Link between Adenomyosis and Endometrial Cancer

Link between Adenomyosis and Endometrial Cancer | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Link between Adenomyosis and Endometrial Cancer Işık Sözen, Gözde Şahin, Mahmut Yassa This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5941649/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Adenomyosis is a noncancerous condition where endometrial tissue is found within the myometrium. Prior uterine surgery, parity, and estrogen exposure are known risk factors. Evidence suggests a connection between adenomyosis and endometrial cancer. This study aimed to examine the association of adenomyosis with endometrial cancer to assess adenomyosis' role as a risk factor for endometrial cancer. Methods This study included 189 patients (aged 18–80) diagnosed with endometrial cancer and who underwent surgery at Başakşehir Çam and Sakura City Hospital between May 2020 and August 2022. Results Out of the total, 131 cases (69.3%) were diagnosed with adenomyosis, while 58 cases (30.7%) were not. There was no link found between adenomyosis and age (p = 0.17), menopausal status (p = 0.58), parity (p = 0.18), or type of delivery (p = 0.66) and CA-125 level (p = 0.9). BMI showed statistical significance in endometrial cancer patients who also had adenomyosis (p = 0.01) Conclusion Endometrial cancer co-occurrence with adenomyosis was linked solely to BMI, not other factors. Findings suggest adenomyosis is not a risk factor for, nor protective against, endometrial cancer. Endometrium BMI Myometrium What does this study adds to the clinical work? This study aimed to investigate whether adenomyosis is a risk factor for endometrial cancer. Adenomyosis is neither a risk factor nor protective against endometrial cancer, only BMI showed a statistically significance in endometrial cancer patients who have adenomyosis. Introduction Adenomyosis, a benign disease, involves the myometrium being invaded by endometrial gland and stroma [ 1, 2, 3,4,5,6]. Among the risk factors are prior uterine surgery, parity, and estrogen exposure [ 2 , 3 ]. Several theories explain how adenomyosis develops, with the leading hypothesis suggesting that a missing junctional zone allows endometrial tissue to invade the myometrium’s muscle layer [ 2 ]. Both adenomyosis and endometrial cancer (EC) are linked by unopposed estrogen as a shared risk factor. [ 7 , 8 ] EC is a prevalent gynecological cancer often diagnosed early due to noticeable symptoms [ 9 , 10 ]. Among the known risk factors are obesity, a state of high estrogen, and metabolic syndrome. The surgical stage dictates the management of EC. Hysterectomy specimens from EC patients often show adenomyosis [ 4 , 11 , 12 , 13 , 14 ]. The link between adenomyosis and EC is thought to have three possibilities. The cancer may have begun in the endometrium, metastasizing to the adenomyoma; or it could have originated in the adenomyoma, spreading to the endometrium; or it might have started simultaneously in both locations [ 3 , 15 ]. Several studies examined the connection between adenomyosis and EC [ 1 , 15 ]. Research on the relationship between adenomyosis and EC has yielded conflicting results, with some studies showing a positive correlation and others a protective effect [ 15 ]. Our study aimed to investigate the link between adenomyosis and EC, exploring adenomyosis as a potential risk factor for EC. Material and Methods Patients aged 18–80 diagnosed with EC and who underwent surgery at Başakşehir Çam and Sakura City Hospital were retrospectively studied from May 2020 to August 2022. The Ethics committee approval has been obtained. This study received ethical approval from the Başakşehir Çam and Sakura City Hospital ethics committee (date: 24.08.2022 number: 267) The study excluded patients who underwent neoadjuvant chemotherapy and did not have surgery. 189 participants underwent histopathological evaluation, dividing them into "adenomyosis (+)" and "adenomyosis (-)" groups based on adenomyosis presence. Participant demographic, clinical, and tumor data were obtained retrospectively via medical records. The following variables were analyzed: Demographic data : Age, body mass index (BMI), parity, menopausal status, and mode of delivery. Laboratory data : Serum CA-125 levels (U/mL). Tumoral characteristics : Stage, histological subtype, tumor size, grade, lymph node metastasis (present/absent), distant metastasis, lymphovascular space invasion (LVSI), and coexisting pathologies (leiomyoma, endometriosis, hyperplasia). Statistical analysis SPSS-27 software was utilized for the statistical analysis of the data. We used Kolmogorov-Smirnov and Shapiro-Wilk tests to check the normality of continuous and descriptive data. Data for a normally distributed variable are presented as mean ± standard deviation (SD). Data for a non-normally distributed variable includes minimum, maximum, and median values. A chi-square test compared the categorical data. Independent samples t-test was used to compare normally distributed numerical data. For non-normally distributed numerical data, Mann-Whitney-U and ANOVA tests were employed. A p-value less than 0.05 indicated statistical significance. Results This study enrolled 189 patients (ages 18–80) who received EC surgery at Başakşehir Çam and Sakura City Hospital between May 2020 and August 2022. Hysterectomy specimens from EC patients revealed adenomyosis in 69.3% (n = 131) of cases. Table 1 displays patient characteristics categorized by adenomyosis presence or absence. The study population had a mean age of 59.1 ± 9.4 years old. A total of 148 (78.3%) EC patients were postmenopausal, 118 (62.4%) patients were obese with a BMI over 30, and 137 (91.9%) patients were multiparous. Age (p = 0.17), menopausal status (p = 0.58), parity (p = 0.18), type of delivery (p = 0.66) and CA-125 level (p = 0.90) were not associated with adenomyosis. BMI showed statistical significance in endometrial cancer patients who also had adenomyosis (p = 0.01). The EC tumor characteristics of participants are shown in Table 2 . The prevalent stage and grade in EC patients with adenomyosis were stage 1 (80.9%, n = 106) and grade 2 (59.5%, n = 78), respectively. Among