Recent Diagnostic and Prognostic Indices in Endometrial Cancer 1) Several prognostic factors for endometrial cancer are discussed including age, race, tumor size and location, histological type, myometrial invasion, lymphovascular space invasion, lymph node involvement, and molecular classification. 2) Accurate staging and prognostication is important to ensure patients receive optimal treatment and are neither overtreated nor undertreated. 3) Prognostic factors associated with worse outcomes include older age, type II histology, deep myometrial invasion, lymphovascular space invasion, lymph node metastasis, and molecular classification as groups 3 and 4.

1. Recent Diagnostic and Prognostic
Indices in Endometrial Cancer
DR.ARGHA BARUAH

2. Introduction:
• Endometrial carcinoma (EC) is generally considered to be associated with
a good prognosis, largely because low-grade endometrioid carcinoma is
the most common subtype and is typically low stage at clinical
presentation.
• However, over 20% of women with EC die of their disease, and there is a
projected increase in both incidence and mortality over the next few
decades
• The aim of accurate and reproducible prognostication is to ensure that
patients receive optimal treatment and are neither overtreated nor
undertreated, thereby improving patient outcomes overall.

4. Age:
• Older women have a worse prognosis and a
lower 5-year survival than younger women.
• Increasing age as a factor associated with
increased risk of recurrence in early stage
patients
• Most endometrial cancer arise in
postmenopausal women

5. Race
• Compared to the US white population, the
lifetime risk is lower for African–Americans,
Hispanics, Asian Pacific Islanders, American
Indian and Native Americans/Alaska Natives.
• African–American women were more likely to
have p53 mutations that are associated with
type II histology and poorer prognosis

6. Tumour size and location:
• Tumor size is reported to predict LN involvement and
recurrence and thereby can be utilized during preoperative
or intraoperative assessment to determine the need for
nodal dissection.
• Approximately 14% of ECs arise in the lower uterine
segment and these are more frequently associated with
mismatch repair gene abnormalities and Lynch Syndrome.
Lower uterine segment involvement has also been shown
to be an independent prognostic factor in conferring a
higher risk of distant recurrence and death

8. Histological type:

10. Histological type
• Type II histology is associated with high
nuclear grade, poor tumor differentiation,
deep myometrial invasion, high frequency of
lymph node metastasis, decreased sensitivity
to progestins and poor 5-year survival rate

13. Myometrial Invasion
• Assessing myometrial invasion may be difficult.
• Depth of invasion should be measured from the
endomyometrial junction to the deepest point of
invasion, which may not be easy because the
endomyometrial junction in normal conditions is often
irregular.
• In these cases, it is always helpful to look for
compressed, non-neoplastic endometrial glands at the
nearby endomyometrial junction or even at the base of
the tumor.

14. • Carcinoma involving adenomyotic foci should not be interpreted as
invasive carcinoma.
• However, the distinction between invasive carcinoma and carcinoma
involving adenomyosis may be difficult, because in some cases invasive
carcinoma may not elicit stromal response.
• In the absence of adenomyosis uninvolved by tumor in other sections of
the specimen, a diagnosis of adenomyosis involved by adenocarcinoma
should be made with caution.
• There are no rules for determining how to measure the depth of invasion
in the rare cases where myoinvasive carcinoma is only encountered in foci
of adenomyosis involved by carcinoma.
• In such cases, it is advised that the distance from the adenomyotic focus
to the deepest area of invasion be measured . Therefore, if there is a
tumor with a 2-mm focus of myoinvasion from a focus of adenomyosis in
the deep myometrium, it is still considered as having <50% of myometrial
invasion.(FIGO stage Ia)

16. • When the junction is completely obliterated, or there
is no junction from which to measure, the vascular
arcuate plexus can be used to assess myoinvasive
depth; invasion well into or through the plexus
usually signifies > 50% myoinvasion; however, if
infiltration barely extends into the plexus, the depth
of invasion should be calculated with reference to
the thickness of the myometrium in the opposite
uterine wall

17. Tumors With an Exophytic Growth or Involving Polyps
• Exophytic tumors often incorporate smooth muscle within their core and
this should not be misinterpreted as myometrial invasion. Thus, depth of
invasion but not tumor thickness should be measured by identifying the
adjacent endomyometrial junction and correlating the findings with the
macroscopic location of the tumor
• Similarly, for tumors involving polyps, invasion into the polyp stroma may
occur but this does not represent myometrial invasion. Measurement of
myoinvasion is performed only if the tumor invades the myometrium in
relation to the endometrial-myometrial interface.
• Correlation with gross findings is useful, as well as taking relevant sections
from elsewhere in the uterine wall, that is, not only those sections that
represent the tumor either in its exophytic areas or within the polyp.

