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How JA, Jazaeri AA, Westin SN, Lawson BC, Klopp AH, Soliman PT, Lu KH. Translating biological insights into improved management of endometrial cancer. Nat Rev Clin Oncol 2024:10.1038/s41571-024-00934-7. [PMID: 39198622 DOI: 10.1038/s41571-024-00934-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2024] [Indexed: 09/01/2024]
Abstract
Endometrial cancer (EC) is the most common gynaecological cancer among women in high-income countries, with both incidence and mortality continuing to increase. The complexity of the management of patients with EC has evolved with greater comprehension of the underlying biology and heterogeneity of this disease. With a growing number of novel therapeutic agents available, emerging treatment regimens seem to have the potential to help to address the concerning trends in EC-related mortality. In this Review, we describe the epidemiology, histopathology and molecular classification of EC as well as the role of the new (2023) International Federation of Gynecologists and Obstetricians (FIGO) staging model. Furthermore, we provide an overview of disease management in the first-line and recurrent disease settings. With increasing use of molecular profiling and updates in treatment paradigms, we also summarize new developments in this rapidly changing treatment landscape.
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Affiliation(s)
- Jeffrey A How
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Amir A Jazaeri
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shannon N Westin
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Barrett C Lawson
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pamela T Soliman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Karen H Lu
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Buderath P, Dang TM, Kimmig R. Cancer-field surgery for endometrial cancer by robotic peritoneal mesometrial resection and targeted compartmental lymphadenectomy (PMMR+TCL). J Gynecol Oncol 2024; 36:36.e13. [PMID: 38945527 DOI: 10.3802/jgo.2025.36.e13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 01/18/2024] [Accepted: 05/21/2024] [Indexed: 07/02/2024] Open
Abstract
OBJECTIVE Cancer-field surgery by peritoneal mesometrial resection and targeted compartmental lymphadenectomy (PMMR+TCL) for the treatment of endometrial cancer (EC) aims at optimal locoregional tumor control without the need for adjuvant radiotherapy. In a previous publication we could demonstrate the feasibility of the method and presented encouraging first oncologic data. METHODS Following up our 2021 publication, we present data on the treatment of EC by PMMR+TCL in much larger cohort and with longer follow-up. RESULTS One hundred and thirty-five patients with EC International Federation of Gynecology and Obstetrics (FIGO) I-IV (75.6% FIGO I) underwent cancer field surgery via PMMR+TCL for EC in the years 2016-2023. Mean follow-up in our cohort was 27.5 months (0, 83; 19.7). The procedure was feasible and safe with favorable intra-and postoperative complication rates. Even though 50.4% of patients had an indication for postoperative radiotherapy following national and international guidelines, the rate of postoperative irradiation administered was 10.4%. The overall recurrence rate was 8.1% and we observed 2 (1.5%) isolated locoregional recurrences. CONCLUSION Our results confirm the feasibility and safety of PMMR+TCL in EC patients. Oncologic data are very encouraging and hint at a superior locoregional control without adjuvant irradiation. Larger studies with longer follow-up will be needed to confirm these results.
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Affiliation(s)
- Paul Buderath
- Department for Gynecology and Obstetrics, University Hospital Essen, Essen, Germany.
| | - Tra My Dang
- Department for Gynecology and Obstetrics, University Hospital Essen, Essen, Germany
| | - Rainer Kimmig
- Department for Gynecology and Obstetrics, University Hospital Essen, Essen, Germany
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Galant N, Krawczyk P, Monist M, Obara A, Gajek Ł, Grenda A, Nicoś M, Kalinka E, Milanowski J. Molecular Classification of Endometrial Cancer and Its Impact on Therapy Selection. Int J Mol Sci 2024; 25:5893. [PMID: 38892080 PMCID: PMC11172295 DOI: 10.3390/ijms25115893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/21/2024] [Accepted: 05/27/2024] [Indexed: 06/21/2024] Open
Abstract
Endometrial cancer (EC) accounts for 90% of uterine cancer cases. It is considered not only one of the most common gynecological malignancies but also one of the most frequent cancers among women overall. Nowadays, the differentiation of EC subtypes is based on immunohistochemistry and molecular techniques. It is considered that patients' prognosis and the implementation of the appropriate treatment depend on the cancer subtype. Patients with pathogenic variants in POLE have the most favorable outcome, while those with abnormal p53 protein have the poorest. Therefore, in patients with POLE mutation, the de-escalation of postoperative treatment may be considered, and patients with abnormal p53 protein should be subjected to intensive adjuvant therapy. Patients with a DNA mismatch repair (dMMR) deficiency are classified in the intermediate prognosis group as EC patients without a specific molecular profile. Immunotherapy has been recognized as an effective treatment method in patients with advanced or recurrent EC with a mismatch deficiency. Thus, different adjuvant therapy approaches, including targeted therapy and immunotherapy, are being proposed depending on the EC subtype, and international guidelines, such as those published by ESMO and ESGO/ESTRO/ESP, include recommendations for performing the molecular classification of all EC cases. The decision about adjuvant therapy selection has to be based not only on clinical data and histological type and stage of cancer, but, following international recommendations, has to include EC molecular subtyping. This review describes how molecular classification could support more optimal therapeutic management in endometrial cancer patients.
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Affiliation(s)
- Natalia Galant
- Department of Pneumonology, Oncology and Allergology, Medical University of Lublin, 20-090 Lublin, Poland; (N.G.); (P.K.); (M.N.); (J.M.)
| | - Paweł Krawczyk
- Department of Pneumonology, Oncology and Allergology, Medical University of Lublin, 20-090 Lublin, Poland; (N.G.); (P.K.); (M.N.); (J.M.)
| | - Marta Monist
- II Department of Gynecology, Medical University of Lublin, 20-090 Lublin, Poland;
| | - Adrian Obara
- Institute of Genetics and Immunology GENIM LCC, 20-609 Lublin, Poland; (A.O.); (Ł.G.)
| | - Łukasz Gajek
- Institute of Genetics and Immunology GENIM LCC, 20-609 Lublin, Poland; (A.O.); (Ł.G.)
| | - Anna Grenda
- Department of Pneumonology, Oncology and Allergology, Medical University of Lublin, 20-090 Lublin, Poland; (N.G.); (P.K.); (M.N.); (J.M.)
| | - Marcin Nicoś
- Department of Pneumonology, Oncology and Allergology, Medical University of Lublin, 20-090 Lublin, Poland; (N.G.); (P.K.); (M.N.); (J.M.)
| | - Ewa Kalinka
- Department of Oncology, Polish Mother’s Memorial Hospital-Research Institute, 93-338 Łódź, Poland;
| | - Janusz Milanowski
- Department of Pneumonology, Oncology and Allergology, Medical University of Lublin, 20-090 Lublin, Poland; (N.G.); (P.K.); (M.N.); (J.M.)
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Hsieh K, Bloom JR, Dickstein DR, Shah A, Yu C, Nehlsen AD, Resende Salgado L, Gupta V, Chadha M, Sindhu KK. Risk-Tailoring Radiotherapy for Endometrial Cancer: A Narrative Review. Cancers (Basel) 2024; 16:1346. [PMID: 38611024 PMCID: PMC11011021 DOI: 10.3390/cancers16071346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/21/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
Endometrial cancer is the most common gynecologic cancer in the United States and it contributes to the second most gynecologic cancer-related deaths. With upfront surgery, the specific characteristics of both the patient and tumor allow for risk-tailored treatment algorithms including adjuvant radiotherapy and systemic therapy. In this narrative review, we discuss the current radiation treatment paradigm for endometrial cancer with an emphasis on various radiotherapy modalities, techniques, and dosing regimens. We then elaborate on how to tailor radiotherapy treatment courses in combination with other cancer-directed treatments, including chemotherapy and immunotherapy. In conclusion, this review summarizes ongoing research that aims to further individualize radiotherapy regimens for individuals in an attempt to improve patient outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Kunal K. Sindhu
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Rios-Doria E, Cun HT, Filippova OT, Mueller JJ, Alektiar KM, Ellenson LH, Makker V, Lakhman Y, Leitao MM, Jhingran A, Soliman PT, Abu-Rustum NR. Isolated vaginal recurrence in women with stage I endometrial cancer. Gynecol Oncol 2023; 179:9-15. [PMID: 37864854 PMCID: PMC11215939 DOI: 10.1016/j.ygyno.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/10/2023] [Accepted: 10/17/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVE To compare clinical and pathologic characteristics of women with surgical stage I endometrial carcinoma by location of first recurrence and describe characteristics of isolated vaginal recurrence. METHODS Patients with 2009 International Federation of Obstetrics and Gynecology (FIGO) stage I endometrial carcinoma treated at two large cancer centers from 1/1/2009-12/31/2017 were identified. Sarcoma histology was excluded. Recurrences were grouped into isolated vaginal or extravaginal. Isolated vaginal recurrences were localized by anatomic location within the vaginal vault. Clinical and pathologic variables were compared with chi-square analysis, and Kaplan-Meier curves with log-rank tests. RESULTS Of 2815 women identified, 278 (10%) experienced a recurrence. Sixty-one patients (2%) had an isolated vaginal recurrence, including 42 (69%) at the vaginal apex; 217 (8%) had an extravaginal recurrence, including 18 with a vaginal component. Median time to recurrence was 11 months (range, 1-68) for isolated vaginal recurrence and 20 months (range, 1-98) for extravaginal recurrence (P < .004). Of 960 patients (34%) treated with adjuvant vaginal brachytherapy (VBT), 156 (16%) recurred; 19 (2%) had an isolated vaginal recurrence, including 16 (84%) at the vaginal apex. Three-year PFS rates for isolated vaginal recurrence were 97.6% (SE ± 0.4%) with minimally invasive surgery (MIS) versus 96.9% (SE ± 1.1%) with open (P = .8), and for extravaginal recurrence were 91.8% (SE ± 0.7%) with MIS versus 90.8% (SE ± 1.8%) with open (P = .8). CONCLUSIONS Isolated vaginal recurrences in stage I endometrial cancer are detected earlier than non-vaginal recurrences. Surgical approach does not appear to impact recurrence. Adjuvant VBT after primary surgery carries a 1%-2% risk of isolated vaginal apex recurrence.