patients lacking adenomyosis, grade 2 was the most common, representing 46.6% (n = 27). Of participants with adenomyosis, a majority (90.4%, n = 103) lacked lymph node involvement, in contrast to 9.6% (n = 11). Statistical analysis revealed no significant association with tumor histology, size, stage, grade, lymph node involvement, or lymphovascular space invasion (LVSI). In EC patients, coexistence of leiomyoma was similar in the group of with adenomyosis and without adenomyosis. Leiomyoma occurrence in EC patient pathology was similar regardless of adenomyosis presence (32.8% vs. 38.9%, p = 0.58) Table 1 Characteristic variables of participants with adenomyosis Variables Total n = 189 Adenomyosis (+) n = 131 Adenomyosis (-) n = 58 p-value Age (years) 0.17 Mean (± SD) 59.1 (9.4) 59.7 (9) 57.6 (10.1) < 60 95 (50.3) 64 (48.9) 31 (53.4) ≥ 60 94 (49.7) 67 (51.1) 27 (46.6) BMI (kg/m 2 ) 0.01 Mean (± SD) 32.8 (7.1) 33.6 (7) 31.2 (7.2) < 30 71 (37.6) 43 (32.8) 28 (48.3) ≥ 30 118 (62.4) 88 (67.2) 30 (51.7) Parity 0.18 Median (min-max) 3 (0–13) 3 (0–13) 2 (0–9) Null 12 (8.1) 6 (5.8) 6 (13.3) Multi 137 (91.9) 98 (94.2) 39 (86.7) Menopause status 0.58 Premenopausal 41 (21.7) 27 (20.6) 14 (24.1) Postmenopausal 148 (78.3) 104 (79.4) 44 (75.9) Type of delivery 0.66 C/S 28 (20.3) 21 (21.2) 7 (17.9) Vaginal 110 (79.7) 78 (78.8) 32 (82.1) Ca-125 level (U/mL) 0.90 Median (min-max) 18.4 (4.2–934) 18.4 (4.2–185) 18.4 (5.6–934) < 35 146 (81.1) 102 (82.3) 44 (78.6) ≥ 35 34 (18.9) 22 (17.7) 12 (21.4) Continuous variables are presented as mean ± standard deviation (SD), while categorical variables are represented as count (percentage). For skewed continuous variables, the median and interquartile range (IQR) are presented. Ca-125: Cancer Antigen 125, max: maximum, min: minimum, ml: milliliters, SD: standard deviation, U: unite. Table 2 Tumoral characteristics of endometrial cancer Variables Total n = 189 Adenomyosis(+) n = = 131 Adenomyosis(-) n = 58 p-value Stage 0.39 1 151 (79.9) 106 (80.9) 45 (77.6) 2 14 (7.4) 11 (8.4) 3 (5.2) 3 19 (10.1) 12 (9.2) 7 (12.1) 4 5 (2.6) 2 (1.5) 3 (5.2) Grade 0.25 1 24 (12.7) 15 (11.5) 9 (15.5) 2 105 (55.6) 78 (59.5) 27 (46.6) 3 60 (31.7) 38 (29) 22 (37.9) Nodal metastasis 0.26 No 146 (88.5) 103 (90.4) 43 (84.3) Yes 19 (11.5) 11 (9.6) 8 (15.7) LVSI 0.53 No 133 (70.4) 94 (71.8) 39 (67.2) Yes 56 (29.6) 37 (28.2) 19 (32.8) Histology 0.13 Endometrioid 144 (76.2) 102 (77.9) 42 (72.4) Serous/clear cell 22 (11.6) 17 (13) 5(8.6) Others 23 (12.2) 12 (9.2) 11 (19) Coexisting findings 0.58 Leiomyoma 70 (37) 51 (38.9) 19 (32.8) Endometriosis 11 (5.8) 9 (6.9) 2 (3.4) Hyperplasia 19 (10.1) 12 (9.2) 7 (12.1) None 89 (47.1) 59 (45) 30 (51.7) Tumor size 0.16 Mean (± SD) 3.84 (2.1) 3.68 ((1.9) 4.2 (2.3) < 2,5 cm 65 (35.9) 46 (36.8) 19 (33.9) ≥ 2,5 cm 116 (64.1) 79 (63.2) 37 (66.1) Continuous variables are presented as mean ± standard deviation (SD), while categorical variables are represented as count (percentage). For skewed continuous variables, the median and interquartile range (IQR) are presented. LVSI: lymphovascular space invasion, SD: standard deviation Discussion This study investigated adenomyosis as a potential risk factor for EC. Adenomyosis, according to this study, is neither a risk nor a protective factor for EC. The prevalence of adenomyosis in EC has been reported as 10–70% in previous studies [ 15 , 16 ]. In a study by Matsuo et al. [ 10 ], adenomyosis was present in 47.5% of the EC population. In 69.3% of participants, hysterectomy specimens revealed adenomyosis. A significant number of patients have both diseases. Several factors promote both diseases, including excessive estrogen, inflammation, and molecular characteristics that encourage cell growth and inflammation. Therefore, it is unsurprising that these two conditions frequently co-occur [ 17 ]. The study by Musa et al. [ 16 ] explored the effects of adenomyosis on lymphatic metastasis. Lower-grade cancer, less myometrial invasion, and the absence of LVSI and lymph node involvement were associated with adenomyosis. Among EC patients with LVSI, the risk of lymph node involvement was minimal [ 16 ]. In EC patients, Yetimalar et al. [ 18 ] found a significant association between adenomyosis and early-stage, low-grade disease without LVSI. According to another study [ 9 ], the absence of adenomyosis was associated with a higher incidence of deep myometrial and LVSI (52.8% vs 39.4%, p = 0.02 and 53.2% vs. 38.6%, p = 0.01). There was no significant difference in 5-year recurrence-free or overall survival between the two groups [ 9 ]. Casaido et al. [ 17 ] reported improved EC prognosis for patients also having adenomyosis. Lymph node involvement (9.6% vs 15.7%) and LVSI (28.2% vs 32.8%) were similar in participants with and without adenomyosis in our study. Findings from our study indicate a possible protective effect of adenomyosis against lymph node invasion. Furthermore, our study demonstrated a low rate of co-occurrence of endometriosis (5.8%) and hyperplasia (10.1%) amongst the endometrial cancer cohort, contrasting with some earlier reports [ 15 , 19 ]. The observed inconsistencies could result from differing patient demographics (age, parity, menopausal status) and diagnostic criteria. A higher prevalence of concomitant endometriosis is observed in younger nulliparous women, unlike our cohort, which was largely comprised of multiparous women in the postmenopausal phase. Adenomyosis in EC patients was linked only to BMI in this study, with conflicting evidence regarding its role as a risk or protective factor [ 17 , 20 ]. Reviewing data from 5681 patients, researchers found no correlation between BMI and the presence of adenomyosis and EC [ 17 ]. Elevated BMI (over 25) was associated with higher EC survival rates in another study [ 20 ]. The valuable insights offered by this study should be considered considering its methodological constraints, such as the lack of longitudinal data and the restricted participant sample. Generalizability of the results is constrained by the relatively small sample size. In addition, the study's lack of a control group consisting of women without endometrial cancer prevents a definitive determination of adenomyosis's independent influence