Background: The incidence of complex atypical hyperplasia and early stage endometrioid endometrial cancer is increasing, in part due to the epidemic of obesity, a risk factor tightly linked to development of endometrial hyperplasia and cancer. The standard upfront treatment for complex atypical hyperplasia and early stage endometrial cancer is hysterectomy. However, non-surgical treatment of early endometrial neoplasia may be necessary due to medical co-morbidities precluding surgery or desired future fertility.
Objective: We sought to evaluate efficacy of the Levonorgestrel Intrauterine Device to treat complex atypical hyperplasia and grade 1 endometrioid endometrial carcinoma.
<strong class="sub-title"> Study design: </strong> A single-institution, single-arm, phase II study of the Levonorgestrel Intrauterine Device (52 mg levonorgestrel, Mirena®) was conducted in patients with complex atypical hyperplasia or grade 1 endometrioid endometrial cancer. The primary endpoint was pathologic response rate at <em>12</em> months, including complete or partial response. Quality of life and toxicity were assessed. Molecular analyses for proliferation markers, hormone-regulated genes, and <em>WNT</em> pathway activation were performed at baseline and 3 months.
<strong class="sub-title"> Results: </strong> Fifty-seven patients were treated (21 endometrial cancer, 36 complex atypical hyperplasia). Median age was 48.0 years, median body mass index was 45.5 kg/m<sup>2</sup>. Of 47 evaluable patients, <em>12</em>-month response rate was 83% (90%CrI 72.7, 90.3); 37 complete responders (8 endometrial cancer; 29 complex atypical hyperplasia), 2 partial responders (2 endometrial cancer), 3 stable disease (2 endometrial cancer, 1 complex atypical hyperplasia), 5 progressive disease (3 endometrial cancer; 2 complex atypical hyperplasia). After stratification for histology, response rate was 90.6% for complex atypical hyperplasia and 66.7% for grade 1 endometrioid endometrial cancer. Four patients (9.5%) had relapse after initial response. Adverse events were mild, primarily irregular bleeding and cramping. Quality of life was not negatively impacted. At 3 months, exogenous progesterone effect was present in 96.9% of responders (31/32) versus 25% (2/8) of non-responders (p=0.001). Non-responders had higher baseline proliferation (Ki67) and lower DKK3 gene expression compared to responders (p=.023 and p=0.030). Non-responders had significantly different changes in sFRP1, FZD8, and RALDH2 compared to responders.
Conclusion: The Levonorgestrel Intrauterine Device has substantial activity in complex atypical hyperplasia and grade 1 endometrioid endometrial cancer, with a modest proportion demonstrating upfront progesterone resistance. Potential biomarkers were identified that may correlate with resistance to therapy, further exploration is warranted.
Keywords: Complex Atypical Hyperplasia; Conservative; Endometrial Cancer; Endometrial Hyperplasia Intrauterine Device; Predictive Biomarkers; Progesterone.