Endometrial carcinoma—endocrinological and clinical studies

Endometrial carcinoma-endocrinological and clinical studies D.

CHARLES,

M.B.,

E.

T.

BELL,

J.

A.

LORAINE,

R.

A.

Glasgow

B.Sc.,

HARKNESS, and

M.R.C.O.G.*

Edinburgh,

PH.D. M.B.,

PH.D.,

M.B.,

PH.D.,

F.R.C.P.E.

M.R.C.P.E.

Scotland

THE LITERATURE containsmuchcontradictory information regarding the endocrine status of patients with endometrial carcinoma. In some subjects with this disease there is evidence of previous endocrine disturbance as indicated by a history of infertility, menstrual disorders, late menopause, obesity, and diabetes mellitus; in others no such history can be elicited. Many investigators believe that estrogens are of etiological importance in endometrial carcinoma. At any age the response of the endometrium to prolonged estrogenic stimulation is one of hyperplasia often associated with marked mitotic activity. Backer’ was the first to note the association of endometrial hyperplasia and endometrial carcinoma while Taylor’ demonstrated that endometrial hyperplasia could be a precursor of malignant change. It is generally agreed that prolonged administration of estrogens to human subjects can produce an endometrial pattern closely simulating that of carcinoma and this finding From the Unizlersity Departments of Gvnaecoloev and Patholoev. Western Infirmary,%lasgow, and thk Clinical Endocrinoloqv Research Unit (Medical Research C&cii), The Irn;rler.$ity. Edinburgh. *Prerent oddrec.v: llni~‘er,ity of Pittsburgh, Department of 0bstetric.c and Gynecology, Magee-Women.7 Hospital. Pitttburgh, Penruylvanin

15213.

D.Sc.,

has strengthened the view that these hormones may play a major role in the pathogenesis of the disease. There are few published reports of endogenous hormone levels in patients with endometrial carcinoma and in particular the relationship of estrogen levels in body fluids to the course and prognosis of the disease has not been adequately studied. The aim of this communication is to present data on the urinary excretion of estrogens together with that of other hormones in a series of patients with endometrial carcinoma and to attempt to correlate this information with the clinical and cytological findings. Materials

and

methods

Patients. The study comprises 9 patients, 8 of whom presented with the symptom of postmenopausal bleeding while the ninth had a vaginal metastasis following an extended total hysterectomy and bilateral salpingooophorectomy. None of the subjects in the series had received estrogens or radiotherapy prior to the period of study. Material obtained from the posterior vaginal fornix was studied for the presence of malignant cells and for pleomorphic features. The cornification index was determined by counting two series of 200 consecutive superficial squamous cells and the number with pyknotic nuclei was expressed as a percentage of the total.

Volume Number

91 8

Endometrial

MM ..s.: AOE 52YEARS: Pm* 4+0

A diagnostic curettage was performed in order to establish the presence of endometrial carcinoma. The following investigations were then carried out: Hemoglobin, leukocyte and platelet counts, erythrocyte sedimentation rate, urine analysis, blood sugar, liver function tests, radiological examination of chest, and intravenous pyelography : these were all normal unless otherwise stated. Design of investigation. In all cases 24 hour urine specimens were collected for periods of 5 to 8 days before definitive treatment of the endometrial carcinoma. In the 8 cases with primary endometrial-carcinoma extended total hysterectomy and bilateral salpingo-oophorectomy were performed and in all of the women daily 24 hour urine samples were collected during the postoperative period. In the patient with the vaginal metastasis, daily 24 hour urine collections were made before and after the implantation of radium needles into the tumor (Case 9). Hormone assay. The following methods were used: Human pituitary gonadotropin levels (HPG) were estimated by the method of Loraine and Brown.3 The end point of the bioassay was the mouse uterus test and results were expressed in terms of the International Reference Preparation for Human Menopausal Gonadotrophin as HMG units per 24 hour urine sample. The method of Brown, Bulbrook, and Greenwood’ was used for the determination of estriol, estrone, and estradiol. Total 17-hydroxycorticosteroids

Table I. Summary

of clinical I

Patient* 1. 2. 3. 4. 5. 6.