18. Tumour involving serosa

20. Leiomyoma and MELF pattern:
• When EC invades a leiomyoma, the thickness of the myometrial
wall at this site should be measured to include the leiomyoma and
this distance should be used in calculating the depth of invasion.
• In EC with a microcystic, elongated and fragmented (MELF) pattern
of invasion, the presence of desmoplasia alone is insufficient to
measure depth of invasion. Cytokeratin stains may be examined if
necessary to identify malignant cells within these areas and
measurement of deepest of invasion should take into account the
deepest area where these are seen. LVSI should not be included in
assessment of myoinvasive depth; only carcinoma infiltrating the
myometrium is included in this measurement.

21. • A MELF pattern of myometrial invasion may be associated in the
deepest areas with a desmoplastic response or inflammatory
reaction which should not be counted as the deepest point of
invasion if no associated malignant cells are identified.
• Especially in inflammatory areas, malignant cells may be difficult to
appreciate as they can display a histiocytoid morphology with very
innocuous cytologic features that may result in misinterpretation as
true histiocytes .
• In either scenario, if malignant cells are not seen, levels and/or
cytokeratin staining can be performed, though the latter are not
generally recommended, or extra sections may be taken to
determine myoinvasive depth

24. LUS
• Literature is scant in providing guidelines to measure depth of
invasion for tumors located in the LUS . It is important to note that
these regions have a much thinner myometrium.
• The LUS is easy to identify from sections that contain the inactive
or ciliated glands and fibrous stroma characteristic of this location
or also contain upper endocervix
• In general, it is agreed that depth of invasion should be measured
as elsewhere in the uterine corpus but it is recommended that
sections from the LUS should not be used to determine
myoinvasive depth unless the tumor is located wholly in this region
or it reaches/breaches the serosa only in this region

25. • The prevalence of Lynch syndrome in patients with LUS endometrial
carcinoma (29%) has been reported to be much greater than that of
the general endometrial cancer patient population (1.8%)
• Cervical Involvement The American Joint Committee on Cancer
(AJCC)/FIGO staging system considers stage II disease only when
cervical stromal involvement is seen. Involvement of the surface
endocervical epithelium and/or endocervical glands (either by
direct extension or drop metastases) does not have any prognostic
significance and doesn’t upgrade the stage

26. Cervical Involvement Recommendations:
• Presence or absence of cervical stromal invasion must be recorded as its presence
upstages an EC to stage II.
• Recognition of cervical stromal invasion may be facilitated by the finding of a
desmoplastic/ inflammatory reaction but may occur in its absence.
• In the latter situation, recognition is facilitated by the observation of altered
architecture relative to normal endocervical crypts. For the purposes of standard
reporting, the uppermost endocervical mucinous gland identified in the section
should be taken as the upper limit of the endocervix.
• In the presence of cervical stromal invasion, the status of radial and distal margins
(including minimum distance) should be included as well as depth of invasion
within the cervical stroma. Cervical epithelial involvement is no longer part of FIGO
staging for EC; however, it is recommended that this finding should be included in
the report.

28. Adnexal Involvement Recommendations:
• The presence or absence of adnexal involvement should be
recorded as its presence upstages an EC to stage IIIA. Care
should be taken to determine whether the adnexal
involvement is considered to be metastatic or
“synchronous.”
• Type of adnexal involvement (ovarian parenchyma/surface,
tubal mucosa/wall, paraadnexal tissue, or lymphovascular
space involvement) should be recorded.
• The presence of lymphovascular space involvement only at
any adnexal site does not affect stage.

31. • ECs involving the adnexa are categorized as
stage IIIA, and patients have an overall survival
rate of ∼75%. This scenario has to be
distinguished from synchronous primary
tumors in the endometrium and the ovary or
tube, that often are associated with an
indolent outcome

32. Fallopian Tube Involvement—Recommendations:
Fallopian tube involvement in EC can have multiple possible
sites/patterns. The following scenarios may be encountered:
• (1) Fragments of tumor or aggregates of tumor cells within the
tubal lumen, with no involvement of the mucosa, wall, or serosa.
Not uncommonly observed in the tubal lumen, seen mainly in
patients operated on using techniques that involve an intrauterine
manipulator, such as a laparoscopically assisted or robotic
hysterectomy .
• So far, it has not been shown that these free-floating tumor
fragments are associated with an adverse outcome; they are
generally noted in the pathology report, but are not viewed as tubal
involvement indicative of stage IIIA disease.