on endometrial cancer risk. To address these knowledge gaps, large-scale studies incorporating diverse populations and appropriate control groups are necessary. Future research integrating molecular and genetic analyses may reveal deeper insights into the shared pathophysiology and potential etiological relationships between adenomyosis and EC. Conclusion This study found no evidence to suggest that adenomyosis either mitigates or elevates the risk of developing EC. The high prevalence of adenomyosis in endometrial cancer patients, consistent with prior research, showed no statistically significant correlation with tumor stage, grade, lymphovascular space invasion, or lymph node metastasis. The association between adenomyosis and increased BMI in endometrial cancer patients suggests a possible role for metabolic factors in the simultaneous occurrence of both conditions. This study's limitations, including small sample size and absence of a control group, necessitate future large-scale, multicenter trials involving diverse populations to investigate the biological and clinical ramifications of adenomyosis in endometrial carcinoma. Further investigation is warranted to clarify the relationship between adenomyosis and EC, potentially leading to improved risk assessment and treatment. Declarations Author Contribution I.S. : project development, data collection, manuscript writing and editing. G. Ş. : data collection, manuscript writing M. Y. : data collection, data analysis, manuscript writing and editing. All authors reviewed the manuscript. Data Availability The data that support the findings of this study are available from the corresponding author upon reasonable request. References Raffone A, Seracchioli R, Raimondo D, Maletta M, Travaglino A, Raimondo I, et al. Prevalence of adenomyosis in endometrial cancer patients: a systematic review and meta-analysis. Arch Gynecol Obstet. 2021;303(1):47–53. Struble J, Reid S, Bedaiwy MA. Adenomyosis: A Clinical Review of a Challenging Gynecologic Condition. J Minim Invasive Gynecol. 2016;23(2):164–85. Szubert M, Kozirog E, Wilczynski J. Adenomyosis as a Risk Factor for Myometrial or Endometrial Neoplasms-Review. Int J Environ Res Public Health. 2022;19(4). Zouzoulas OD, Tsolakidis D, Efstratiou I, Pervana S, Pazarli E, Grimbizis G. Correlation between Adenomyosis and Endometrial cancer: 6-year experience of a single center. Facts Views Vis Obgyn. 2018;10(3):147–152. PMID: 31191849; PMCID: PMC6548412. Aydin HA, Toptas T, Bozkurt S, Pestereli E, Simsek T. Impact of coexistent adenomyosis on outcomes of patients with endometrioid endometrial cancer: a propensity score-matched analysis. Tumori. 2018 Jan-Feb;104(1):60–65. doi: 10.5301/tj.5000698 . PMID: 29192745. Mitranovici MI, Chiorean DM, Moraru L, Moraru R, Caravia L, Tiron AT, Cotoi TC, Toru HS, Cotoi OS. Shared Pathogenic and Therapeutic Characteristics of Endometriosis, Adenomyosis, and Endometrial Cancer: A Comprehensive Literature Review. Pharmaceuticals (Basel). 2024;17(3):311. doi: 10.3390/ph17030311 . PMID: 38543097; PMCID: PMC10976130. Wang DG, Ji LM, Jia CL, Shao MJ. Effect of coexisting adenomyosis on tumour characteristics and prognosis of endometrial cancer: A systematic review and meta-analysis. Taiwan J Obstet Gynecol. 2023;62(5):640–650. doi: 10.1016/j.tjog.2023.07.004. PMID: 37678989. Yilmaz A, Cokmez H, Gulbahar A. 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Taneichi A, Fujiwara H, Takahashi Y, Takei Y, Machida S, Saga Y, Takahashi S, Suzuki M. Influences of uterine adenomyosis on muscle invasion and prognosis of endometrioid adenocarcinoma. Int J Gynecol Cancer. 2014;24(8):1429-33. doi: 10.1097/IGC.0000000000000243 . PMID: 25188882. Gizzo S, Patrelli TS, Dall'asta A, DI Gangi S, Giordano G, Migliavacca C, Monica M, Merisio C, Nardelli GB, Quaranta M, Noventa M, Berretta R. Coexistence of adenomyosis and endometrioid endometrial cancer: Role in surgical guidance and prognosis estimation. Oncol Lett. 2016;11(2):1213–1219. doi: 10.3892/ol.2015.4032. Epub 2015 Dec 15. PMID: 26893721; PMCID: PMC4734061. Koshiyama M, Okamoto T, Ueta M. The relationship between endometrial carcinoma and coexistent adenomyosis uteri, endometriosis externa and myoma uteri. Cancer Detect Prev. 2004;28(2):94 – 8. doi: 10.1016/j.cdp.2003.12.008 . PMID: 15068832. Habiba M, Pluchino N, Petignat P, Bianchi P, Brosens IA, Benagiano G. Adenomyosis and Endometrial Cancer: Literature Review. Gynecol Obstet Invest. 2018;83(4):313–28. Musa F, Frey MK, Im HB, Chekmareva M, Ellenson LH, Holcomb K. Does the presence of adenomyosis and lymphovascular space invasion affect lymph node status in patients with endometrioid adenocarcinoma of the endometrium? Am J Obstet Gynecol. 2012;207(5):417.e1-6. Casadio P, Raffone A, Maletta M, Travaglino A, Raimondo D, Raimondo I, et al. Clinical Characteristics of Patients with Endometrial Cancer and Adenomyosis. Cancers (Basel). 2021;13(19). Yetimalar MH, Kilic D, Bezircioglu I, Yigit S. The impact of uterine adenomyosis on the histopathological risk factors and survival in patients with endometrial adenocarcinoma. J Obstet Gynaecol. 2022;42(6):2213–9. Johnatty SE, Stewart CJR, Smith D, Nguyen A, J OD, O'Mara TA, et al. Co-existence of leiomyomas, adenomyosis and endometriosis in women with endometrial cancer. Sci Rep. 2020;10(1):3621. Zhang Z, Yang B, Zhang W, Gao X, Zhao C, Zhang X, et al. Clinicopathological characteristics and survival outcomes of patients with coexistence of adenomyosis and endometrial carcinoma. Int J Clin Exp Pathol. 2018;11(2):956–62. