict an advanced disease. Results Thrombocytosis, serum CA125 > 35 U/mL, preoperative high-risk histology (nonendometrioid or grade 3 endometrioid carcinoma) and tumor size ≥ 3 cm were independently associated with an advanced disease. These predictors were internally validated by a bootstrapping method with statistical significance. A risk-scoring system with an area under the receiver operating characteristic curve of 0.852 (95% confidence interval, 0.821–0.883) was developed. Total risk score points ranged from 0 to 8 for individual patients. With a cut-off of 1 point, stratifying 66.3% of patients to surgical staging, the model predicted stage IIIC–IV carcinomas with a sensitivity of 100%, specificity of 38.0%, positive predictive value of 17.1%, and negative predictive value of 100%. With the same cut-off, the corresponding values were 100%, 34.7%, 16.5% and 100% in predicting stage IIIC carcinomas in a subgroup that underwent lymphadenectomy and had a stage I–IIIC disease. Conclusions This risk-scoring system is highly sensitive in predicting an advanced stage endometrial carcinoma at a cut-off of risk score points that is associated with an acceptable lymphadenectomy rate.
Uterine leiomyomas are benign smooth muscle tumors occurring in 70% of women of reproductive age. The majority of leiomyomas harbor one of three well-established genetic changes: a hotspot mutation ...in
, overexpression of
, or biallelic loss of
. The majority of studies have classified leiomyomas by complex and costly methods, such as whole-genome sequencing, or by combining multiple traditional methods, such as immunohistochemistry and Sanger sequencing. The type of specimens and the amount of resources available often determine the choice. A more universal, cost-effective, and scalable method for classifying leiomyomas is needed. The aim of this study was to evaluate whether RNA sequencing can accurately classify formalin-fixed paraffin-embedded (FFPE) leiomyomas. We performed 3'RNA sequencing with 44 leiomyoma and 5 myometrium FFPE samples, revealing that the samples clustered according to the mutation status of
,
, and
. Furthermore, we confirmed each subtype in a publicly available fresh frozen dataset. These results indicate that a targeted 3'RNA sequencing panel could serve as a cost-effective and robust tool for stratifying both fresh frozen and FFPE leiomyomas. This study also highlights 3'RNA sequencing as a promising method for studying the abundance of unexploited tissue material that is routinely stored in hospital archives.
Abstract
Uterine adenomyosis is a relatively common disorder characterized by the abnormal presence of endometrial glands and stroma in the myometrium. The estimated prevalence of adenomyosis varies ...between 20-30% in hysterectomy specimens. Approximately 65% of the patients develop symptoms, including dysmenorrhea and heavy menstrual bleeding. Additionally, adenomyosis has been shown to significantly associate with peritoneal endometriosis in infertile patients. A circumscribed and nodular form of adenomyosis is called an adenomyoma (AM). This lesion is often misdiagnosed as uterine leiomyoma (ULM), a benign smooth muscle tumor of the uterus. To date, the molecular mechanisms underlying adenomyosis are rather poorly understood. The aim of this study was to investigate the molecular genetic background of uterine AMs by whole-exome sequencing, as well as to examine if the known ULM driver changes play a role in the genesis of AMs.
This study focused on patients with nodular uterine AMs. A total of 16 AMs and matched normal myometrium samples from 14 hysterectomy patients entered exome sequencing. From each lesion, genomic DNA was extracted separately from both the myometrial and endometrial components. Coding regions were enriched using SeqCap EZ System (Roche Nimblegen) and sequencing was performed with Illumina HiSeq 4000. Comprehensive clinical information was available for 13 out of 14 patients.
The average age at diagnosis was 45 years and at hysterectomy 49 years among patients. All patients had experienced dysmenorrhea (9/13, 69%), heavy menstrual bleeding (10/13, 77%), or both as symptoms. Endometriosis had been diagnosed in 62% (8/13) and infertility in 15% (2/13) of the patients. ULMs occurred in 8/14 (57%) patients. The average coverage of exome sequencing data was 44x for AMs. In each sample, 85% of targeted bases were covered with at least 10 reads. After filtering out germline variation, all AM samples displayed, on average, 16 somatic variants. The most prominent variants are validated in a set of additional adenomyosis samples.
Based on our results, the genetic background of AMs differs from that of ULMs due to the lack of ULM driver changes: MED12 mutations, HMGA2 overexpression, and biallelic FH inactivation. Only one AM had a somatic missense mutation in MED12, and no HMGA2 overexpression was detected. Studies on FH inactivation are still ongoing. Knowledge of the molecular background of AMs is important for understanding the development of the condition and essential for improving the management of these lesions. This is the first exome sequencing study to our knowledge to comprehensively profile somatic variation in uterine AMs.