Mrs. Mrs. Mrs. Miss Mrs. Miss

7. Mrs. a. Mrs. 9. Miss “Malignant +Co~nification

~ A. H. M. M. A. W.

Fig. 1. Hormone excretion before

and after hysterrectomy and salpingo-oophorectomy (Case 1) The broken line indicates a result in which the reading is “less than” the figure shown.

and total 17-oxosteroids were estimated by modifications of the methods of Appleby and co-workerq5 and Vestergaard,6 respectively. Results The results of the clinical, cytological, and histoIogica1 studies are summarized in Tables I and II. Hormone assay results in individual patients are shown in Figs. 1 through 9.

/

Parity

I

IDuration

1 zt

‘~~~~~~

52 76 45 57 74 58

41-n 2+1 1 + 1 o+o 0 + 0 o+o

49 49 45 52 45 48

3 10 1 2

J. E. s. s. A. C.

76 58 64

n+1

40 46 50

present index

in assessed

all

4+0 o+o

I (‘E$$)

time

of

readmission.

I

I Cornifi-

1 #fkfe

1 Diabetes

1 ‘:g;

= _”

4

160/100 135/75 150/80 iao/ioo 160/85 140/100

7 2 6

164 177 104

200/100 lOO/SO iao/loo

-

1

for

I la2 iai ii8 133 176 152

smears. at

ENoOMETR(*L CmCINoM*

OPER*TION

I

B. C. H. B. C. S.

cells

1051

data I

Age

carcinoma

mctastatic

lesion.

-

24 49 56 48 23 Atrophic smear 36 27 58

1052

Charles

MRS

HC.AGE

Apil Am. J. Ohst.

et al.

76YEARS:

PARA2+1

ENDOMETRIAL

15, I!%:, SCCynec.

CARCINOMA

OPERATION

GONADOTROPHINS

I

I7-HYDROXYCORTICOSTEROIOS

k

I,-OXOSTEROIDS

CESTFWDiOL

15

Fig. 2. Hormone salpingo-oophorectomy

excretion before (Case 2).

20 DAY OF ,N”E&ATKlN

and

after

hysterectomy

Case 1, Mrs. A. B. (Fig. 1). During the preoperative period, from days 1 to 9, excretion values for 17-hydroxycorticosteroids, l’i-oxosteroids, and estrogens were within the normal range for postmenopausal subjects (Borth, Linder, and Riondel,’ Hamburger,8 and McBrideg). HPG readings were below the range previously encountered in hospitalized patients suffering from malignant disease (Apostolakis and Loraine*O). Following operation, a marked rise in hormone excretion was observed. In the case of HPG, the highest level was found on the eleventh day of the study while increased values for 17-hydroxycorticosteroids, 17-oxosteroids, and estrogens were noted in the immediate postoperative period. It will be seen that the rise in estriol output postdated that of 17-hydroxycortico-

30

and

steroids and 17-oxosteroids. By the sixteenth day of the investigation the readings were similar to those encountered in the control period. Case 2, Mrs. H. C. (Fig. 2). During the control period, urinary HPG levels were in general lower than those encountered in normal ambulant postmenopausal subjects (Apostolakis and Loraine.10 However, excretion vales for 17-hydroxycorticosteroids, 17-oxosteroids, and estrogens were within the normal range. Following operation no definite effect on HPG excretion was observed but a marked rise in steroid levels occurred. The very high values for 17-hydroxycorticosteroids on days 12 to 14 of the investigation should be noted. By day 17 of the study steroid levels in urine had returned to the preoperative values.