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5941649","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":411050248,"identity":"425948fb-d103-4d7a-b776-7243739c83cb","order_by":0,"name":"Işık Sözen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYBACNgbGZgiLvQFIGFiQooXnAEiLBFEWMUMoiQQwSVg9H//hZsMfFXVy5pLPr274USDBwN/enYDfYRKJzck8Z9iMLWfnlN3sATpM4szZDQS0MDYfZmzjSdxwOyftBg9Qi4FELgEt/AebD/5sk6jfcPNM2s0/RGlhSGxO4G0zSDC4wX7sNnG2AP1izHMmwXDDmRy22zIGEjwE/SLff/yxJDDE5A2OH392880fGzn+9l78WpAAjwGYJFY5CLA/IEX1KBgFo2AUjCAAAE9PQ0MXtb9qAAAAAElFTkSuQmCC","orcid":"","institution":"Başakşehir Çam and Sakura City Hospital, Department of Gynecologic Oncology","correspondingAuthor":true,"prefix":"","firstName":"Işık","middleName":"","lastName":"Sözen","suffix":""},{"id":411050249,"identity":"f724028f-fbec-44b9-9d5c-4578728e86a0","order_by":1,"name":"Gözde Şahin","email":"","orcid":"","institution":"Başakşehir Çam and Sakura City Hospital, Department of Gynecologic Oncology","correspondingAuthor":false,"prefix":"","firstName":"Gözde","middleName":"","lastName":"Şahin","suffix":""},{"id":411050250,"identity":"48b6d7bd-f60a-408a-b6d5-b943482ccecb","order_by":2,"name":"Mahmut Yassa","email":"","orcid":"","institution":"Başakşehir Çam and Sakura City Hospital, Department of Gynecologic Oncology","correspondingAuthor":false,"prefix":"","firstName":"Mahmut","middleName":"","lastName":"Yassa","suffix":""}],"badges":[],"createdAt":"2025-02-01 11:53:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5941649/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5941649/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":77803889,"identity":"28b56687-1072-4bc3-bfa4-81e577305fce","added_by":"auto","created_at":"2025-03-05 17:08:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":641929,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5941649/v1/1f6b890a-4f1b-474c-ba1c-3dc6872f5c9d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Link between Adenomyosis and Endometrial Cancer","fulltext":[{"header":"What does this study adds to the clinical work?","content":"\u003cp\u003eThis study aimed to investigate whether adenomyosis is a risk factor for endometrial cancer. Adenomyosis is neither a risk factor nor protective against endometrial cancer, only BMI showed a statistically significance in endometrial cancer patients who have adenomyosis.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eAdenomyosis, a benign disease, involves the myometrium being invaded by endometrial gland and stroma [\u003c/p\u003e \u003cp\u003e1, 2, 3,4,5,6]. Among the risk factors are prior uterine surgery, parity, and estrogen exposure [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Several theories explain how adenomyosis develops, with the leading hypothesis suggesting that a missing junctional zone allows endometrial tissue to invade the myometrium\u0026rsquo;s muscle layer [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Both adenomyosis and endometrial cancer (EC) are linked by unopposed estrogen as a shared risk factor. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eEC is a prevalent gynecological cancer often diagnosed early due to noticeable symptoms [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Among the known risk factors are obesity, a state of high estrogen, and metabolic syndrome. The surgical stage dictates the management of EC. Hysterectomy specimens from EC patients often show adenomyosis [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe link between adenomyosis and EC is thought to have three possibilities. The cancer may have begun in the endometrium, metastasizing to the adenomyoma; or it could have originated in the adenomyoma, spreading to the endometrium; or it might have started simultaneously in both locations [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral studies examined the connection between adenomyosis and EC [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Research on the relationship between adenomyosis and EC has yielded conflicting results, with some studies showing a positive correlation and others a protective effect [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Our study aimed to investigate the link between adenomyosis and EC, exploring adenomyosis as a potential risk factor for EC.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003ePatients aged 18\u0026ndash;80 diagnosed with EC and who underwent surgery at Başakşehir \u0026Ccedil;am and Sakura City Hospital were retrospectively studied from May 2020 to August 2022. The Ethics committee approval has been obtained. This study received ethical approval from the Başakşehir \u0026Ccedil;am and Sakura City Hospital ethics committee (date: 24.08.2022 number: 267)\u003c/p\u003e \u003cp\u003eThe study excluded patients who underwent neoadjuvant chemotherapy and did not have surgery.\u003c/p\u003e \u003cp\u003e189 participants underwent histopathological evaluation, dividing them into \"adenomyosis (+)\" and \"adenomyosis (-)\" groups based on adenomyosis presence.\u003c/p\u003e \u003cp\u003eParticipant demographic, clinical, and tumor data were obtained retrospectively via medical records. The following variables were analyzed:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eDemographic data\u003c/b\u003e: Age, body mass index (BMI), parity, menopausal status, and mode of delivery.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eLaboratory data\u003c/b\u003e: Serum CA-125 levels (U/mL).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eTumoral characteristics\u003c/b\u003e: Stage, histological subtype, tumor size, grade, lymph node metastasis (present/absent), distant metastasis, lymphovascular space invasion (LVSI), and coexisting pathologies (leiomyoma, endometriosis, hyperplasia).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eSPSS-27 software was utilized for the statistical analysis of the data. We used Kolmogorov-Smirnov and Shapiro-Wilk tests to check the normality of continuous and descriptive data. Data for a normally distributed variable are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). Data for a non-normally distributed variable includes minimum, maximum, and median values. A chi-square test compared the categorical data. Independent samples t-test was used to compare normally distributed numerical data. For non-normally distributed numerical data, Mann-Whitney-U and ANOVA tests were employed. A p-value less than 0.05 indicated statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis study enrolled 189 patients (ages 18\u0026ndash;80) who received EC surgery at Başakşehir \u0026Ccedil;am and Sakura City Hospital between May 2020 and August 2022. Hysterectomy specimens from EC patients revealed adenomyosis in 69.3% (n\u0026thinsp;=\u0026thinsp;131) of cases. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e displays patient characteristics categorized by adenomyosis presence or absence. The study population had a mean age of 59.