Anne Ørbo

The molecular genetics and morphometry‐based endometrial intraepithelial neoplasia classification system predicts disease progression in endometrial hyperplasia more accurately than the 1994 World Health Organization classification system

The objective of this study was to compare the accuracy of disease progression prediction of the molecular genetics and morphometry‐based Endometrial Intraepithelial Neoplasia (EIN) and World Health Organization 1994 (WHO94) classification systems in patients with endometrial hyperplasias.

Treatment results of endometrial hyperplasia after prospective D-score classification A follow-up study comparing effect of LNG-IUD and oral progestins versus observation only

OBJECTIVES Three different treatment options for endometrial hyperplasia were evaluated in a prospective long-time follow-up study, comparing effects of intrauterine levonorgestrel impregnated device (LNG-IUD), low oral dose of medroxyprogesterone acetate (MPA) and no treatment (observation only). To select patients with high probability for co-existing or future carcinoma we used the objective morphometric algorithm, D-score, stratifying patients into three different risk groups. As far as we know, this is the first prospective long-time follow-up study in which treatment recommendation and outcome is based on the D-score assessment. METHODS From a total of 370 patients initially diagnosed with endometrial hyperplasia from eight different hospitals in North Norway, 258 were available for long-time follow-up. After D-score classification, one of three different treatment options was chosen: LNG-IUD, low oral dose of MPA or observation only. Follow-up controls were performed and biopsies taken in the local hospitals. RESULTS Among the 370 investigated cases with endometrial hyperplasia, only ten endometrial cancers were detected at the entrance of the study, all belonging to the high risk group (D-score <0). No further cancers were detected during follow-up, irrespective of risk group. After 6 months treatment with LNG-IUD proved significantly superior to oral treatment (p=0.001 for D-score >1 and p=0.003 for D-score 0-1 groups) and observation only (p=0.001 for D-score >1 and p=0.001 for D-score 0-1 groups). After 56 to 108 months the LNG-IUD proved significantly superior to oral treatment and to the observation group. Comparison of oral therapy to observation only showed no significant differences, neither after 6 months nor after long-time observation. CONCLUSIONS LNG-IUD is the optimal treatment for endometrial hyperplasia. Outcome after oral low-dose MPA regimen is comparable to expectation.

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 ≤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 ≤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.

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

50 per case).

Topographic criteria in the diagnosis of tumor emboli in intramammary lymphatics

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).

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

Topographic relationships to adjacent structures were used as criteria to identify intramammary lymphatics with tumor emboli in breast cancer patients, in addition to conventional morphologic criteria. Patterns of relationship to blood vessels, non‐neoplastic lobules and ducts, and empty lymphatics were defined. Ninety‐five cases were independently reviewed by two observers. Interobserver reproducibility of the diagnosis of lymphatic vessel invasion (LVI) was 82% (kappa 0.60). The observers agreed on the presence of LVI in 23 patients (24%), of whom 21 (91%) had positive lymph nodes. Only among patients in whom more than ten emboli were identified was the frequency of positive lymph nodes markedly higher than in the total material. The location of tumor emboli relative to the invasive tumor was of little significance. LVI was a more powerful predictor of lymph node status than tumor size, margin contour, histologic grade and histologic type, and was highly significant also when controlled for these features.

Gene expression in endometrial cancer cells (Ishikawa) after short time high dose exposure to progesterone

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.

Down-regulated progesterone receptor A and B coinciding with successful treatment of endometrial hyperplasia by the levonorgestrel impregnated intrauterine system