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Affiliation(s)
- Eric Rios-Doria
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Han T Cun
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Olga T Filippova
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jennifer J Mueller
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Kaled M Alektiar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lora H Ellenson
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vicky Makker
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Yulia Lakhman
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mario M Leitao
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pamela T Soliman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA.
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Kuhn TM, Dhanani S, Ahmad S. An Overview of Endometrial Cancer with Novel Therapeutic Strategies. Curr Oncol 2023; 30:7904-7919. [PMID: 37754489 PMCID: PMC10528347 DOI: 10.3390/curroncol30090574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/15/2023] [Accepted: 08/25/2023] [Indexed: 09/28/2023] Open
Abstract
Endometrial cancer (EC) stands as the most prevalent gynecologic malignancy. In the past, it was classified based on its hormone sensitivity. However, The Cancer Genome Atlas has categorized EC into four groups, which offers a more objective and reproducible classification and has been shown to have prognostic and therapeutic implications. Hormonally driven EC arises from a precursor lesion known as endometrial hyperplasia, resulting from unopposed estrogen. EC is usually diagnosed through biopsy, followed by surgical staging unless advanced disease is expected. The typical staging consists of a hysterectomy with bilateral salpingo-oophorectomy and sentinel lymph node biopsies, with a preference placed on a minimally invasive approach. The stage of the disease is the most significant prognostic marker. However, factors such as age, histology, grade, myometrial invasion, lymphovascular space invasion, tumor size, peritoneal cytology, hormone receptor status, ploidy and markers, body mass index, and the therapy received all contribute to the prognosis. Treatment is tailored based on the stage and the risk of recurrence. Radiotherapy is primarily used in the early stages, and chemotherapy can be added if high-grade histology or advanced-stage disease is present. The risk of EC recurrence increases with advances in stage. Among the recurrences, vaginal cases exhibit the most favorable response to treatment, typically for radiotherapy. Conversely, the treatment of widespread recurrence is currently palliative and is best managed with chemotherapy or hormonal agents. Most recently, immunotherapy has emerged as a promising treatment for advanced and recurrent EC.
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Affiliation(s)
- Theresa M. Kuhn
- Gynecologic Oncology Program, AdventHealth Cancer Institute, Orlando, FL 32804, USA
| | - Saeeda Dhanani
- Gynecologic Oncology Program, AdventHealth Cancer Institute, Orlando, FL 32804, USA
- Philadelphia College of Osteopathic Medicine, Suwanee, GA 30024, USA
| | - Sarfraz Ahmad
- Gynecologic Oncology Program, AdventHealth Cancer Institute, Orlando, FL 32804, USA
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Martínez A, Chargari C, Kalbacher E, Gaillard AL, Leary A, Koskas M, Chopin N, Serre AA, Hardy-Bessard AC, Akladios C, Lecuru F. Recommandations pour la pratique clinique Nice/Saint-Paul-de-Vence 2022–2023 : prise en charge du cancer de l'endomètre localisé. Bull Cancer 2023; 110:6S20-6S33. [PMID: 37573036 DOI: 10.1016/s0007-4551(23)00331-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/14/2023]
Abstract
Recommendations for clinical practice, Nice/Saint-Paul-de-Vence 2022-2023: Management of localized endometrial cancer Endometrial cancer is the most frequent gynecological cancers in industrialized countries and its incidence increases. The newmolecularclassification allows determination of the risk of recurrence and helps orienting therapeutic management. Surgery remains the cornerstone of treatment. Minimally invasive approach must be preferred for stages I and II. Surgery includes hysterectomy with bilateral adnexectomy, sentinel lymph node biopsy even in high risk diseases and omentectomy for non-endometrioid tumors (except in case of clear cells tumors). Fertility preservation can be proposed in low grade, stage I tumors without myometrial involvement. In stage III/IV disease, lymph node debulking without totallymphadenectomy is indicated. In case of peritoneal carcinomatosis, first-line cytoreductive surgery is recommended if complete resection can be achieved. Adjuvant therapy is not recommended in low risk tumors. In intermediate risk tumors, curietherapy is indicated. In tumors with high-intermediate risk, curietherapy and external radiotherapy are indicated according to prognostic factors (stage II, lymphovascular invasion); adjuvant chemotherapy can be considered on a case-by-case basis. In high risk tumors, chemotherapy and external radiotherapy are recommended using a concomitant or sequential approach.
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Affiliation(s)
- Alejandra Martínez
- Département de chirurgie oncologique, institut Claudius-Regaud, institut universitaire du cancer Toulouse Oncopole, France; Centre de recherche en cancérologie de Toulouse, UMR 1037 INSERM, France.
| | - Cyrus Chargari
- Département d'oncologie-radiothérapie, hôpital de la Pitié Salpêtrière, France
| | - Elsa Kalbacher
- Département d'oncologie médicale, hôpital de Besançon, France
| | | | - Alexandra Leary
- Département d'oncologie médicale, institut Gustave-Roussy, France
| | - Martin Koskas
- Département de gynécologie-obstétrique, hôpital Bichat, France
| | - Nicolás Chopin
- Département de gynécologie-obstétrique, centre Léon-Bérard, France
| | | | | | - Chérif Akladios
- Département de gynécologie-obstétrique, hôpitaux universitaires de Strasbourg, France
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Goel P, Singh V, Sharma R, Chaudhary D, Chatterjee A, Dora T, Sancheti S, Goel A, Khandelwal S, Sali AP, Kaur H, Guru A, Kapoor R. Early endometrial carcinoma: Experience and outcomes. J Cancer Res Ther 2023; 19:S0. [PMID: 37147968 DOI: 10.4103/jcrt.jcrt_920_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Aim Endometrial carcinoma (EC) data from India are very sparse. We did a retrospective analysis of our patients registered at this peripheral cancer center based in rural Punjab and studied their outcome. Materials and Methods Ninety-eight Stage I and II EC patients with endometroid histology registered at our institute from January 2015 to April 2020 were studied for demography, histopathology, treatment received, and outcomes. FIGO 2009 staging and new European Society for Medical Oncology (ESMO) risk group classification was used. Results Our patients had a median age of 60 years (range 32-93 years). There were 39 (39.8%), 41 (42.0%), 4 (4.1%), 12 (12.2%) patients in the low risk, intermediate risk (IR), high intermediate risk, and high risk groups, respectively, as per new ESMO risk classification. Two (2.0%) patients had incomplete information to assign them to a particular risk group. Fifty (46.7%) patients underwent complete surgical staging and 54 (50.5%) patients received adjuvant RT. With a median follow-up of 27.0 months, there were 1 locoregional and 2 distant recurrences. There were 8 deaths in total. Three-year overall survival for the entire group is 90.6%. Conclusions The risk group determines adjuvant treatment in endometrial cancer. Patients operated at dedicated cancer center tend to have better surgical staging and thus better outcome because of better risk stratification and grouping for adjuvant therapy. IR histology was more common in our group of patients, which is variable as compared to available literature.