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4 years old. A total of 148 (78.3%) EC patients were postmenopausal, 118 (62.4%) patients were obese with a BMI over 30, and 137 (91.9%) patients were multiparous. Age (p\u0026thinsp;=\u0026thinsp;0.17), menopausal status (p\u0026thinsp;=\u0026thinsp;0.58), parity (p\u0026thinsp;=\u0026thinsp;0.18), type of delivery (p\u0026thinsp;=\u0026thinsp;0.66) and CA-125 level (p\u0026thinsp;=\u0026thinsp;0.90) were not associated with adenomyosis. BMI showed statistical significance in endometrial cancer patients who also had adenomyosis (p\u0026thinsp;=\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003eThe EC tumor characteristics of participants are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The prevalent stage and grade in EC patients with adenomyosis were stage 1 (80.9%, n\u0026thinsp;=\u0026thinsp;106) and grade 2 (59.5%, n\u0026thinsp;=\u0026thinsp;78), respectively. Among patients lacking adenomyosis, grade 2 was the most common, representing 46.6% (n\u0026thinsp;=\u0026thinsp;27). Of participants with adenomyosis, a majority (90.4%, n\u0026thinsp;=\u0026thinsp;103) lacked lymph node involvement, in contrast to 9.6% (n\u0026thinsp;=\u0026thinsp;11). Statistical analysis revealed no significant association with tumor histology, size, stage, grade, lymph node involvement, or lymphovascular space invasion (LVSI).\u003c/p\u003e \u003cp\u003eIn EC patients, coexistence of leiomyoma was similar in the group of with adenomyosis and without adenomyosis. Leiomyoma occurrence in EC patient pathology was similar regardless of adenomyosis presence (32.8% vs. 38.9%, p\u0026thinsp;=\u0026thinsp;0.58)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristic variables of participants with adenomyosis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;189\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdenomyosis (+)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;131\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdenomyosis (-)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;58\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMean (\u0026plusmn;\u0026thinsp;SD)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59.1 (9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.7 (9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57.6 (10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;60\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95 (50.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64 (48.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (53.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ge;\u0026thinsp;60\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94 (49.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67 (51.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (46.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMean (\u0026plusmn;\u0026thinsp;SD)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.8 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.6 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.2 (7.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;30\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (37.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (32.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (48.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ge;\u0026thinsp;30\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118 (62.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88 (67.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (51.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMedian (min-max)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (0\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (0\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNull\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (5.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMulti\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e137 (91.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98 (94.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (86.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMenopause status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePremenopausal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (20.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (24.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePostmenopausal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e148 (78.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e104 (79.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 (75.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of delivery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eC/S\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (20.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (21.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (17.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eVaginal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110 (79.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (78.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (82.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCa-125 level (U/mL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMedian (min-max)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.4 (4.2\u0026ndash;934)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.4 (4.2\u0026ndash;185)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.4 (5.6\u0026ndash;934)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;35\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e146 (81.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 (82.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 (78.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ge;\u0026thinsp;35\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (18.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (17.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eContinuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), while categorical variables are represented as count (percentage). For skewed continuous variables, the median and interquartile range (IQR) are presented. Ca-125: Cancer Antigen 125, max: maximum, min: minimum, ml: milliliters, SD: standard deviation, U: unite.