34. • Interestingly, it has been recently reported that patients
with aggressive forms of EC such as serous carcinoma were
likely to have lower stage disease and lower mortality if
they had a prior tubal ligation, which would obstruct
transtubal spread of tumor .
• Thus, it is particularly important to note the presence of
intratubal tumor cells in serous carcinoma and other types
of high-grade EC, although there is currently no consensus
to upstage these EC based only on the presence of tumor
cells within the fallopian tube lumen.

35. (2) Involvement of tubal mucosa only with a pattern of growth that
raises the question of intraepithelial carcinoma.
Even though an intraepithelial carcinoma might be viewed as
evidence of a primary process, it has been shown that metastatic
carcinomas in the fallopian tube can show intraepithelial growth
that mimics a primary intraepithelial carcinoma . Factors such as
prior tubal ligation, site of tubal involvement, patterns of WT1, p53,
and p16 immunohistochemistry in serous carcinomas and
molecular studies may permit a more accurate determination of
whether an intraepithelial carcinoma in the fallopian tube
represents the primary site or, in rare cases, a synchronous primary
.

36. (3) Involvement of deep layers of the fallopian tube wall, often with
tumor in lymphovascular spaces, with no mucosal involvement. This
is indicative of metastatic EC. A tubal carcinoma cannot be a
synchronous primary tumor without a component that involves the
tubal mucosa (including intraepithelial), so if the carcinoma is
limited to the deeper layers of the fallopian tube wall or serosa, it is
metastatic.
• Occasionally, the only site of tubal involvement by a metastatic EC is
within tubal lymphovascular spaces; an entirely intravascular
carcinoma is certainly metastatic to the tube, but does not upstage
the primary tumor. The prognostic significance of this finding has
not been adequately studied.

39. Parametrial Invasion Recommendations:
• Presence or absence of parametrial invasion should be recorded as
its presence upstages an EC to stage IIIB.
• The fibroconnective tissue around the isthmus, at the cervix/lower
uterine segment junction should be regarded as part of the
parametria.
• Parametrial spread may be in direct continuity with the primary
tumor (continuous spread), or may be identified as discrete
metastases, in lymphovascular spaces, or in LNs (discontinuous
spread). Continuous spread or discrete metastases into or in the
parametrial tissue is required for diagnosis of parametrial
involvement and staging of an EC as IIIB.

40. Vaginal Involvement Recommendations:
Presence or absence of vaginal involvement should be
recorded where vaginal tissue is included in the
resection specimen or submitted separately, as its
presence upstages an EC to stage IIIB.
The term “drop-metastasis” should not be used in
surgical pathology reports, as it is nonspecific.
Identification of any true involvement by EC (i.e.
nonfloater), regardless of size, should be reported.

41. • Peritoneal Washings or Ascitic Fluid :The prognostic significance of
presence of tumor cells in peritoneal washings or ascites fluid is
controversial. There are studies that indicate either a worse
prognosis or no alteration of prognosis on the basis of positive
cytology. Consequently, staging systems no longer utilize positive
cytology to alter stage. When collected, however, cytology results
should be recorded.
• Margins The parametrial/paracervical soft tissue and the vaginal
cuff are the only true margins in total hysterectomy specimens.
These margins should be reported if the cervix and/or
parametrium/paracervix is involved by carcinoma. If not, reporting
the status of the vaginal and parametrial margins in a hysterectomy
specimen is optional.

42. LN Involvement (Nonsentinel) Recommendations:
• Presence or absence of lymph nodal metastasis > 0.2 mm in size should be recorded
where LN are included as part of the resection as its presence upstages an EC to stage
IIIC.
• Slicing of LN at 2 to 3 mm intervals along an axis perpendicular to the longest axis for
histologic processing is preferable to bisecting nodes. If sectioned in this way, additional
levels are not routinely recommended.
• The number of involved nodes and the total number of nodes retrieved from each site
should be provided in the pathology report; in formal LN dissections, this may be
expressed as the lymph node ratio (LNR)
• On the basis of limited evidence, the pattern of LN metastases and the presence of
extracapsular spread should be reported. Size of metastatic nodal deposits may be
documented in pathology reports. According to TNM , the presence of isolated tumor
cells (ITCs) defined as metastatic disease