Volume Number

91 8

Endometrial

Case 3, Mrs. M. H. (Fig. 3). HPG and estrogen excretion values in the pre-operative period were within the normal range for a postmenopausal subject. Operation produced no effect on HPG excretion but there was a slight rise in estrogen excretion on day 14 of the investigation. Case 4, Miss M. B. (Fig. 4). The excretion values for HPG and estrogens prior to operation were within the normal range. Following operation a slight rise in HPG excretion occurred on day 12 of the investigation but there was no effect on estrogen output.

Table

II. Summary

of pathological

Case 5, Mrs. A. C. (Fig. 5). HPG readings in the control period were in the same range as for normal ambulant postmenopausal subjects. The abnormally high estriol levels found at the commencement of the study may represent an artifact due to drug administration (Brown, Bulbrook, and Greenwood4). The estrogen values obtained from day 6 to 10 were normal. Operation produced no effect on HPG excretion but a slight rise in estrogen output was observed. Case 6, Miss W. S. (Fig. 6). In the control period HPG and estrogen excretion values were normal. Operation produced a small rise in

pattern

1. Mrs.

A. B.

Fundus

Poorly differentiated adenocarcinoma with squamous metaplasia

Atropic

2. Mrs.

H. C.

Fundus

Papillary adenocarcinema with squamous metaplasia

Inactive cystic

3. Mrs.

M. H.

Fundus

Well-differentiated adenocarcinoma

adenomatous endometrial hyperplasia

Posterior wall

Poorly differentiated adenocarcinoma

4. Miss M. B.

-

-

t

+

Hyperplasia tubal epithelium

Atropic

t

t

-

+

5.

Mrs. A. C.

Fundus and posterior wall

Well-differentiated adenocarcinoma with high mitotic rate

Atropic

6.

Miss W. S.

Fundus

Papillary adenocarcinema with squamous metaplasia

Atropic

Anterior and posterior uterine walls

Adenocarcinoma high mitotic

Atropic

Fundus

Well-differentiated papillary adenocarcinoma

Inactive

Upper posterior wall

Poorly differentiated papillary adenocarcinoma with squamous metaplasia. Similar pattern to primary . . lesion

Atropic

7. Mrs.

8.

J. E.

Mrs. S. S.

9 Miss A. C.

*C.S.H.-Cortical

rtromal

hyperplasia;

1053

details

Tumor

Patient

carcinoma

+H.C.H.-hilar

with rate

cell

hyperplasii.

+

i

of

Metastases in left ovary and vesical peritoneum -

-

+

Metastasis vaginal

in vault

Metastases in lower third anterior vaginal wall

1054

Charles

April 15, 1965 Am. J. Obst. & Gynec.

et al.

MRS.M.H.:

AGE

45YEARS

: PARA

I+I

ENDOMETRIAL OPI

CARCINOMA

ATION

kl

r-i

OESTRIOL

OESTRONE ,

n

I OESTRADIOL

F---lYO I5

Fig. 3. Hormone (Case 3).

MISS

excretion

M.B:AGE

before

57 YEARS

and after

:PARAOtO

hysterectomy

ENDOh4ETRlAL

20 DAY OF INVESTIGATION

and salpingo-oophorectomy

CARCINOMA

GONADOTROPHINS

I I H L--I 2

I------

2

I

$0 : t

-

OESTRIOL

OESTRONE

2 0

0

OESTRADIOL

2 -Ez

0

I

I

5

I I5

I 20

DAY OF INVESTIGATION

Fig. 4. Hormone (Case 4).

excretion

before

and

after

hysterectomy

and

salpingo-oophorectomy

I

Volume Number

estrogen

91 8

Endometriol

excretion

which

was

followed

by

assays

a

The low

marked rise in urinary HPG output on day 16 and 17. At the conclusion of the study urinary HPG excretion values were stiiI above those observed Case

in the 7, Mrs.