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Affiliation(s)
- Priyanka Goel
- Department of Departments of Surgical Oncology, Radiation Oncology, Medical Oncology and Pathology, Homi Bhabha Cancer Hospital, Sangrur, Punjab, India
| | - Vikram Singh
- Department of Departments of Surgical Oncology, Radiation Oncology, Medical Oncology and Pathology, Homi Bhabha Cancer Hospital, Sangrur, Punjab, India
| | - Rakesh Sharma
- Department of Departments of Surgical Oncology, Radiation Oncology, Medical Oncology and Pathology, Homi Bhabha Cancer Hospital, Sangrur, Punjab, India
| | - Debashish Chaudhary
- Department of Departments of Surgical Oncology, Radiation Oncology, Medical Oncology and Pathology, Homi Bhabha Cancer Hospital, Sangrur, Punjab, India
| | - Abhishek Chatterjee
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Tapas Dora
- Department of Departments of Surgical Oncology, Radiation Oncology, Medical Oncology and Pathology, Homi Bhabha Cancer Hospital, Sangrur, Punjab, India
| | - Sankalp Sancheti
- Department of Departments of Surgical Oncology, Radiation Oncology, Medical Oncology and Pathology, Homi Bhabha Cancer Hospital, Sangrur, Punjab, India
| | - Alok Goel
- Department of Departments of Surgical Oncology, Radiation Oncology, Medical Oncology and Pathology, Homi Bhabha Cancer Hospital, Sangrur, Punjab, India
| | - Sachin Khandelwal
- Department of Departments of Surgical Oncology, Radiation Oncology, Medical Oncology and Pathology, Homi Bhabha Cancer Hospital, Sangrur, Punjab, India
| | - Akash Pramod Sali
- Department of Departments of Surgical Oncology, Radiation Oncology, Medical Oncology and Pathology, Homi Bhabha Cancer Hospital, Sangrur, Punjab, India
| | - Harpreet Kaur
- Department of Nursing, Homi Bhabha Cancer Hospital, Sangrur, Punjab, India
| | - Arvind Guru
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Rakesh Kapoor
- Department of Departments of Surgical Oncology, Radiation Oncology, Medical Oncology and Pathology, Homi Bhabha Cancer Hospital, Sangrur, Punjab, India
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Gupta N, Pandey A, Dimri K, Sehgal A, Bhagat R, Suraj, Gill G. Endometrial cancer risk factors, treatment, and survival outcomes as per the European Society for Medical Oncology (ESMO) - European Society of Gynaecological Oncology (ESGO) - European Society for Radiotherapy and Oncology (ESTRO) risk groups and International Federation of Gynecology and Obstetrics (FIGO) staging: An experience from developing world. J Cancer Res Ther 2023; 19:701-707. [PMID: 37470597 DOI: 10.4103/jcrt.jcrt_1173_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Introduction There is limited data on endometrial cancer from developing countries. The risk groups as defined by the ESMO-ESGO-ESTRO and their recommendations for adjuvant treatment have redefined the management protocols. In this retrospective analysis, the outcomes are assessed in the light of the new risk groups and FIGO staging. Material Methods One hundred and two patients of endometrial cancer reporting to the Department of Radiation Oncology from 2015 to 2019 were analysed retrospectively. Patients were stratified as per the ESMO-ESGO-ESTRO risk groups and FIGO staging. Patients were analysed for demographic profile, histopathology details, FIGO stage, treatment modalities received as per the ESMO-ESGO-ESTRO risk groups and the outcomes in terms of disease free survival and overall survival. Results A total of 102 patients were analysed. The mean age at presentation was 57.7 years. Seventy four percent (74.41%) were stage I patients, 14.7 % were stage II, 8.8% were stage III and remaining 2% were stage IV. The mean disease free survival for the patients in FIGO stage I, II, III and IV were found to be 63.5 (59.9 - 67) months, 60.5 (54.2 - 66.9) months, 30.9 (21.5 - 40.2) months and 15.4 (7.8 - 23.0) months respectively. The 5-year overall survival of patients in Stage I was 90.3%. The 3-year mortality of Stage III patients was 58.3%. While there was no mortality observed among Stage II patients, none of the Stage IV patient survived beyond 20 months. The 5-year disease-free survival for patients in Low Risk (LR) group, Intermediate Risk (IR) group and High Risk (HR) group was found to be 91.3%, 90% and 87% respectively. None of the patient in High Intermediate Risk (HIR) group experienced progression of disease and 33.3% patients in advanced group were disease free at 2 years follow-up. The multivariate analysis showed that lymph node involvement is significantly associated with disease-free (p=0.03) and overall survival (p=0.04). Conclusion Even in the developing world, majority of patients present in early stage with survival outcomes comparable to the West. FIGO stage and lymph node involvement continue to be the most important prognostic markers for disease outcomes.
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Affiliation(s)
- Nidhi Gupta
- Department of Radiation Oncology, Government Medical College and Hospital, Chandigarh, India
| | - Awadhesh Pandey
- Department of Radiation Oncology, Government Medical College and Hospital, Chandigarh, India
| | - Kislay Dimri
- Department of Radiation Oncology, Government Medical College and Hospital, Chandigarh, India
| | - Alka Sehgal
- Department of Obstetrics and Gynaecology, Government Medical College and Hospital, Chandigarh, India
| | - Ranjeev Bhagat
- Department of Pathology, Government Medical College and Hospital, Chandigarh, India
| | - Suraj
- Department of Radiation Oncology, Government Medical College and Hospital, Chandigarh, India
| | - Gurbir Gill
- Department of Radiation Oncology, Government Medical College and Hospital, Chandigarh, India
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10
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The Polish Society of Gynecological Oncology Guidelines for the Diagnosis and Treatment of Endometrial Carcinoma (2023). J Clin Med 2023; 12:jcm12041480. [PMID: 36836017 PMCID: PMC9959576 DOI: 10.3390/jcm12041480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Due to the increasing amount of published data suggesting that endometrial carcinoma is a heterogenic entity with possible different treatment sequences and post-treatment follow-up, the Polish Society of Gynecological Oncology (PSGO) has developed new guidelines. AIM to summarize the current evidence for diagnosis, treatment, and follow-up of endometrial carcinoma and to provide evidence-based recommendations for clinical practice. METHODS The guidelines have been developed according to standards set by the guideline evaluation tool AGREE II (Appraisal of Guidelines for Research and Evaluation). The strength of scientific evidence has been defined in agreement with The Agency for Health Technology Assessment and Tariff System (AOTMiT) guidelines for scientific evidence classification. The grades of recommendation have been based on the strength of evidence and the level of consensus of the PSGO development group. CONCLUSION Based on current evidence, both the implementation of the molecular classification of endometrial cancer patients at the beginning of the treatment sequence and the extension of the final postoperative pathological report of additional biomarkers are needed to optimize and improve treatment results as well as to pave the route for future clinical trials on targeted therapies.
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11
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Jreij M, El Ahmar A, Finianos P. Applicators used for vaginal high dose rate brachytherapy: Effect of type and shape on dose distribution and toxicity, a literature review. Cancer Radiother 2023; 27:80-85. [PMID: 35973915 DOI: 10.1016/j.canrad.2021.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 10/26/2021] [Indexed: 02/06/2023]
Abstract
The aim of this article is to represent a literature review on the applicators used for vaginal high dose rate brachytherapy for patients with endometrial cancer. The different types and shapes of the clinically used applicator as well as the effects of their characteristics on dose distribution, target coverage and dose received by organs at risk are discussed in detail.
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Affiliation(s)
- Mirna Jreij
- American University of Science and Technology, Beirut, Lebanon.