The potent antiproliferative effect of progestins has been utilized in clinical regimens for treatment of endometrial proliferative disorders. The progestin infiltrated intrauterine device used as therapy for endometrial carcinoma as well as endometrial hyperplasia yields a hundred-fold increase of local progestin concentration in the endometrium compared to that of oral treatment. The genetic basis for the complex effects of high dose progestins and the different signalling pathways regulated by these genes have never been accurately surveyed. The aim of the present study was to determine the gene expression pattern in highly differentiated endometrial cancer cells (Ishikawa) after short time exposure to high progesterone doses. In eight independent experiments, cells were treated with progesterone (30microg/ml) for 4h and gene expression was compared to that of untreated cells, which served as controls. Microarray analysis revealed 247 differentially expressed genes of which 126 were up-regulated and 121 were down-regulated. Of these, 135 genes are known to be involved in biological processes like cell cycle, cell proliferation and differentiation, developmental processes, immune responses, intracellular protein traffic and transport. Our study shows that microarray analysis can detect relevant gene expression changes in endometrial cells treated with progestin, including those involved in several alternative transcriptional factors and signalling pathways. Many of the differentially expressed genes were not previously known to be affected by progesterone or have unknown biological functions. Characterization of these genes may give new insights into molecular responses to treatment with high progesterone doses. Alternative signalling pathways for progesterone, rather than the classical steroid receptors pathways are also suggested.

Prognosis of early cervical cancer (FIGO Stages IA2, IB, and IIA) in northern Norway predicted by malignancy grading score and objective morphometric image analysis.

Objective. To investigate whether regression of endometrial hyperplasia observed after 3 months of treatment with levonorgestrel impregnated intrauterine system device (LNG‐IUS) was sustained after 6 months and whether these effects were still occurring synchronously with extinguished expression of progesterone receptors and increased apoptosis. Design. Retrospective population‐based observational study. Setting. Six local hospitals and one university hospital in northern Norway. Population. Patients (n = 41) with low and medium risk endometrial hyperplasia. Methods. Histopathological treatment response comparing LNG‐IUS (n = 25) and standard per oral medroxyprogesterone (n = 16). Expression of progesterone receptor A (PR‐A), progesterone receptor B (PR‐B), ER‐alpha, ER‐beta, Bcl‐2, BAX, Caspase‐3 and metallothionein (MT) were investigated by immunohistochemistry; results were evaluated by a semi‐quantitative H‐score. Main outcome measures. Response to progestin treatment. Results. All the LNG‐IUS treated patients had therapy response after 6 months. PR‐A and PR‐B in glands were almost extinguished for IUD users compared to the oral group. Estrogen receptors were also reduced. Co‐existent changes in apoptosis were differently modulated in glands and stroma in the two treatment groups. Bcl‐2 was different in glands and stroma in responders and non‐responders to oral therapy. Conclusion. The study confirms that LNG‐IUS can be safely used for 6 months as treatment for endometrial hyperplasia. The clinical effect is accompanied by almost extinguished PR‐receptors in glands coinciding with modulation of apoptosis. The results strongly indicate that progestins activate non‐classical initiated signaling pathways.

A Semiautomated Test for Microsatellite Instability and its Significance for the Prognosis of Sporadic Endometrial Cancer in Northern Norway

Summary Recurrence of early-stage cervical cancer after primary surgery represents a considerable clinical problem, and, so far, few reliable markers for prediction of recurrence exist. Thus, the prognostic value of the malignancy grading score (MGS) classification system was evaluated in 82 patients with early-stage cervical cancer (International Federation of Gynecology and Obstetrics stages IA2, IB, and IIA) and long-time follow-up (5-16 years). Recurrence or not, the likelihood of lymph node metastases and reproducibility of the MGS semiquantitative system were tested. The prognostic power of the MGS to identify high-risk cases prone to recurrence in patients lacking lymph node metastases at primary surgery was a main purpose of the present study. The semiquantitative MGS classification system was performed independently by 2 pathologists unaware of prognosis and clinical data using light microscopy. Routine hematoxylin and eosin sections from surgical specimens were used, and investigation area was defined in the deep part of the tumor. Data-based image analysis was also used to investigate if objective morphometric parameters could add any prognostic power to MGS. The 5-year survival for the whole patient group was 92%. Malignancy grading score of greater than 17 risk points was statistically highly significant in predicting relapse and lymph node metastases (n = 82). High-risk cases lacking lymph node metastases (n = 70) were also statistically associated with high MGS. Depth of invasion and vascular invasion were statistically related to recurrence. Objective image analysis of nuclear parameters was of no additional statistical value for the prediction of outcome. The MGS classification system proved to be a useful tool in predicting recurrence and lymph node metastases and, most importantly, was a predictor of high-risk patients without metastases at primary surgery.