43. Sentinel LN Ultrastaging Recommendations:
• Sentinel LNs may undergo
ultrastaging by a protocol that
includes examination of deeper
levels +/− immunohistochemistry
in addition to an initial
hemotoxylin and eosin (H&E)
section if this is negative for
metastasis
• Micrometastasis (defined as a
focus of metastatic disease 0.2–2
mm in maximum diameter) and
ITCs (defined as metastatic
disease

44. LVSI Recommendations:
• Presence or absence of LVSI should be recorded in the
pathology report.
• The sites of LVSI should be recorded.
• Before diagnosing LVSI, mimics should be excluded, such as
retraction, MELF pattern of invasion, and artifactual
displacement of tumor cells .
• When present, LVSI should be reported as the number of
vessels involved or semiquantified as “focal” or
“substantial/extensive

46. Molecular Classification TGCA
• Group 1 includes tumours with a hypermutant profile and mainly DNA polymerase
epsilon, catalytic subunit (POLE) exonuclease inactivation mutations, which have a
favourable overall prognosis.
• Group 2 refers to EC which is associated with microsatellite instability (MSI), and
more specifically with hypermethylation of the promoter region of the mutL
homolog 1 (MLH1) gene; the latter has been found to be the primary MSI-
associated mechanism of carcinogenesis in sporadic colorectal cancer (CRC) .
• Group 3 includes tumours with low somatic copy number alterations (SCNA); the
latter refers to various segmental aneuploidies, focal events, and whole-
chromosome aneuploidies . SCNA are strongly associated with chromosomal
instability.Groups 2 and 3 have similar prognosis.
• Group 4 represents a high SCNA group, which mostly incorporates TP53 mutation,
and includes serous-like EC, indicating a poor overall prognosis.

47. MSI in Endometrial Cancer:
• Colon carcinoma is the most common malignancy in hereditary nonpolyposis colon cancer
(HNPCC; Lynch syndrome (LS)). However, endometrial carcinoma develops before colon
carcinoma in >50% of women with HNPCC.
• Lower uterine segment tumors and high grade tumors in the endometrium seem to have a
higher rate of being LS-associated tumors, tumor morphology and anatomic location of tumor
cannot be used to select patients for screening for LS. Many LS associated endometrial
carcinomas are seen in that do not meet Bethesda or Amsterdam personal/family history
criteria for Lynch Syndrome.
• However, when examining an endometrial carcinoma in a patient under 50 years of age or
with a personal or family history of colon carcinoma, it is important to consider the possibility
of an HNPCC/LS-related endometrial carcinoma.
• According to the NCCN guidelines there should be universal testing of endometrial carcinomas
for mismatch repair (MMR) proteins/microsatellite instability (MSI). This can be tested on the
hysterectomy specimen or the pre-surgical biopsy.
• Testing for defective DNA mismatch repair proteins by immunohistochemistry is the most
cost-effective method (MLH1, MSH2, MSH6, and PMS2 antibodies are commercially available).
Loss of MSH2 or MSH6 expression essentially always indicates Lynch syndrome.

49. Hormone receptors
Estrogen and progesterone receptor positivity are independent
prognostic factors with a significantly improved disease-free
survival .
Hormone therapy including progestins, aromatase inhibitors and
selective estrogen receptor modulators are attractive first-line
therapies for young patients wanting fertility sparing options and
supplemental therapies for patients with advanced disease since
they lack adverse toxicities.

52. HER2/neu
The HER2 protein is a transmembrane glycoprotein from the human EGFR
tyrosine kinase family.
HER2 gene amplification and receptor overexpression has been
demonstrated in endometrial cancer with highest rates of overexpression
occurring in serous histology carcinomas
HER2 gene amplification is an independent prognostic factor related to
poor overall survival. While HER2 overexpression is associated with poor
surgical–pathologic prognostic factors and poor survival, it also serves as
an important target for the treatment of uterine serous carcinomas.
Trastuzumab and pertuzumab are two US FDA-approved humanized
monoclonal antibodies targeting the extracellular domain of the HER2
receptor and are currently being evaluated in clinical trials for the
treatment of endometrial cancer .

55. PTEN
PTEN is a tumor suppressor gene encoding a phosphatase enzyme
that regulates cell cycle arrest in the G1 phase and enables
apoptosis through signaling pathway.
PTEN mutations leading to inactivation of the protein are the most
common genetic defects in type I endometrial carcinomas and have
been reported in 57–83% of cases .
PTEN inactivation is one of the earliest changes in endometrial
carcinogenesis and therefore its presence is especially important in
detecting precursor lesions at high risk of progressing to cancer.
It is associated with a favorable histology and better outcome.