| | - Ali El Ahmar
- American University of Science and Technology, Beirut, Lebanon
| | - Pascal Finianos
- American University of Science and Technology, Beirut, Lebanon
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Harkenrider MM, Abu-Rustum N, Albuquerque K, Bradfield L, Bradley K, Dolinar E, Doll CM, Elshaikh M, Frick MA, Gehrig PA, Han K, Hathout L, Jones E, Klopp A, Mourtada F, Suneja G, Wright AA, Yashar C, Erickson BA. Radiation Therapy for Endometrial Cancer: An American Society for Radiation Oncology Clinical Practice Guideline. Pract Radiat Oncol 2023; 13:41-65. [PMID: 36280107 DOI: 10.1016/j.prro.2022.09.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE With the results of several recently published clinical trials, this guideline informs on the use of adjuvant radiation therapy (RT) and systemic therapy in the treatment of endometrial cancer. Updated evidence-based recommendations provide indications for adjuvant RT and the associated techniques, the utilization and sequencing of adjuvant systemic therapies, and the effect of surgical staging techniques and molecular tumor profiling. METHODS The American Society for Radiation Oncology convened a multidisciplinary task force to address 6 key questions that focused on the adjuvant management of patients with endometrial cancer. The key questions emphasized the (1) indications for adjuvant RT, (2) RT techniques, target volumes, dose fractionation, and treatment planning aims, (3) indications for systemic therapy, (4) sequencing of systemic therapy with RT, (5) effect of lymph node assessment on utilization of adjuvant therapy, and (6) effect of molecular tumor profiling on utilization of adjuvant therapy. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for quality of evidence grading and strength of recommendation. RESULTS The task force recommends RT (either vaginal brachytherapy or external beam RT) be given based on the patient's clinical-pathologic risk factors to reduce risk of vaginal and/or pelvic recurrence. When external beam RT is delivered, intensity modulated RT with daily image guided RT is recommended to reduce acute and late toxicity. Chemotherapy is recommended for patients with International Federation of Gynecology and Obstetrics (FIGO) stage I to II with high-risk histologies and those with FIGO stage III to IVA with any histology. When sequencing chemotherapy and RT, there is no prospective data to support an optimal sequence. Sentinel lymph node mapping is recommended over pelvic lymphadenectomy for surgical nodal staging. Data on sentinel lymph node pathologic ultrastaging status supports that patients with isolated tumor cells be treated as node negative and adjuvant therapy based on uterine risk factors and patients with micrometastases be treated as node positive. The available data on molecular characterization of endometrial cancer are compelling and should be increasingly considered when making recommendations for adjuvant therapy. CONCLUSIONS These recommendations guide evidence-based best clinical practices on the use of adjuvant therapy for endometrial cancer.
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Affiliation(s)
- Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois.
| | - Nadeem Abu-Rustum
- Department of Gynecologic Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Kevin Albuquerque
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Kristin Bradley
- Department of Radiation Oncology, University of Wisconsin, Madison, Wisconsin
| | | | - Corinne M Doll
- Department of Radiation Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Mohamed Elshaikh
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, Michigan
| | - Melissa A Frick
- Department of Radiation Oncology, Stanford University, Palo Alto, California
| | - Paola A Gehrig
- Division of Gynecologic Oncology, University of Virginia, Charlottesville, Virginia
| | - Kathy Han
- Department of Radiation Oncology, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Lara Hathout
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Ellen Jones
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Ann Klopp
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Firas Mourtada
- Department of Radiation Oncology, Sidney Kimmel Cancer Center at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Gita Suneja
- Department of Radiation Oncology, Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah
| | - Alexi A Wright
- Department of Medical Oncology, Dana-Farber Cancer Center, Boston, Massachusetts
| | - Catheryn Yashar
- Department of Radiation Oncology, University of California, San Diego, California
| | - Beth A Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Cebecik Özmüş D, Güzelöz Z, Şancı M. Evaluation of vaginal brachytherapy for treating early-stage endometrial cancer according to the European Society of Medical Oncology 2020 risk stratification. Turk J Obstet Gynecol 2022; 19:308-314. [DOI: 10.4274/tjod.galenos.2022.47835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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14
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Zammarrelli WA, Kim SH, Da Cruz Paula A, Rios-Doria EV, Ehmann S, Yeoshoua E, Hanlon EJ, Zhou Q, Iasonos A, Alektiar KM, Aghajanian C, Makker V, Leitao MM, Abu-Rustum NR, Ellenson LH, Weigelt B, Mueller JJ. Risk Stratification of Stage I Grade 3 Endometrioid Endometrial Carcinoma in the Era of Molecular Classification. JCO Precis Oncol 2022; 6:e2200194. [PMID: 36240474 PMCID: PMC9616646 DOI: 10.1200/po.22.00194] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/07/2022] [Accepted: 07/27/2022] [Indexed: 02/16/2023] Open
Abstract
PURPOSE The role of adjuvant therapy in stage I grade 3 endometrioid endometrial carcinoma (EEC) is debatable. We sought to define the agreement between Post Operative Radiation Therapy in Endometrial Carcinoma 1 (PORTEC-1) high-intermediate risk (HIR) and Gynecologic Oncology Group (GOG)-99 HIR criteria, assess their concordance with The Cancer Genome Atlas molecular subtypes, and evaluate oncologic outcomes in this population. METHODS We identified patients with stage I grade 3 EECs who underwent surgical staging at our institution from January 2014 to January 2020. Patients were stratified into PORTEC-1 HIR, GOG-99 HIR, and The Cancer Genome Atlas molecular subtypes. Adjuvant treatment, and progression-free survival (PFS), and overall survival (OS) were analyzed. RESULTS Seventy-five patients were included. The agreement between PORTEC-1 and GOG-99 HIR classification was 68% (95% CI, 56.2 to 78.3), with a kappa of 0.36 (P = .001). There was no agreement between PORTEC-1 or GOG-99 HIR classification and a dichotomized molecular classification (copy number-high [CN-H] v other subtypes), with a kappa of 0.03 (P = .39) and -0.03 (P = .601), respectively. There was no difference in PFS between PORTEC-1 HIR and non-HIR (HR, 10.9; 95% CI, 0.28 to 4.21) or between GOG-99 HIR and non-HIR (HR, 1.22; 95% CI, 0.32 to 4.6) stage I grade 3 EECs. Patients with CN-H compared with non-CN-H EEC had worse PFS (HR, 5.67; 95% CI, 1.73 to 18.63) and OS (HR, 5.05; 95% CI, 1.13 to 22.5). CONCLUSION In surgically staged patients with stage I grade 3 EEC, PORTEC-1 and GOG-99 HIR criteria were not prognostic and did not identify CN-H patients. Patients with CN-H EEC had worse PFS and OS compared with those with other molecular subtypes. The integration of the molecular classification with recognized clinicopathologic factors may identify patients with higher-risk stage I grade 3 EEC who benefit from additional therapy.
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Affiliation(s)
- William A. Zammarrelli
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sarah H. Kim
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Arnaud Da Cruz Paula
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Eric V. Rios-Doria
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sarah Ehmann
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Effi Yeoshoua
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Etta J. Hanlon
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Qin Zhou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alexia Iasonos
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kaled M. Alektiar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Carol Aghajanian
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Vicky Makker
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Mario M. Leitao
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY
| | - Nadeem R. Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY
| | - Lora H. Ellenson
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Britta Weigelt
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jennifer J. Mueller
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY
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15
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Espenel S, Pointreau Y, Genestie C, Durdux C, Haie-Meder C, Chargari C. [Molecular-integrated risk profile: An opportunity for therapeutic de-escalation in intermediate and high-intermediate risk endometrial cancer]. Cancer Radiother 2022; 26:931-937. [PMID: 36031498 DOI: 10.1016/j.canrad.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/05/2022] [Indexed: 10/15/2022]
Abstract
In Europe, endometrial cancer is the fourth most common cancer among women. The majority of patients are diagnosed at a localized stage. For these patients, the standard of care is based on an hysterectomy with salpingo oophorectomy±lymph node staging. Through the assessment of histopathologic features, risk groups are determined: low, intermediate, high-intermediate, and high risk. Adjuvant strategies are guided by these risk groups. While the prognosis of low-risk and high-risk is well known, that of intermediate and high-intermediate risk is more heterogeneous, and the therapeutic index of adjuvant treatments is more questionable. Several trials (PORTEC [Post Operative Radiation Therapy in Endometrial Carcinoma] I, GOG [Gynecologic Oncology Group] 99, ASTEC [A Study in the Treatment of Endometrial Cancer] EN.5, PORTEC II, Sorbe et al trial) have assessed observation, vaginal cuff brachytherapy and/or pelvic external beam radiotherapy in this population. Vaginal cuff brachytherapy reduces the local recurrence rate, and pelvic external beam radiotherapy the pelvic recurrence rate. However, no benefit in terms of overall survival or occurrence of distant metastases is highlighted. Compared to observation, brachytherapy and above all external beam radiotherapy are associated with an increased morbidity, and with a decreased quality of life. In order to improve the therapeutic ratio and to optimize medico-economic decisions, therapeutic de-escalation strategies, based on the molecular profiles, are emerging in clinical trials, and in the recommendations for the management of intermediate and high-intermediate risk endometrial cancers. The four main molecular profiles highlighted by the genomic analyzes of The Cancer Genome Atlas (TCGA) - POLE (polymerase epsilon) mutation, non-specific molecular profile, MMR (MisMatch repair) deficiency, and p53 mutation - but also the quantification of lymphovascular space invasion (absent, focal or substantial), and the assessment of L1CAM (L1 cell adhesion molecule) overexpression represent growing concerns. Thus, the use of molecular-integrated risk profile to determine the best adjuvant treatment represent a major way to personalize adjuvant treatment of endometrial cancers, with therapeutic de-escalation opportunity for around half of the high-intermediate risks. However, in the absence of prospective data, inclusion in clinical trials assessing molecular profile-based treatment remains the best therapeutic opportunity.