Fig. 5. Hormone (Case 5).

control J. E.

period. (Fig. 7).

excretion

before

In

and

this

after

were

conducted

prior

carcinoma

1055

to operation

only.

excretion values for HPG as compared with ambulant

were abnormally postmenopausal

women. Values for 17-hydroxycorticosteroids, oxosteroids, and estrogens were not abnormal. Case 8, Mrs. S. S. (Fig. 8). In this patient

subject

hysterectomy

MISS W.S. AGE 58YEAIS

and

: PARA

17also

salpingo-oophorectomy

ENDOMETRIAL

0 +O OPEI

CARCINOMA

‘ON

% 4I

01

I OESTRONE

2 0

0

r

I

I 1

1

0

1

0

I

I

I

I

OESTRADIOL

t,

10 20

IS

DAY OF INVESTIGATION

Fig. 6 Hormone (Case 6).

excretion

before

and

after

hysterectomy

and

salpingo-oophorectomy

1056

Charles

et al.

Am.

MRS. JE AGE 76yeors PARAOtI ENDOMETRIAL CARCINOMA

GONADOTROPHlNS I

.f30IO 17I2015 ioc 5 $ o-x7.5,5 E so2.5o-

i‘ $0

I

I

HYDROXYCORTICOSTEF7OiDS

17-OXOSTEROIDS I 1

QESTRIOL

I

1 OFCrRONE

1 1

DAY OF INVESTIGATION

Fig. 7 Hormone excretion before hysterectomy and bilateral salpingo-oophorectomy (Case 7).

preoperative assays only were performed. Urinary HPG readings fluctuate markedly from 7 to 102 HMG units per 24 hours. Excretion values for the steroid hormones were within the normal range. Case 9, Miss A. C. (Fig. 9). In this subject hormone assays were conducted before and after implantation of radium. HPG readings obtained prior to implantation were abnormaIly low while estrogen excretion values were within the normal range. Radium implantation produced a small rise in HPG excretion on days 14 and 15 of the study; thereafter the levels fluctuated markedly. The treatment had no effect on estrogen output. Comment In the present investigation hormone assays were performed in 9 patients with endometrial carcinoma, of whom 8 were subjected to hysterectomy and bilateral salpingo-oophorectomy and one was treated with radium. In all 9 patients urinary estrogen levels during the preoperative period were within the normal range for postmenopausal subjects. This finding is in keeping with that of &own, Keller, and MatthewI who conducted similar assays in 5 patients with this dis-

April 12, 1965 J. Obst. & Gynec.

ease. Following operation a rise in estrogen output occurred in all subjects in the present series except in Cases 4 and 9; the most marked effect was observed in Cases 1 and 2. In 4 patients 17-hydroxycorticosteroids and 1 7-oxosteroids were measured, and during the preoperative period the excretion values were within the normal range. In 2 patients in whom these assays were performed postoperatively, evidence of adrenocortical hyperactivity was more marked in Case 2 than in Case 1. It is generally assumed that the 17hydroxycorticosteroids, 17-oxosteroids, and estrogens found in the urine of postmenopausal women are derived from precursors secreted by the adrenal cortex, and it is virtually certain that the increased urinary excretion of these hormones following total hysterectomy and bilateral salpingo-oophorectomy in the patients studied herein resulted from adrenocortical stimulation. In 6 of the 9 patients HPG excretion in the preoperative period was within the normal range for ambulant postmenopausal subjects and in the remaining three (Cases I, low values were re7, and 9) abnormally corded. 0peration produced an increase in HPG excretion in 3 women (Cases 1, 4, and 6) while in the remainder this effect was not noted. In the patient treated by radium implantation (Case 9) a transient rise in HPG output was observed following therapy. The reason for the variation in HPG output in individual subjects following operative stress is at present obscure and clearly merits further investigation. Sherman and Woolf” using the ventral prostatic weight test in hypophysectomized rats reported abnormally high levels of luteinizing hormone in urine in 31 patients with endometrial carcinoma. Unfortunately, in the study reported by these investigators a reference preparation was not used and for this reason the data reported are of little quantitative significance. In the present investigation in which a nonspecific assay method measuring both follicle-stimulating hormone and luteinizing hormone was employed abnormally high urinary HPG levels were not found.