56. P13K/AKT/mTOR pathway
• The PI3K/AKT/mTOR pathway is the most commonly deregulated signaling
pathway and is affected in more than 80% of type I endometrial cancers .
• In addition to the previously mentioned loss of PTEN function, activating
mutations in PIK3CA (the gene encoding the catalytic subunit of PI3K)
causes an upregulation of the PI3K/AKT/mTOR pathway. PIK3CA mutations
occur in up to 36% of endometrial carcinomas, more frequently in tumors
that also have PTEN mutations..
• Even though PTEN and PIK3CA mutations affect the same pathway, PIK3CA
may serve as a marker of invasion given that mutations are significantly
more common in invasive disease. Further studies are needed to
determine whether this finding has significant clinical use in predicting
prognosis

57. p53
• The tumor suppressor gene p53 is activated in response to various stress
signals in the cell and it provokes several pathways leading to inhibition of
growth, cell cycle arrest and apoptosis .
• In type II endometrial cancers, the most common mutation identified has
been in p53 with mutations in up to 54% of nonendometrioid cancers and
over 90% of serous carcinomas compared with only 20% of type I cancers .
Some studies suggest that loss-of-function mutations in p53 may be an
early event in serous carcinogenesis since it is found in approximately 75%
of precursor lesions . In addition to the association with type II histology,
p53 mutations are also associated with poor clinical outcome.
• Identifying patients with p53 mutations is critical as postsurgical adjuvant
therapy can significantly improve the overall survival of these women.

59. KRAS Mutations as Biomarkers of Early-stage Type I EC
• KRAS mutations have been mostly associated with
type I oestrogen-related EC and their frequency is
estimated at around 10-30% .
• KRAS mutations occur at the early stages of the EC
pathway and are present in 6-16% of endometrial
hyperplasia specimens . Similar notions have been
discussed in the case of CRC, where in the classic
adenoma–carcinoma pathway, KRAS mutations seem
to appear early in the neoplastic route.

60. EGFR:
• EGFR overexpression has also been reported in 40–46%
of type I and 34% of type II endometrial carcinomas .
• In a study of uterine serous carcinoma, no EGFR
mutations were identified; however,
immunohistochemistry analysis showed moderate to
strong EGFR membrane staining in 56% of tumors
• Although EGFR overexpression is common in
endometrial cancers, EGFR inhibitors have not proven
to be clinically significant in treatment of advanced
disease.

61. Microvessel density
• In various studies calculation of microvessel density,
microvascular proliferation and vascular proliferation index
based on the histomorphological markers of KI67 and factor
VIII verified that high micro vascular proliferation was
correlated with high tumor volume and a reduced
progression-free survival and prognosis.
• VEGF is also the main mediator for endothelial cell
proliferation in endometrial carcinoma . A Phase II trial of
single-agent bevacizumab, a US FDAapproved recombinant
human monoclonal IgG antibody binding to VEGF, showed
encouraging results in the treatment of recurrent or
persistent endometrial cancer

62. MicroRNAs
• Upregulation of miR-944 and miR-301 have been
shown to be associated with more aggressive
disease and lower survival rates.
• In contrast, higher expression levels of miR-205
are associated with <50% myometrial invasion
and early-stage endometrioid endometrial
cancers with improved overall survival

63. Circulating tumour DNA
• Circulating tumour DNA (ctDNA) has been proven
as a valuable biomarker in cancer for both early
diagnosis and as a marker of recurrence risk.
• They are easily detectable in plasma, they are
also excreted by the kidneys and therefore there
is scope for detection in urine
• There are some ongoing studies researching
ctDNA in endometrial cancer, the results of which
are awaited.

69. References:
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Euscher E, Hecht JL, Horn LC, Ioffe O, Matias-Guiu X, McCluggage WG, Mikami
Y, Ordi J, Parkash V, Quddus MR, Quick CM, Staebler A, Zaloudek C, Nucci M,
Malpica A, Oliva E. Pathologic Prognostic Factors in Endometrial Carcinoma
(Other Than Tumor Type and Grade). Int J Gynecol Pathol. 2019 Jan;38 .
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2014 Women's Health, Volume: 10 issue: 3,
3.Hutt S, Tailor A, Ellis P, Michael A, Butler-Manuel S, Chatterjee J. The role of
biomarkers in endometrial cancer and hyperplasia: a literature review. Acta
Oncol. 2019 Mar;58(3):342-352.
4.CAP Protocol for Endometrial Cancer

70. THANK YOU