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Affiliation(s)
- S Espenel
- Département de radiothérapie, Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France.
| | - Y Pointreau
- Département de radiothérapie, ILC-Institut interrégionaL de cancérologie, centre Jean-Bernard, 72000 Le Mans, France; Département de radiothérapie, centre régional universitaire de cancérologie Henry-S.-Kaplan, 37044 Tours, France
| | - C Genestie
- Département d'anatomopathologie, Gustave-Roussy, 94805 Villejuif, France
| | - C Durdux
- Département de radiothérapie, hôpital européen Georges-Pompidou, 75015 Paris, France
| | - C Haie-Meder
- Département d'oncologie radiothérapie, Centre de cancérologie, 92250 La Garenne-Colombes, France
| | - C Chargari
- Département de radiothérapie, Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France; Institut de recherche biomédicale des armées, 91220 Brétigny-sur-Orge, France
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16
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Garg V, Jayaraj AS, Kumar L. Novel approaches for treatment of endometrial carcinoma. Curr Probl Cancer 2022; 46:100895. [PMID: 35986972 DOI: 10.1016/j.currproblcancer.2022.100895] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 07/26/2022] [Accepted: 07/26/2022] [Indexed: 11/03/2022]
Abstract
Endometrial cancer (EC) is common malignancy in women and its incidence is slowly on the rise. Accurate surgical staging, with aggressive cytoreduction when indicated, remains the most critical step in the treatment. Careful pathological evaluation and/or molecular risk stratification guides for proper systemic adjuvant radiotherapy ± chemotherapy. Recurrent and metastatic EC has dismal prognosis and palliative therapies (chemotherapy, hormonal therapy or radiation) forms the backbone of treatment. There is an unmet need of newer therapies to improve survival in such cases. A number of tyrosine kinase inhibitors are currently under evaluation. Recent data on therapeutic targeting of HER2 positive serous EC is exciting. Data on check point inhibitors particularly based on biomarker select population has raised hope for potentially effective treatment for women with high risk endometrial cancer .
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Affiliation(s)
- Vikas Garg
- Department of Medical Oncology and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Aarthi S Jayaraj
- Department of Medical Oncology and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Lalit Kumar
- Department of Medical Oncology and Gynaecology, All India Institute of Medical Sciences, New Delhi, India.
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17
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Barretina-Ginesta MP, Quindós M, Alarcón JD, Esteban C, Gaba L, Gómez C, Fidalgo JAP, Romero I, Santaballa A, Rubio-Pérez MJ. SEOM-GEICO clinical guidelines on endometrial cancer (2021). Clin Transl Oncol 2022; 24:625-634. [PMID: 35312947 PMCID: PMC8986694 DOI: 10.1007/s12094-022-02799-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2022] [Indexed: 11/28/2022]
Abstract
Endometrial cancer (EC) is the second most common gynecological malignancy worldwide, the first in developed countries [Sung et al. in CA Cancer J Clin 71:209–249, 2021]. Although a majority is diagnosed at an early stage with a low risk of relapse, an important proportion of patients will relapse. Better knowledge of molecular abnormalities is crucial to identify high-risk groups in early stages as well as for recurrent or metastatic disease for whom adjuvant treatment must be personalized. The objective of this guide is to summarize the current evidence for the diagnosis, treatment, and follow-up of EC, and to provide evidence-based recommendations for clinical practice.
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Affiliation(s)
- María Pilar Barretina-Ginesta
- Medical Oncology Department, Institut Català d'Oncologia (ICO), Department of Medical Sciences, Girona Biomedical Research Institute (IDIBGI). Department of Medical Sciences, Medical School University of Girona (UdG), Girona, Spain.
| | - María Quindós
- Medical Oncology Department, Complexo Hospitalario Universitario de A Coruña. Biomedical Research Institute (INIBIC), A Coruña, Spain
| | - Jesús Damián Alarcón
- Medical Oncology Department, Hospital Universitari Son Espases, Fundació Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | - Carmen Esteban
- Medical Oncology Department, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Lydia Gaba
- Medical Oncology Department, Hospital Clínic of Barcelona, Therapeutics in Solid Tumors, Translational Genomic and Targeted, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - César Gómez
- Department of Medical Oncology, Infanta Sofía and Henares Hospitals Foundation for Biomedical Research and Innovation (FIIB HUIS HHEN), Infanta Sofía University Hospital, Madrid, Spain
| | - José Alejandro Pérez Fidalgo
- Medical Oncology Department, Hospital Clínico Universitario of Valencia. Biomedical Research Institute INCLIVA. CIBERONC, Valencia, Spain
| | - Ignacio Romero
- Department of Medical Oncology, Fundación Instituto Valenciano de Oncología (IVO), Valencia, Spain
| | - Ana Santaballa
- Medical Oncology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - María Jesús Rubio-Pérez
- Medical Oncology Department, Hospital Universitario Reina Sofía. University of Córdoba, Córdoba, Spain
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van den Heerik ASVM, Horeweg N, Creutzberg CL, Nout RA. Vaginal brachytherapy management of stage I and II endometrial cancer. Int J Gynecol Cancer 2022; 32:304-310. [DOI: 10.1136/ijgc-2021-002493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/30/2021] [Indexed: 11/04/2022] Open
Abstract
Adjuvant radiotherapy is an important component of post-operative therapy for patients with early-stage endometrial cancer. In the past decades, many trials have been conducted to determine the optimal adjuvant treatment strategy, pelvic external beam radiotherapy or vaginal brachytherapy. As a result, vaginal brachytherapy became the treatment of choice for patients with early-stage endometrial cancer at high-intermediate risk, based on clinicopathological risk factors. Vaginal brachytherapy maximizes local control and has only mild side effects with limited impact on quality of life, in comparison with pelvic external beam radiotherapy. The most frequently used treatment schedule is the one which was used in the PORTEC-2 trial (21 Gy in three fractions specified at 5 mm depth) and, whenever available, image-guided brachytherapy should be used. However, the most convenient and effective treatment schedule remains to be established. More recently, the discovery and integration of four molecular classes in the risk assessment of endometrial cancer patients has created new opportunities to prevent over- and undertreatment. The 2021 endometrial cancer guideline of the European Society of Gynaecological Oncology (ESGO), European Society for Radiotherapy and Oncology (ESTRO), and the European Society of Pathology (ESP) now proposes an integrated risk stratification, in which both clinicopathologic and molecular factors are combined, to direct adjuvant therapy. This rationale is now investigated in multiple prospective trials. This review provides an overview of the rationale and currently recommended and new strategies for vaginal brachytherapy in patients with stage I and II endometrial cancer.
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19
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Edwards DM, Jolly S. External beam management of stage I and II uterine cancer. Int J Gynecol Cancer 2022; 32:297-303. [DOI: 10.1136/ijgc-2021-002472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/02/2021] [Indexed: 12/24/2022] Open
Abstract
This review article highlights the treatment paradigms for early-stage endometrial cancer with a focus on the role of external beam radiation therapy. We aim for this review to serve as an introductory resource for gynecological oncologists, radiation oncologists, medical oncologists, and other practitioners to understand the treatments for this disease. The main treatment of endometrial cancer is surgical resection with total hysterectomy and bilateral salpingo-oophorectomy. The benefit of adjuvant radiation after surgery is primarily to prevent local recurrence. Patients with low risk of recurrence can be observed post-operatively. Vaginal cuff brachytherapy, which has been shown to be equally effective as pelvic radiation with fewer side effects, is typically recommended for high–intermediate risk patients (with characteristics such as lymphovascular space invasion, high grade, or significant myometrial invasion). In the adjuvant setting, pelvic radiation therapy is reserved for patients who have deeply invasive stage I grade 2 or 3 disease, stage II disease, and non-endometrioid histologies. In patients who are not medically operable, definitive treatment consists of brachytherapy±pelvic external beam radiation therapy. We have highlighted the main acute and long-term side effects of pelvic radiation as well as recommendations for symptom management and summarized promising evidence showing improved rates of toxicities with more conformal radiation techniques.
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The role for vaginal cuff brachytherapy boost after external beam radiation therapy in endometrial cancer. Brachytherapy 2022; 21:177-185. [PMID: 35210017 DOI: 10.1016/j.brachy.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 10/10/2021] [Accepted: 10/19/2021] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the role and technique of a vaginal cuff brachytherapy (VB) boost to adjuvant external beam (EB) radiation for endometrial cancer through a systematic review. METHODS AND MATERIALS Relevant trials were identified through a systematic search of the literature. RESULTS A total of 21 prospective and retrospective studies which had a patient cohort undergoing EB + VB was identified to evaluate for rates of vaginal and pelvic recurrences, overall survival, and toxicity. Additional database studies were utilized to demonstrate differences in local control and overall survival between EB and EB + VB. CONCLUSIONS While there is limited prospective evidence to guide the use of a VB boost after EB, the evidence suggests that patients with a higher risk of a vaginal recurrence such as those with cervical stromal involvement in select Stage III patients may derive local control and survival benefits from a VB boost. Additional individual risk factors such as grade, histology, extent of invasion, margin status, age, and the use of lower doses of EB should be considered when deciding when to add a VB boost.