Citation Format: Jaana Tolvanen, Hanna-Riikka Heinonen, Nanna Sarvilinna, Jari Sjöberg, Oskari Heikinheimo, Annukka Pasanen, Ralf Bützow, Lauri A. Aaltonen, Netta Mäkinen. The landscape of somatic mutations in uterine adenomyomas abstract. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr LB-375.
Uterine leiomyomas can be classified into molecularly distinct subtypes according to their genetic triggers: MED12 mutations, HMGA2 upregulation, or inactivation of FH. The aim of this study was to ...identify metabolites and metabolic pathways that are dysregulated in different subtypes of leiomyomas.
We performed global metabolomic profiling of 25 uterine leiomyomas and 17 corresponding myometrium specimens using liquid chromatography-tandem mass spectroscopy.
A total of 641 metabolites were detected. All leiomyomas displayed reduced homocarnosine and haeme metabolite levels. We identified a clearly distinct metabolomic profile for leiomyomas of the FH subtype, characterised by metabolic alterations in the tricarboxylic acid cycle and pentose phosphate pathways, and increased levels of multiple lipids and amino acids. Several metabolites were uniquely elevated in leiomyomas of the FH subtype, including N6-succinyladenosine and argininosuccinate, serving as potential biomarkers for FH deficiency. In contrast, leiomyomas of the MED12 subtype displayed reduced levels of vitamin A, multiple membrane lipids and amino acids, and dysregulation of vitamin C metabolism, a finding which was also compatible with gene expression data.
The study reveals the metabolomic heterogeneity of leiomyomas and provides the requisite framework for strategies designed to target metabolic alterations promoting the growth of these prevalent tumours.
The aim of this study was to investigate the association of predictors of an advanced disease and/or poor outcome with the occurrence of tumor relapses in different anatomical sites in patients with ...stage I-II endometrioid endometrial cancer.
A total of 929 patients were included in the study. The median follow-up time was 57 months (range, 1-108 months). The studied variables were: poor tumor differentiation, myometrial invasion 50% or greater, tumor size 3 cm or greater, lymphovascular space invasion, cervical stromal invasion, positive peritoneal cytology, old age (>77 years), obesity (body mass index ≥30 kg/m), and diabetes.
A relapse was diagnosed in 98 patients (10.5%) (vaginal in 15, pelvic in 27, intra-abdominal beyond the pelvis in 27, extra-abdominal in 29). None of the variables were associated with an altered risk of vaginal or pelvic relapses in univariate analyses. Poor differentiation, myometrial invasion 50% or greater, tumor size 3 cm or greater, and positive peritoneal cytology were associated with an increased risk of intra-abdominal relapses beyond the pelvis (odds ratios ORs between 2.2 and 9.6). With the exception of obesity and diabetes, all variables were associated with an increased risk of extra-abdominal relapses (ORs between 2.3 and 13). Tumor size 3 cm or greater (OR, 3.1) and positive peritoneal cytology (OR, 16) predicted intra-abdominal relapses beyond the pelvis in multivariate analysis, whereas poor differentiation (OR, 2.9), myometrial invasion 50% or greater (OR, 4.0), and positive peritoneal cytology (OR, 27) predicted extra-abdominal relapses. Compared with vaginal relapses, intra-abdominal relapses beyond the pelvis and extra-abdominal relapses were associated with a worse disease-specific survival. Survival of patients with a pelvic relapse did not differ from that of patients with a vaginal relapse.
Risk variables of endometrial cancer are differently associated with relapses in different locations. Our findings may promote studies that explore the most efficient adjuvant therapy in high-risk early-stage endometrioid endometrial cancer.
Introduction
The purpose of this study was to determine the incidence of, and risk factors for, surgical site infections in a contemporary cohort of women with endometrial carcinoma.
Material and ...methods
We retrospectively studied 1164 women treated for endometrial carcinoma by hysterectomy at a single institution in 2007–2013. In all, 912 women (78.4%) had minimally invasive hysterectomy. Data on surgical site infections were collected from medical records. Univariate and multivariate analyses were used to identify risk factors for incisional and organ/space infections.
Results
Ninety‐four women (8.1%) were diagnosed with a surgical site infection. Twenty women (1.7%) had an incisional infection and 74 (6.4%) had an organ/space infection. The associations of 17 clinico‐pathologic and surgical variables were tested by univariate analyses. Those variables that were identified as potential risk factors in univariate analyses (p < 0.15) were used in logistic regression models with incisional and organ/space infections as dependent variables. Obesity (body mass index ≥ 30 kg/m2), diabetes, and long operative time (>80th centile) were independently associated with a higher risk of incisional infection, whereas minimally invasive surgery was associated with a smaller risk. Smoking, conversion to laparotomy, and lymphadenectomy were associated with a higher risk of organ/space infection.