Endometrial

MRS.S&:AGE

SSyean:PARA

40

.=-IN

CARCINOMA

DPE$#TlO~

Fig. 8 Hormone excretion before hysterectomy and bilateral salpingo-oophorectomy (Case 8).

carcinoma

1057

In the present series of patients many of the clinical and histological features associated with endocrine dysfunction were present. Thus, Cases 1, 2, 5, 6, 7, and 8 were obese; ovarian cortical stromal hyperplasia and hilar cell hyperplasia were present in Cases 1, 3, 4, 5, and 7 and 3, 4, and 7, respectively, and Patient 4 had diabetes mellitus. There was evidence of endometrial hyperplasia and epithelial activity of the tubal mucosa in Case 3 while squamous metaplasia was present in the endometrial carcinoma in Cases 1 and 6 and in the vaginal metastatic lesion in Case 9. The role of the estrogenic hormones in the pathogenesis of endometrial carcinoma is still in doubt. Meissner, Sommers, and ShermanI have shown in the rabbit that prolonged administration of stilbestrol is capable of causing tumor formation. In human subjects long-term estrogen therapy is only rarely associated with endometrial carcinoma although Freemont Smith and co-workers” and Bromberg, Liban, and Lauferl’ have reported isolated cases in which tumors devel-

MlSSA~:AGE64years:PARAO+O

ENDOMETRIAL

CARCINOMA

RADIUM

tooZONADOTROPHINS

90f f :

80706050-

p 40;

-

30-

120IOOESTRIOL

OESTRONE

I 0

0 OESTRADIOL

?O

Fig. 9. Hormone (Case 9).

0

0

5

excretion

IO

0

0 0 I5 xl DAY OF INVESTIGATION

before and after radium

implantation

1058

Charles et al.

oped under this form of treatment. At the time of writing the relationship between histological and morphological changes in the ovary and endometrial carcinoma has not been clarified (see Sommers and Meissner,“’ Jones and Brewer, I7 Woll and co-workers,lY and Novak and MohIe?). In the present investigation no correlation could be demonstrated between urinary estrogen excretion on the one hand and the presence of cortical stromal hyperplasia or hilar cell hyperplasia on the other. The association between ovarian tumors and cancer of the endometrium is also obscure (Manse11 and Hertig,” Kottmeier,‘l Dockerty and Mussey,22 Emge,‘” and Larson’“). In the one subject in the present series showing metastasis in the left ovary (Case 5) the hormone assay findings prior to operation were not abnormal, It has previously been suggested on the basis of cytological evidence that patients with endometrial carcinoma are likely to show abnormally high levels of estrogens in body fluids, Thus Ayre and Rauld,25 Berg and Durfee2’” and WachtelY’ have reported that the cornification index in patients with this disease is generally higher than in normal postmenopausal subjects. In the present study cytological features consistent with estrogenic activity were noted in 8 of the 9 patients studied, the remaining subject showing an atrophic vaginal smear. If no hormone assays had been conducted it might have been postulated that the 8 patients showed evidence of estrogenic activity in body fluids. However, such a conclusion is not justified because in all these subjects urinary estrogen levels were in the range normally encountered in postmenopausal women indicating virtual absence of ovarian activity. Accord-

REFERENCES

1. Backer, J,: Zcntralbl. Gynak. 28: 735, 1904. 2. Taylor, H. C., Jr.: AM. J. OBST. & GYNRC. 23: 309, 1932. :S. Loraine, J. .4., and Brown. J. B.: J. Endocrinol. 18: 77. 1959. -4. Brown, J. B.. Bulbrook, R. D., and Gremwood, F. C.: J. Endocrinol. 16: 49, 1957. 5. Appleby, J. I., Gibson, G., Norymbcrski, J.

hr.