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTumoral characteristics of endometrial cancer\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;189\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdenomyosis(+)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;=\u0026thinsp;131\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdenomyosis(-)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;58\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e151 (79.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e106 (80.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45 (77.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e3\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (9.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e4\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGrade\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (12.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (15.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (59.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (46.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e3\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (31.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (37.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNodal metastasis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e146 (88.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e103 (90.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43 (84.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (15.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLVSI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e133 (70.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94 (71.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (67.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (29.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (28.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (32.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEndometrioid\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e144 (76.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 (77.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42 (72.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSerous/clear cell\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (11.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5(8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOthers\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (9.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCoexisting findings\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLeiomyoma\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (38.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (32.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEndometriosis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (5.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHyperplasia\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (9.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNone\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89 (47.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (51.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTumor size\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMean (\u0026plusmn;\u0026thinsp;SD)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.84 (2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.68 ((1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.2 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;2,5 cm\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (35.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (33.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ge;\u0026thinsp;2,5 cm\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116 (64.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79 (63.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (66.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eContinuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), while categorical variables are represented as count (percentage). For skewed continuous variables, the median and interquartile range (IQR) are presented. LVSI: lymphovascular space invasion, SD: standard deviation\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated adenomyosis as a potential risk factor for EC. Adenomyosis, according to this study, is neither a risk nor a protective factor for EC.\u003c/p\u003e \u003cp\u003eThe prevalence of adenomyosis in EC has been reported as 10\u0026ndash;70% in previous studies [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In a study by Matsuo et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], adenomyosis was present in 47.5% of the EC population. In 69.3% of participants, hysterectomy specimens revealed adenomyosis. A significant number of patients have both diseases. Several factors promote both diseases, including excessive estrogen, inflammation, and molecular characteristics that encourage cell growth and inflammation. Therefore, it is unsurprising that these two conditions frequently co-occur [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study by Musa et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] explored the effects of adenomyosis on lymphatic metastasis. Lower-grade cancer, less myometrial invasion, and the absence of LVSI and lymph node involvement were associated with adenomyosis. Among EC patients with LVSI, the risk of lymph node involvement was minimal [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In EC patients, Yetimalar et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] found a significant association between adenomyosis and early-stage, low-grade disease without LVSI. According to another study [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], the absence of adenomyosis was associated with a higher incidence of deep myometrial and LVSI (52.8% vs 39.4%, p\u0026thinsp;=\u0026thinsp;0.02 and 53.2% vs. 38.6%, p\u0026thinsp;=\u0026thinsp;0.01). There was no significant difference in 5-year recurrence-free or overall survival between the two groups [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Casaido et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] reported improved EC prognosis for patients also having adenomyosis. Lymph node involvement (9.6% vs 15.7%) and LVSI (28.2% vs 32.8%) were similar in participants with and without adenomyosis in our study. Findings from our study indicate a possible protective effect of adenomyosis against lymph node invasion.