The levonorgestrel-releasing intrauterine system (LNG-IUS) is a conservative management option for atypical hyperplasia (AH) and low grade early stage endometrial cancer (EEC), but around 1 in 3 patients fail to respond to treatment. The aim of this study was to investigate if serum and/or tissue HE4 expression could predict response to LNG-IUS therapy. Patients with AH or presumed Stage I EEC had serum and endometrial samples taken at baseline and at 3-month intervals over 12 months post-insertion of LNG-IUS. 74 patients were recruited and baseline demographics recorded. Of 57 patients for whom response was histologically determinable, 39 (68%) were responders and 18 (32%) non-responders. Mean baseline serum HE4 was significantly lower in responders (62.1 ± 1.1 pM, 95% confidence interval (CI) 52.7–73.2), compared to non-responders (125.6 ± 1.3 pM, 95% CI 74.5–211.7, p = 0.014), including when considering age, BMI, menopausal status, smoking status, and histological grade as covariables (p = 0.005). Baseline tissue HE4 expression was not significantly different in responders compared to non-responders (p = 0.999). Responders showed a significant mean reduction (−9.8 ± 3.4%, 95% CI −16.7 to −2.8%, p = 0.008) in serum HE4 between baseline and 3 months (p = 0.008), whereas non-responders showed no significant change (p = 0.676). Neither responders nor non-responders showed a significant percentage change in serum HE4 from baseline beyond 3 months (p > 0.05). Change in serum HE4 between baseline and 3 and 6 months and tissue HE4 tissue expression between baseline and 3, 6, and 12 months was not significantly different in responders compared to non-responders (p > 0.05). This study suggests that baseline serum HE4, but not baseline tissue HE4 expression, is independently predictive of response to the LNG-IUS and could be used to guide management decisions.
Purpose
Endometrioid endometrial cancer is strongly associated with obesity
and insulin resistance. Metformin,an insulin sensitizer, reduces endometrial
tumor growth in vitro. Presurgical window studies allow
rapid in vivo assessment of antitumor activity. Previous
window studies found metformin reduced endometrial cancer proliferation but
these lacked methodological rigor. PREMIUM measured the anti-proliferative
effect of metformin in vivo using a robust window study
design.
Patients and Methods
A multicenter, double-blind, placebo-controlled trial randomized
women with atypical hyperplasia or endometrioid endometrial cancer to
receive metformin (850 mg daily for 3 days, and twice daily thereafter) or
placebo for 1 to 5 weeks until surgery. The primary outcome was
posttreatment IHC expression of Ki-67. Secondary outcomes investigated the
effect of metformin on markers of the PI3K–Akt–mTOR and
insulin signaling pathways and obesity.
Results
Eighty-eight women received metformin (n = 45) or
placebo (n = 43) and completed treatment. There was no
overall difference in posttreatment Ki-67 between the metformin and placebo
arms, in an ANCOVA analysis adjusting for baseline Ki-67 expression (mean
difference −0.57%; 95% CI, −7.57%–6.42%;
P = 0.87). Metformin did not affect expression of
markers of the PI3K–Akt–mTOR or insulin signaling pathways,
and did not result in weight loss.
Conclusions
Short-term treatment with standard diabetic doses of metformin does
not reduce tumor proliferation in women with endometrioid endometrial cancer
awaiting hysterectomy. This study does not support a biological effect of
metformin in endometrial cancer and casts doubt on its potential application
in the primary and adjuvant treatment settings.
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