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21
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Glatzer M, Tanderup K, Rovirosa A, Fokdal L, Ordeanu C, Tagliaferri L, Chargari C, Strnad V, Dimopoulos JA, Šegedin B, Cooper R, Nakken ES, Petric P, van der Steen-Banasik E, Lössl K, Jürgenliemk-Schulz IM, Niehoff P, Hermansson RS, Nout RA, Putora PM, Plasswilm L, Tselis N. Role of Brachytherapy in the Postoperative Management of Endometrial Cancer: Decision-Making Analysis among Experienced European Radiation Oncologists. Cancers (Basel) 2022; 14:cancers14040906. [PMID: 35205653 PMCID: PMC8869913 DOI: 10.3390/cancers14040906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/01/2022] [Accepted: 02/05/2022] [Indexed: 02/05/2023] Open
Abstract
Simple Summary There are various society-specific guidelines addressing adjuvant brachytherapy (BT) after surgery for endometrial cancer (EC). However, these recommendations are not uniform. Against this background, clinicians need to make decisions despite gaps between best scientific evidence and clinical practice. We analysed decision criteria influencing the selection for adjuvant radiotherapy among European radiation oncology experts. For this, GEC-ESTRO provided 19 European radiation oncology experts on gynaecological brachytherapy for decision-making analyses. The manuscript presents patterns in decision-making among these experts and demonstrates areas of consensus/discrepancies. We also analysed dose prescription and techniques of brachytherapy. This analysis is of special value as the objective approach enabled us to obtain an unbiased description of decision-making among the specialists (the study was not aimed to create or enforce a consensus). The manuscript provides valuable insight into clinical decision-making with a high impact on treatment selection, as expected differences between experts were observed. With this manuscript we are able to visualize and quantify these. This information is relevant for interdisciplinary discussions. Abstract Background: There are various society-specific guidelines addressing adjuvant brachytherapy (BT) after surgery for endometrial cancer (EC). However, these recommendations are not uniform. Against this background, clinicians need to make decisions despite gaps between best scientific evidence and clinical practice. We explored factors influencing decision-making for adjuvant BT in clinical routine among experienced European radiation oncologists in the field of gynaecological radiotherapy (RT). We also investigated the dose and technique of BT. Methods: Nineteen European experts for gynaecological BT selected by the Groupe Européen de Curiethérapie and the European Society for Radiotherapy & Oncology provided their decision criteria and technique for postoperative RT in EC. The decision criteria were captured and converted into decision trees, and consensus and dissent were evaluated based on the objective consensus methodology. Results: The decision criteria used by the experts were tumour extension, grading, nodal status, lymphovascular invasion, and cervical stroma/vaginal invasion (yes/no). No expert recommended adjuvant BT for pT1a G1-2 EC without substantial LVSI. Eighty-four percent of experts recommended BT for pT1a G3 EC without substantial LVSI. Up to 74% of experts used adjuvant BT for pT1b LVSI-negative and pT2 G1–2 LVSI-negative disease. For 74–84% of experts, EBRT + BT was the treatment of choice for nodal-positive pT2 disease and for pT3 EC with cervical/vaginal invasion. For all other tumour stages, there was no clear consensus for adjuvant treatment. Four experts already used molecular markers for decision-making. Sixty-five percent of experts recommended fractionation regimens of 3 × 7 Gy or 4 × 5 Gy for BT as monotherapy and 2 × 5 Gy for combination with EBRT. The most commonly used applicator for BT was a vaginal cylinder; 82% recommended image-guided BT. Conclusions: There was a clear trend towards adjuvant BT for stage IA G3, stage IB, and stage II G1–2 LVSI-negative EC. Likewise, there was a non-uniform pattern for BT dose prescription but a clear trend towards 3D image-based BT. Finally, molecular characteristics were already used in daily decision-making by some experts under the pretext that upcoming trials will bring more clarity to this topic.
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Affiliation(s)
- Markus Glatzer
- Department of Radiation Oncology, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland; (P.M.P.); (L.P.)
- Correspondence:
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark; (K.T.); (L.F.)
| | - Angeles Rovirosa
- Department of Radiation Oncology, Hospital Clinic Barcelona, 08036 Barcelona, Spain;
- Fonaments Clinics Department, Faculty of Medicine, Universitat de Barcelona, 08036 Barcelona, Spain
| | - Lars Fokdal
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark; (K.T.); (L.F.)
| | - Claudia Ordeanu
- Department of Radiotherapy, Institute of Oncology “Prof. Dr. Ion Chiricuta”, 400015 Cluj-Napoca, Romania;
| | - Luca Tagliaferri
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Roma, Italy;
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Comprehensive Cancer Center, 94805 Paris, France;
| | - Vratislav Strnad
- Department of Radiation Oncology, University Hospital Erlangen, 91054 Erlangen, Germany;
| | - Johannes Athanasios Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - Barbara Šegedin
- Department of Radiation Oncology, Institute of Oncology Ljubljana, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Rachel Cooper
- Radiotherapy Research Group, Leeds Cancer Centre, St. Jame’s University Hospital, Leeds LS9 7TF, UK;
| | | | - Primoz Petric
- Department of Radiation Oncology, University Hospital Zurich, 8091 Zurich, Switzerland;
| | | | - Kristina Lössl
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3041 Bern, Switzerland;
| | - Ina M. Jürgenliemk-Schulz
- Department of Radiation Oncology, Cancer Center, University Medical Center Utrecht, 3584 AB Utrecht, The Netherlands;
| | - Peter Niehoff
- Department of Radiation Oncology, Sana Klinikum Offenbach GmbH, 63069 Offenbach, Germany;
| | - Ruth S. Hermansson
- Department of Oncology, Faculty of Medicine and Health, Örebro University, 70 185 Örebro, Sweden;
| | - Remi A. Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute, 3000 CA Rotterdam, The Netherlands;
| | - Paul Martin Putora
- Department of Radiation Oncology, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland; (P.M.P.); (L.P.)
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3041 Bern, Switzerland;
| | - Ludwig Plasswilm
- Department of Radiation Oncology, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland; (P.M.P.); (L.P.)
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3041 Bern, Switzerland;
| | - Nikolaos Tselis
- Klinik für Strahlentherapie und Onkologie, Universitätsklinikum Frankfurt, Goethe Universität, 60590 Frankfurt, Germany;
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22
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Barcellini A, Dominoni M, Dal Mas F, Biancuzzi H, Venturini SC, Gardella B, Orlandi E, Bø K. Sexual Health Dysfunction After Radiotherapy for Gynecological Cancer: Role of Physical Rehabilitation Including Pelvic Floor Muscle Training. Front Med (Lausanne) 2022; 8:813352. [PMID: 35186978 PMCID: PMC8852813 DOI: 10.3389/fmed.2021.813352] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 12/09/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction The present study aims to describe: 1. How the side effects of radiotherapy (RT) could impact sexual health in women; 2. The effectiveness of physical rehabilitation including pelvic floor muscle training (PFMT) in the management of sexual dysfunction after RT. Materials and Methods Search keys on PubMed, Web of Science, Scopus, PEDro, and Cochrane were used to identify studies on women treated with radical or adjuvant RT and/or brachytherapy for gynecological cancers with an emphasis on vulvo-vaginal toxicities and PFMT studies on sexual dysfunction for this group of women. Results Regarding the first key question, we analyzed 19 studies including a total of 2,739 women who reported vaginal dryness, stenosis, and pain as the most common side effects. Reports of dosimetric risk factors and dose-effect data for vaginal and vulvar post-RT toxicities are scant. Only five studies, including three randomized controlled trials (RCTs), were found to report the effect of PFMT alone or in combination with other treatments. The results showed some evidence for the effect of training modalities including PFMT, but to date, there is insufficient evidence from high-quality studies to draw any conclusion of a possible effect. Conclusions Gynecological toxicities after RT are common, and their management is challenging. The few data available for a rehabilitative approach on post-actinic vulvo-vaginal side effects are encouraging. Large and well-designed RCTs with the long-term follow-up that investigate the effect of PFMT on vulvo-vaginal tissues and pelvic floor muscle function are needed to provide further guidance for clinical management.