Conclusions
Organ/space infections comprised the majority of surgical site infections. Risk factors for incisional and organ/space infections differed. Minimally invasive hysterectomy was associated with a smaller risk of incisional infections but not of organ/space infections.
Abstract
Uterine leiomyomas (ULs) are extremely common smooth muscle tumors, occurring in an estimated 77% of women of reproductive age. Although benign, ULs form a major burden to women's health and ...are the leading cause of hysterectomy worldwide. Recent findings show that ULs can be classified into at least three distinct molecular subclasses, each with a characteristic genetic driver aberration and global gene expression profile: MED12 (mediator complex subunit 12) mutation-positive, HMGA2 (high mobility group AT-hook 2)-overexpressing, FH (fumarate hydratase)-deficient. However, ULs are currently treated without taking into account the possible different subclasses. The aim of this project is to develop and characterize 3D in vitro models of ULs. The models will be used to examine responses to existing treatments in different subclasses of UL and to identify subclass-specific novel lead compounds for drugs. The work is based on the hypothesis that different molecular UL subclasses have distinct sensitivity and resistance patterns to existing treatment options. Therefore, ULs should not be treated as a single entity. The study material consists of UL tissue belonging to different subclasses and myometrium, collected from hysterectomy patients during surgery in Helsinki University Hospital, Finland. Freshly operated samples are processed to initiate primary cell cultures. The primary cells are seeded on Ultra-Low Attachment (ULA) multiwell plates and grown to form 3D spheroids. In case of MED12-mutated tumors, the spheroids are screened for MED12 mutations by Sanger sequencing. MED12-wild type samples and spheroids are analyzed for overexpression of HMGA2 and FH-deficiency. Immunofluorescence staining is performed to characterize different cell types in the spheroid structure. The presence of live/dead cells in spheroids is monitored during the drug treatments in 384-well plates with high-content confocal microscopy. The approach will first focus on the most common subclasses (MED12-mutated and HMGA2-overexpressing tumors) and most common treatment options. Here, we have set up novel patient-derived cell models for ULs. We have characterized myometrium and UL-derived spheroids and show that they retain the characteristics and genetic driver aberration of the original samples. Furthermore, we show they are composed mostly of live cells. Subsequent in vitro high-throughput drug screening will lead to characterization of drug sensitivities and identification of novel lead compounds for drugs. This information is important for rational drug design, where the effects of candidate drugs can be evaluated in light of the molecular class of the respective tumors. This work will lead to new knowledge towards precision medicine, which has potential for scientific breakthrough, since it would avoid exposing the patients to ineffective treatment options.
Citation Format: Simona Bramante, Vilja Pietiäinen, Lassi Paavolainen, Annukka Pasanen, Netta Mäkinen, Hanna-Riikka Heinonen, Pirjo Ikonen, Oskari Heikinheimo, Jari Sjöberg, Ralf Bützow, Lauri Aaltonen. Development of uterine leiomyoma 3D in vitro models for high-throughput drug and chemical compound screenings: Towards personalized medicine abstract. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 1159.
Uterine leiomyomas, or fibroids, are very common smooth muscle tumors that arise from the myometrium. They can be divided into distinct molecular subtypes. We have previously shown that ...3'RNA-sequencing is highly effective in classifying archival formalin-fixed paraffin-embedded (FFPE) leiomyomas according to the underlying mutation. In this study, we performed 3'RNA-sequencing with 111 FFPE leiomyomas previously classified as negative for driver alterations in mediator complex subunit 12 (MED12), high mobility group AT-hook 2 (HMGA2), and fumarate hydratase (FH) by Sanger sequencing and immunohistochemistry. This revealed 43 tumors that displayed expression features typically seen in HMGA2-positive tumors, including overexpression of PLAG1. We explored 12 such leiomyomas by whole-genome sequencing to identify their underlying genomic drivers and to evaluate the feasibility of detecting chromosomal driver alterations from FFPE material. Four tumors with significant HMGA2 overexpression at the protein-level served as controls. We identified chromosomal rearrangements targeting either HMGA2, HMGA1, or PLAG1 in all 16 tumors, demonstrating that it is possible to detect chromosomal driver alterations in archival leiomyoma specimens as old as 18 years. Furthermore, two tumors displayed biallelic loss of DEPDC5 and one tumor harbored a COL4A5-COL4A6 deletion. These observations suggest that instead of only HMGA2-positive leiomyomas, a distinct leiomyoma subtype is characterized by rearrangements targeting either HMGA2, HMGA1, or PLAG1. The results indicate that the frequency of HMGA2-positive leiomyomas may be higher than estimated in previous studies where immunohistochemistry has been used. This study also demonstrates the feasibility of detecting chromosomal driver alterations from archival FFPE material.