April 15, 1965 J. Obst. & Gym.

ingly, the early maturation of parabasal to intermediate and superficial cells found in the vaginal smears of the 8 patients should probably be considered as a response to the presence of the tumor rather than as a result of excessive estrogen production by the body. Summary

Hormone assay studies in urine together with clinical and cytological observations have been performed in 8 patients with endometrial carcinoma, all of whom were treated by hysterectomy and bilateral salpingooophorectomy. In one woman with vaginal metastasis from a previous endometrial carcinoma similar studies were made before and after radium implantation. In all subjects prior to operation estrogen levels were within the normal range for postmenopausal women. In spite of this finding only one patient had an atrophic vaginal smear, the remainder showing abnormally high corniiication indices. It is, therefore, suggested that cytological evidence provides and unreliable index of estrogenic activity in patients with endometrial carcinoma. No relationship between hilar cell hyperplasia and cortical stromal hyperplasia on the one hand and urinary estrogen output on the other could be demonstrated. Followirq operation adrenocortical stimulation as judged by assays of estrogens, 17hydroxycorticosteroids: and 17-oxosteroids was observed in four out of the 6 patients studied. In none of the subjects were urinary HPG levels above the range normally found in postmenopausal women. The effect of operation on HPG excretion showed no consistent pattern.

K.. and Stuhbs, R. D.: Biochem. J. 60: 453, 1955. 6. Vestcrgaartl. P.: Ac.1;) rnclocrinol. 8: 19::. 1951. 7. Borth, R.. Lindrr, A., and Riondrl, A.: Arta endocrinol. 25: 33, 1957. 8. Hamburger, C.: Acta endocrinol. 1: 19. 1948. 9. McBride, J. M.: J. Clin. Endocrinol. 17: 1440, 1957.

Endometrial

10. 11.

Apostolakis, M., and Loraine, J. A.: J. Clin. Endocrinol. 20: 1437, 1960. Brown, J. B., Kellar, R. J., and Matthew, G. yi;,J. Obst. & Gynaec. Brit. Emp. 66: 177,.

19. 20.

12. 13. 14.

15. 16. 17. 18.

Sherman,

A.

I.,

and Woolf, R. B.: AM. J” OBST. & GYNEC. 77: 233, 1959. Meissner, W. G., Sommers, S. C., and Sherman, G.: Cancer 10: 500, 1957. Freemont Smith, M., Meigs, J. V., Graham, R. M., and Gilbert, H. H.: J. A. M. A. 131: 805, 1946. Bromberg, Y. M., Liban, E. and Laufer, A.: Obst. & Gynec. 14: 221, 1959. Sommers, S. C., and Meissner, W. A.: Cancer 10: 516, 1957. Jones, W. D., and Brewer, J. I.: AM. J. OBST. & GYNEC. 42: 207, 1941. Woll, E., Hertig, A. T., Smith, G. V. S., and

21. 22. 23. 24. 25. 26. 27.

carcinoma

1059

Johnson, L. C.: A&r. J. OBST. & GYNEC. 56: 617, 1948. Novak, E. R., and Mohler, D. I.: AM. J. OBST. & GYNEC. 65: 1099. 1953. Mansell, H., and Hertig, ‘A. T.: Obst. & Gynec. 6: 385, 1955. Kottmeier, H. L.: Acta obstet. gynec. scandinav. 27: Suppl. 1, 1947. Dockerty, M. B., and Mussey, E.: AM. J. OBST. & GYNEC. 61: 147. 1951. Emge, L. A.: Obst. & GGec. 1: 511, 1953. Larson, J. A.: Obst. & Gynec. 3: 551, 1954. Ayre, J. E., and Bauld, W. A. G.: Science 103: 441, 1946. Berg, J. W., and Durfee, G. R.: Cancer 11: 158, 1958. Wachtel, E.: J. Obst. & Gynaec. Brit. Emp. 63: 176, 1956.