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Affiliation(s)
- Amelia Barcellini
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
- *Correspondence: Amelia Barcellini
| | - Mattia Dominoni
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesca Dal Mas
- Lincoln International Business School, University of Lincoln, Lincoln, United Kingdom
- Center of Organization and Governance of the Public Administration, University of Pavia, Pavia, Italy
| | - Helena Biancuzzi
- Ipazia, International Observatory on Gender Research, Rome, Italy
| | | | - Barbara Gardella
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Ester Orlandi
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Kari Bø
- Department of Sports Medicine, Norwegian School of Sports Sciences, Oslo, Norway
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lorenskog, Norway
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Abstract
Although endometrial cancer management remains challenging, a deeper understanding of the genetic diversity as well as the drivers of the various pathogenic states of this disease has led to development of divergent management approaches in an effort to improve therapeutic precision in this complex malignancy. This comprehensive review provides an update on the epidemiology, pathophysiology, diagnosis and molecular classification, recent advancements in disease management, as well as important patient quality-of-life considerations and emerging developments in the rapidly evolving therapeutic landscape of endometrial cancers.
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Affiliation(s)
- Vicky Makker
- Gynecologic Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
| | - Helen MacKay
- University of Toronto, Division of Medical Oncology & Hematology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Isabelle Ray-Coquard
- Department of Medical Oncology, Centre Leon Berard, Laboratoire Reshape University Claude Bernard Lyon, Lyon, France
| | - Douglas A Levine
- Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
- Merck Research Labs, Rahway, NJ, USA
| | - Shannon N Westin
- Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Daisuke Aoki
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Ana Oaknin
- Gynaecologic Cancer Programme, Vall d'Hebron Institute of Oncology (VHIO), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
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24
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Cook AE, Aref I, Burmeister C, Hijaz M, Elshaikh MA. Quantification of recurrence risk based on number of adverse prognostic factors in women with stage I uterine endometrioid carcinoma. J Turk Ger Gynecol Assoc 2021; 22:262-267. [PMID: 34866366 PMCID: PMC8667001 DOI: 10.4274/jtgga.galenos.2021.2021.0073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/30/2021] [Indexed: 12/01/2022] Open
Abstract
Objective The goal was to develop an updated model to predict the risk of recurrence, based on the number of adverse pathologic features in women with International Federation of Gynecology and Obstetrics stage I uterine endometrioid carcinoma, who did not undergo any adjuvant treatment. Material and Methods Women at a single center who underwent surgical staging without adjuvant therapy between January 1990 and December 2019 were included. Cox proportional hazards model was used to identify independent predictors of relapse free survival (RFS). Prognostic groups were then created based on the number of independent predictors of recurrence that were identified (0, 1, or 2-3 risk factors). Overall survival (OS) and disease specific survival (DSS) were also calculated for each group. Results In total 1133 women were eligible for inclusion. Median follow-up was 84 months. Independent prognostic factors of recurrence included: age ≥60; grade 2 or 3 differentiation; and presence of lymphovascular space invasion (LVSI). Due to the small number of patients with either 2 or 3 risk factors, these groups were combined into one (group 2/3). Isolated vaginal cuff recurrence was the most common site of recurrence in all study groups (2%, 7%, and 17% for groups 0, 1, and 2/3, respectively). Five-year RFS rates were 96%, 85%, and 57% for groups 0, 1, and 2/3 (p<0.01), respectively. Five-year DSS rates were 99%, 96%, and 85% and 5-year OS rates were 94%, 85%, and 62% (p<0.01), respectively. Conclusion We identified older age, high grade, and presence of LVSI as independent predictors of recurrence for women with stage I uterine endometrioid carcinoma. Using these prognostic factors, recurrence risk can be quantified for individual patients, and these factors can be used in deciding the appropriate adjuvant management course.
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Affiliation(s)
- Andrew E. Cook
- Department of Radiation Oncology, Henry Ford Cancer Institute, Michigan, United States of America
| | - Ibrahim Aref
- Department of Radiation Oncology, Henry Ford Cancer Institute, Michigan, United States of America
| | - Charlotte Burmeister
- Department of Public Health Sciences, Henry Ford Health System, Michigan, United States of America
| | - Miriana Hijaz
- Department of Women’s Health, Division of Gynecologic Oncology, Henry Ford Hospital, Michigan, United States of America
| | - Mohamed A. Elshaikh
- Department of Radiation Oncology, Henry Ford Cancer Institute, Michigan, United States of America
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25
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Marnitz S. [Importance of pre-operative immunohistochemistry in patients with endometrial cancer-which parameters do we need?]. Strahlenther Onkol 2021; 197:1148-1150. [PMID: 34762138 PMCID: PMC8604832 DOI: 10.1007/s00066-021-01862-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2021] [Indexed: 11/05/2022]
Affiliation(s)
- S Marnitz
- Klinik für Radioonkologie, Cyberknife und Strahlentherapie, Medizinische Fakultät, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
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26
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Meljen VT, Mittenzwei R, Wong J, Puechl A, Whitaker R, Broadwater G, Hall AH, Bean SM, Bentley RC, Elvin JA, Berchuck A, Previs RA, Strickland KC. Endometrial Adenocarcinomas With No Specific Molecular Profile: Morphologic Features and Molecular Alterations of "Copy-number Low" Tumors. Int J Gynecol Pathol 2021; 40:587-596. [PMID: 33720082 DOI: 10.1097/pgp.0000000000000747] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The study evaluated morphologic patterns, mutational profiles, and β-catenin immunohistochemistry (IHC) in copy-number low (CNL) endometrial adenocarcinomas (EAs). CNL EAs (n=19) with next-generation or whole genome sequencing results and available tissue for IHC were identified from our institutional database. Clinical data and histologic slides were reviewed. IHC for β-catenin was performed and correlated with mutation status. Images of digital slides of CNL EAs from The Cancer Genome Atlas (TCGA) database (n=90) were blindly reviewed by 4 pathologists, and morphology was correlated with mutation status. Categorical variables were analyzed using the Fisher exact test, and agreement was assessed using Fleiss κ. CTNNB1 mutations were present in 63% (12/19) of CNL EAs. β-catenin nuclear localization was present in 83% of CTNNB1-mutated tumors (10/12) and in 0% (0/7) of CTNNB1-wildtype tumors (sensitivity 0.83, specificity 1.00). Squamous differentiation (SD) was present in 47% (9/19) and was more often observed in CTNNB1-mutated tumors (P=0.02). Mucinous differentiation (MD) was associated with KRAS mutations (P<0.01). Digital image review of TCGA CNL EAs revealed that pathologist agreement on SD was strong (κ=0.82), whereas agreement on MD was weak (κ=0.48). Pathologists identified SD in 22% (20/90), which was significantly associated with the presence of CTNNB1 mutations (P<0.01). CNL EAs demonstrate several morphologies with divergent molecular profiles. SD was significantly associated with CTNNB1 mutations and nuclear localization of β-catenin in these tumors. Nuclear expression of β-catenin is a sensitive and specific IHC marker for CTNNB1 mutations in CNL EAs. CNL EAs with KRAS mutations often displayed MD.
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27
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Nero C, Ciccarone F, Pietragalla A, Duranti S, Daniele G, Scambia G, Lorusso D. Adjuvant Treatment Recommendations in Early-Stage Endometrial Cancer: What Changes With the Introduction of The Integrated Molecular-Based Risk Assessment. Front Oncol 2021; 11:612450. [PMID: 34540651 PMCID: PMC8442623 DOI: 10.3389/fonc.2021.612450] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 07/29/2021] [Indexed: 11/13/2022] Open
Abstract
Adjuvant therapy recommendations for endometrial cancer were historically based on the individual patient's risk of disease recurrence using clinicopathologic factors such as age, stage, histologic subtype, tumor grade, and lymphovascular space invasion. Despite the excellent prognosis for early stages, considerable under- and overtreatment remains. Integrated genomic characterization by the Cancer Genome Atlas (TCGA) in 2013 defined four distinct endometrial cancer subgroups (POLE mutated, microsatellite instability, low copy number, and high copy number) with possible prognostic value. The validation of surrogate markers (p53, Mismatch repair deficiency, and POLE) to determine these subgroups and the addition of other molecular prognosticators (CTNNB1, L1CAM) resulted in a practical and clinically useful molecular classification tool. The incorporation of such molecular alterations into established clinicopathologic risk factors resulted in a refined, improved risk assessment. Thus, the ESGO/ESTRO/ESP consensus in 2020 defined for the first time different prognostic risk groups integrating molecular markers. Finally, the feasibility and clinical utility of molecular profiling for tailoring adjuvant therapy in the high-intermediate-risk group is currently under investigation (NCT03469674).