Stanniocalcin-1 (STC-1) is a glycoprotein hormone involved in diverse biological processes, including regulation of calcium phosphate homeostasis, cell proliferation, apoptosis, inflammation, ...oxidative stress responses, and cancer development. The role of STC-1 in endometrial cancer (EC) is yet to be elucidated. In this study, we investigated the protein expression pattern of STC-1 in a tissue microarray (TMA) cohort of hysterectomy specimens from 832 patients with EC. We then evaluated the prognostic value of STC-1 expression regarding the clinicopathologic features and patients survival over a period of 140 months. Our results revealed that in EC tissue samples, STC-1 is mainly localized in the endometrial epithelium, although some expression was also observed in the stroma. Decreased STC-1 expression was associated with factors relating to a worse prognosis, such as grade 3 endometrioid tumors (
= 0.030), deep myometrial invasion (
= 0.003), lymphovascular space invasion (
= 0.050), and large tumor size (
= 0.001). Moreover, STC-1 expression was decreased in tumors obtained from obese women (
= 0.014) and in women with diabetes mellitus type 2 (DMT2;
= 0.001). Interestingly, the data also showed an association between DNA mismatch repair (MMR) deficiency and weak STC-1 expression, specifically in the endometrial epithelium (
= 0.048). No association was observed between STC-1 expression and disease-specific survival. As STC-1 expression was particularly low in cases with obesity and DMT2 in the TMA cohort, we also evaluated the correlation between metformin use and STC-1 expression in an additional EC cohort that only included women with DMT2 (n = 111). The analysis showed no difference in STC-1 expression in either the epithelium or the stroma in women undergoing metformin therapy compared to metformin non-users. Overall, our data may suggest a favorable role for STC-1 in EC behavior; however, further studies are required to elucidate the detailed mechanism and possible applications to cancer treatment.
Abstract
Uterine leiomyomas (ULs), benign smooth muscle tumors, represent one of the most common neoplasms in women with an estimated prevalence varying from 20% to over 70% during the reproductive ...years. Approximately every fourth woman with ULs has clinically relevant lesions, which cause morbidity and thus require treatment. Still today, hysterectomy is the primary treatment option for ULs worldwide, and remarkably, their annual societal costs exceed those of colon and breast cancer combined. Our previous findings, derived from the use of high-throughput technologies, suggest that there are at least three distinct molecular UL subclasses, each displaying a characteristic genetic driver aberration and unique global gene expression profile: MED12 (mediator complex subunit 12) mutation-positive, HMGA2 (high mobility group AT-hook 2)-overexpressing, and FH (fumarate hydratase)-deficient ULs. The aim of this study is to examine the molecular subclasses, their respective proportions, and clinical characteristics in a large UL patient cohort. The study material consists of 1026 ULs and corresponding normal myometrium tissue from 322 patients, who had ultrasound-diagnosed ULs and underwent hysterectomy in Helsinki University Hospital, Finland between October 2013 and June 2016. From each uterus, we harvested all feasible ULs ≥1 cm in diameter and a piece of the corresponding normal myometrium tissue. The location of the collected samples in the uterus, their size, and any observed special characteristics were carefully documented at the time of sample removal. In addition, comprehensive clinical information of the patients was obtained from medical and pathology reports, as well as from a questionnaire, and the histopathology of all lesions were characterized according to the WHO 2014 criteria. All collected ULs have been systematically screened for MED12 mutations by Sanger sequencing. Overexpression of HMGA2 typically arises from a chromosomal translocation, and deletions at FH locus suggest the presence of potential biallelic FH inactivation. Therefore, HMGA2-overexpressing and FH-deficient ULs have tentatively been identified using a high-density customizable Infinium® HumanCore-24+ BeadChip with over 305,000 markers. Currently, the data analyses are ongoing. Sufficient numbers of well-documented high-quality samples are a prerequisite for successful research. We hypothesize that ULs can emerge through several distinct molecular mechanisms that contribute to different biological and clinicopathological features and response to treatment. Their molecular classification and further characterization will lead to increased knowledge on UL genesis as well as improved management of the disease.
Citation Format: Netta Mäkinen, Hanna-Riikka Heinonen, Annukka Pasanen, Jaana Tolvanen, Simona Bramante, Miika Mehine, Jari Sjöberg, Oskari Heikinheimo, Ralf Bützow, Lauri A. Aaltonen. Molecular classification and clinical characterization of a large uterine leiomyoma patient cohort abstract. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 2461. doi:10.1158/1538-7445.AM2017-2461
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