\u003c/p\u003e \u003cp\u003eFurthermore, our study demonstrated a low rate of co-occurrence of endometriosis (5.8%) and hyperplasia (10.1%) amongst the endometrial cancer cohort, contrasting with some earlier reports [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The observed inconsistencies could result from differing patient demographics (age, parity, menopausal status) and diagnostic criteria. A higher prevalence of concomitant endometriosis is observed in younger nulliparous women, unlike our cohort, which was largely comprised of multiparous women in the postmenopausal phase.\u003c/p\u003e \u003cp\u003eAdenomyosis in EC patients was linked only to BMI in this study, with conflicting evidence regarding its role as a risk or protective factor [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Reviewing data from 5681 patients, researchers found no correlation between BMI and the presence of adenomyosis and EC [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Elevated BMI (over 25) was associated with higher EC survival rates in another study [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe valuable insights offered by this study should be considered considering its methodological constraints, such as the lack of longitudinal data and the restricted participant sample. Generalizability of the results is constrained by the relatively small sample size. In addition, the study's lack of a control group consisting of women without endometrial cancer prevents a definitive determination of adenomyosis's independent influence on endometrial cancer risk. To address these knowledge gaps, large-scale studies incorporating diverse populations and appropriate control groups are necessary. Future research integrating molecular and genetic analyses may reveal deeper insights into the shared pathophysiology and potential etiological relationships between adenomyosis and EC.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study found no evidence to suggest that adenomyosis either mitigates or elevates the risk of developing EC. The high prevalence of adenomyosis in endometrial cancer patients, consistent with prior research, showed no statistically significant correlation with tumor stage, grade, lymphovascular space invasion, or lymph node metastasis. The association between adenomyosis and increased BMI in endometrial cancer patients suggests a possible role for metabolic factors in the simultaneous occurrence of both conditions. This study's limitations, including small sample size and absence of a control group, necessitate future large-scale, multicenter trials involving diverse populations to investigate the biological and clinical ramifications of adenomyosis in endometrial carcinoma. Further investigation is warranted to clarify the relationship between adenomyosis and EC, potentially leading to improved risk assessment and treatment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eI.S. : project development, data collection, manuscript writing and editing. G. Ş. : data collection, manuscript writing M. Y. : data collection, data analysis, manuscript writing and editing. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRaffone A, Seracchioli R, Raimondo D, Maletta M, Travaglino A, Raimondo I, et al. Prevalence of adenomyosis in endometrial cancer patients: a systematic review and meta-analysis. Arch Gynecol Obstet. 2021;303(1):47\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStruble J, Reid S, Bedaiwy MA. Adenomyosis: A Clinical Review of a Challenging Gynecologic Condition. J Minim Invasive Gynecol. 2016;23(2):164\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSzubert M, Kozirog E, Wilczynski J. Adenomyosis as a Risk Factor for Myometrial or Endometrial Neoplasms-Review. Int J Environ Res Public Health. 2022;19(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZouzoulas OD, Tsolakidis D, Efstratiou I, Pervana S, Pazarli E, Grimbizis G. Correlation between Adenomyosis and Endometrial cancer: 6-year experience of a single center. Facts Views Vis Obgyn. 2018;10(3):147\u0026ndash;152. PMID: 31191849; PMCID: PMC6548412.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAydin HA, Toptas T, Bozkurt S, Pestereli E, Simsek T. Impact of coexistent adenomyosis on outcomes of patients with endometrioid endometrial cancer: a propensity score-matched analysis. Tumori. 2018 Jan-Feb;104(1):60\u0026ndash;65. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5301/tj.5000698\u003c/span\u003e\u003cspan address=\"10.5301/tj.5000698\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 29192745.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMitranovici MI, Chiorean DM, Moraru L, Moraru R, Caravia L, Tiron AT, Cotoi TC, Toru HS, Cotoi OS. Shared Pathogenic and Therapeutic Characteristics of Endometriosis, Adenomyosis, and Endometrial Cancer: A Comprehensive Literature Review. Pharmaceuticals (Basel). 2024;17(3):311. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ph17030311\u003c/span\u003e\u003cspan address=\"10.3390/ph17030311\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 38543097; PMCID: PMC10976130.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang DG, Ji LM, Jia CL, Shao MJ. Effect of coexisting adenomyosis on tumour characteristics and prognosis of endometrial cancer: A systematic review and meta-analysis. Taiwan J Obstet Gynecol. 2023;62(5):640\u0026ndash;650. doi: 10.1016/j.tjog.2023.07.004. PMID: 37678989.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYilmaz A, Cokmez H, Gulbahar A. Effect of coexisting adenomyosis on patients with endometrioid adenocarcinoma: Determination of intraoperative risk factors for tumor metastasis and estimation of prognosis. J Cancer Res Ther. 2022 Apr-Jun;18(3):599\u0026ndash;602. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/jcrt.JCRT_1277_20\u003c/span\u003e\u003cspan address=\"10.4103/jcrt.JCRT_1277_20\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 35900528.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoonlak S, Aue-Aungkul A, Kietpeerakool C, Kleebkaow P, Chumworathayi B, Luanratanakorn S, et al. Impact of Coexisting Uterine Adenomyosis on the Survival Outcome of Patients with Endometrial Cancer: A Retrospective Cohort Study. Asian Pac J Cancer Prev. 2019;20(4):1185\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatsuo K, Cahoon SS, Gualtieri M, Scannell CA, Jung CE, Takano T, et al. Significance of adenomyosis on tumor progression and survival outcome of endometrial cancer. Ann Surg Oncol. 2014;21(13):4246\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaimondo D, Raffone A, Travaglino A, Maletta M, Casadio P, Ambrosio M, et al. Impact of adenomyosis on the prognosis of patients with endometrial cancer. Int J Gynaecol Obstet. 2022;157(2):265\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaneichi A, Fujiwara H, Takahashi Y, Takei Y, Machida S, Saga Y, Takahashi S, Suzuki M. Influences of uterine adenomyosis on muscle invasion and prognosis of endometrioid adenocarcinoma. Int J Gynecol Cancer. 2014;24(8):1429-33. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/IGC.0000000000000243\u003c/span\u003e\u003cspan address=\"10.1097/IGC.0000000000000243\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 25188882.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGizzo S, Patrelli TS, Dall'asta A, DI Gangi S, Giordano G, Migliavacca C, Monica M, Merisio C, Nardelli GB, Quaranta M, Noventa M, Berretta R. Coexistence of adenomyosis and endometrioid endometrial cancer: Role in surgical guidance and prognosis estimation. Oncol Lett. 2016;11(2):1213\u0026ndash;1219. doi: 10.3892/ol.2015.4032. Epub 2015 Dec 15. PMID: 26893721; PMCID: PMC4734061.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoshiyama M, Okamoto T, Ueta M. The relationship between endometrial carcinoma and coexistent adenomyosis uteri, endometriosis externa and myoma uteri. Cancer Detect Prev. 2004;28(2):94\u0026thinsp;\u0026ndash;\u0026thinsp;8. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.cdp.2003.12.008\u003c/span\u003e\u003cspan address=\"10.1016/j.cdp.2003.12.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 15068832.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHabiba M, Pluchino N, Petignat P, Bianchi P, Brosens IA, Benagiano G. Adenomyosis and Endometrial Cancer: Literature Review. Gynecol Obstet Invest. 2018;83(4):313\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMusa F, Frey MK, Im HB, Chekmareva M, Ellenson LH, Holcomb K. Does the presence of adenomyosis and lymphovascular space invasion affect lymph node status in patients with endometrioid adenocarcinoma of the endometrium? Am J Obstet Gynecol. 2012;207(5):417.e1-6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCasadio P, Raffone A, Maletta M, Travaglino A, Raimondo D, Raimondo I, et al. Clinical Characteristics of Patients with Endometrial Cancer and Adenomyosis. Cancers (Basel). 2021;13(19).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYetimalar MH, Kilic D, Bezircioglu I, Yigit S. The impact of uterine adenomyosis on the histopathological risk factors and survival in patients with endometrial adenocarcinoma. J Obstet Gynaecol. 2022;42(6):2213\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnatty SE, Stewart CJR, Smith D, Nguyen A, J OD, O'Mara TA, et al. Co-existence of leiomyomas, adenomyosis and endometriosis in women with endometrial cancer. Sci Rep. 2020;10(1):3621.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Z, Yang B, Zhang W, Gao X, Zhao C, Zhang X, et al. Clinicopathological characteristics and survival outcomes of patients with coexistence of adenomyosis and endometrial carcinoma. Int J Clin Exp Pathol. 2018;11(2):956\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Endometrium, BMI, Myometrium","lastPublishedDoi":"10.21203/rs.3.rs-5941649/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5941649/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eAdenomyosis is a noncancerous condition where endometrial tissue is found within the myometrium. Prior uterine surgery, parity, and estrogen exposure are known risk factors. Evidence suggests a connection between adenomyosis and endometrial cancer. This study aimed to examine the association of adenomyosis with endometrial cancer to assess adenomyosis' role as a risk factor for endometrial cancer.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study included 189 patients (aged 18\u0026ndash;80) diagnosed with endometrial cancer and who underwent surgery at Başakşehir \u0026Ccedil;am and Sakura City Hospital between May 2020 and August 2022.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOut of the total, 131 cases (69.3%) were diagnosed with adenomyosis, while 58 cases (30.7%) were not. There was no link found between adenomyosis and age (p\u0026thinsp;=\u0026thinsp;0.17), menopausal status (p\u0026thinsp;=\u0026thinsp;0.58), parity (p\u0026thinsp;=\u0026thinsp;0.18), or type of delivery (p\u0026thinsp;=\u0026thinsp;0.66) and CA-125 level (p\u0026thinsp;=\u0026thinsp;0.9). BMI showed statistical significance in endometrial cancer patients who also had adenomyosis (p\u0026thinsp;=\u0026thinsp;0.01)\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eEndometrial cancer co-occurrence with adenomyosis was linked solely to BMI, not other factors. Findings suggest adenomyosis is not a risk factor for, nor protective against, endometrial cancer.\u003c/p\u003e","manuscriptTitle":"Link between Adenomyosis and Endometrial Cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-06 07:28:33","doi":"10.21203/rs.3.rs-5941649/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"907a9813-efad-433a-b188-302962d9f54f","owner":[],"postedDate":"February 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-05T17:08:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-06 07:28:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5941649","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5941649","identity":"rs-5941649","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}