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Affiliation(s)
- Camilla Nero
- Direzione Scientifica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Dipartimento di Scienze della vita e sanità pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesca Ciccarone
- Direzione Scientifica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonella Pietragalla
- Direzione Scientifica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Simona Duranti
- Direzione Scientifica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gennaro Daniele
- Direzione Scientifica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- Direzione Scientifica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Dipartimento di Scienze della vita e sanità pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenica Lorusso
- Direzione Scientifica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Dipartimento di Scienze della vita e sanità pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
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Patterns of Myometrial Invasion in Endometrial Adenocarcinoma with Emphasizing on Microcystic, Elongated and Fragmented (MELF) Glands Pattern: A Narrative Review of the Literature. Diagnostics (Basel) 2021; 11:diagnostics11091707. [PMID: 34574048 PMCID: PMC8469256 DOI: 10.3390/diagnostics11091707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 09/15/2021] [Accepted: 09/15/2021] [Indexed: 11/17/2022] Open
Abstract
Endometrioid endometrial adenocarcinoma (EEC) is the most common malignancy of the female genital tract. According to the 2009 FIGO staging system, the depth of myometrial invasion (MI), and tumor spread to adjacent organs or tissues are the staging criteria for endometrial carcinoma (EC). Therefore, assessment of the depth of MI is of great importance. There is a spectrum of morphological patterns of MI. Still, their number and features vary according to the scientific literature, with a certain overlap that creates difficulties and controversies in the precise assessment of MI depth. The purpose of this review is to present and discuss the most important and recent information about patterns of MI, focusing on the more aggressive and the elongated and fragmented glands (MELF) pattern in particular. Assessment of MI depth and correct staging of EC is possible only after the precise recognition of each MI pattern.
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29
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Adjuvant and post-surgical treatment in endometrial cancer. Best Pract Res Clin Obstet Gynaecol 2021; 78:52-63. [PMID: 34420863 DOI: 10.1016/j.bpobgyn.2021.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 06/09/2021] [Indexed: 12/26/2022]
Abstract
Endometrial cancer (EC) usually presented as a localized disease at diagnosis (67%), 20% of patients diagnosed with regional spread, and distant metastasis accounted for 9%. The standard treatments include hysterectomy, bilateral salpingo-oophorectomy, and pelvic with/without paraaortic lymph node dissection/biopsy. Adjuvant therapy is arranged according to risk factors and stages. Risk group classification varied among different guidelines and studies and evolved with time. Adjuvant modalities include chemotherapy, radiotherapy, chemoradiotherapy, antiangiogenesis agents, immune checkpoint inhibitors, and multi-target agents. We review the recent literature to incorporate important advances in trial results, real-world big data, and knowledge in biomarkers of EC to update appropriate adjuvant therapy and post-surgical treatment of EC patients.
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Adjuvant vaginal cuff brachytherapy in surgically treated endometrial carcinoma patients - in view of the recent evidence. J Contemp Brachytherapy 2021; 13:221-230. [PMID: 33897797 PMCID: PMC8060967 DOI: 10.5114/jcb.2021.105291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 03/01/2021] [Indexed: 12/24/2022] Open
Abstract
Vaginal cuff brachytherapy is an essential component of adjuvant post-operative therapy in endometrial carcinoma. Brachytherapy boost, as a part of adjuvant pelvic radiotherapy, including concomitant chemoradiotherapy combined with four cycles carboplatin/paclitaxel chemotherapy, is used in early-stage high-risk and advanced stage disease. This strategy is widely accepted and recommended by international guidelines, despite the fact that combined therapy has never been verified in randomized trials. Brachytherapy alone is the adjuvant treatment of choice for many patients with early-stage endometrial cancer, with high-intermediate features, replacing external beam pelvic radiotherapy. It provides equivalent vaginal control with a lower risk of toxicity, and minimal impact on health-related quality of life. Available evidence did not demonstrate the superiority of sole vaginal brachytherapy combined with three cycles of carboplatin/paclitaxel chemotherapy, over the standard pelvic irradiation for patients with early-stage, high-intermediate-, and high-risk endometrial cancer. This article summarized the available evidence on the role of post-operative vaginal cuff brachytherapy in endometrial cancer patients. Additionally, the risk groups definition, some aspects of brachytherapy technique, and the importance of pathological and molecular risk factors for endometrial cancer risk stratification were presented. Furthermore, the role of brachytherapy according to the European Society of Gynecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology 2021 guidelines for the management of patients with endometrial carcinoma was presented.
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31
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Improved disease-free survival with adjuvant radiotherapy in early-stage endometrial cancer: 10-year outcome analysis. J Contemp Brachytherapy 2020; 12:572-578. [PMID: 33437305 PMCID: PMC7787210 DOI: 10.5114/jcb.2020.101690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 09/16/2020] [Indexed: 12/24/2022] Open
Abstract
Purpose The purpose of this study was to evaluate long-term treatment outcomes and prognostic factors affecting survival of patients with early-stage endometrial carcinoma. Material and methods Data of 311 patients with FIGO stage I-II endometrial cancer, curatively treated at two different tertiary centers between June 2001 and December 2016 were retrospectively reviewed. The patients had primary surgery, 74 (24%) received no further treatment, 4 (1%) obtained chemotherapy only, 234 (75%) received radiotherapy, and 24 (7%) received both. Results Median follow-up time was 102 (range, 3-205) months. During this period, 68 (21.9%) patients died. 5-year and 10-year disease-free survival (DFS) were 76% and 74.3%, respectively. In multivariate analysis, lower uterine segment invasion positivity and no adjuvant radiotherapy were determined as independent unfavorable prognostic factors for DFS. The 5-year and 10-year disease-specific survival (DSS) were 86.8% and 82.2%, respectively. For DSS, high-grade, lymphovascular space invasion positivity, stage II, ≥ 65 age, and no adjuvant radiotherapy were found to be independent unfavorable prognostic markers. Conclusions The findings of our cohort have confirmed the importance of adjuvant radiotherapy on long-term early-stage endometrial carcinoma outcome.
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32
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Garzon S, Uccella S, Zorzato PC, Bosco M, Franchi MP, Student V, Mariani A. Fertility-sparing management for endometrial cancer: review of the literature. Minerva Med 2020; 112:55-69. [PMID: 33205638 DOI: 10.23736/s0026-4806.20.07072-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Primary surgery is effective in low-risk endometrial cancer (EC). However, in young women, this approach compromises fertility. Therefore, fertility-sparing management in the case of atypical endometrial hyperplasia, or grade 1 EC limited to the endometrium can be considered. EVIDENCE ACQUISITION We performed a literature review to identify studies involving women with EC or atypical hyperplasia who underwent fertility-sparing management. We conducted multiple bibliographic databases research from their inception to May 2020. EVIDENCE SYNTHESIS Oral therapy with medroxyprogesterone acetate and megestrol acetate is recommended based on extensive experience, although without consensus on dosages and treatment length. The pooled complete response rate, recurrence rate, and pregnancy rate of EC were 76.3%, 30.7% and 52.1%, respectively. Endometrial hyperplasia was associated with better outcomes. LNG-IUSs appears an alternative treatment, particularly in patients who do not tolerate oral therapy. In a randomized controlled trial, megestrol acetate plus metformin guaranteed an earlier complete response rate than megestrol acetate alone for endometrial hyperplasia. Hysteroscopic resection followed by progestogens is associated with a higher complete response rate, live birth rate, and lower recurrence rate than oral progestogens alone. Pooled complete response, recurrence, and live birth rates were 98.1%, 4.8% and 52.6%. CONCLUSIONS Fertility preservation appears feasible in young patients with grade 1 EC limited to the endometrium or atypical endometrial hyperplasia. Progestins are the mainstay of such management. The addition of Metformin and hysteroscopic resection seems to provide some improvements. However, fertility preservation is not the standard approach for staging and treatment, potentially worsening oncologic outcomes.
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Affiliation(s)
- Simone Garzon
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, MN, USA -
| | - Stefano Uccella
- Department of Obstetrics and Gynecology, University Hospital of Verona, University of Verona, Verona, Italy
| | - Pier Carlo Zorzato
- Department of Obstetrics and Gynecology, University Hospital of Verona, University of Verona, Verona, Italy
| | - Mariachiara Bosco
- Department of Obstetrics and Gynecology, University Hospital of Verona, University of Verona, Verona, Italy
| | - Massimo P Franchi
- Department of Obstetrics and Gynecology, University Hospital of Verona, University of Verona, Verona, Italy
| | - Vladimir Student
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, MN, USA
| | - Andrea Mariani
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, MN, USA
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Wortman BG, Astreinidou E, Laman MS, van der Steen-Banasik EM, Lutgens LCHW, Westerveld H, Koppe F, Slot A, van den Berg HA, Nowee ME, Bijmolt S, Stam TC, Zwanenburg AG, Mens JWM, Jürgenliemk-Schulz IM, Snyers A, Gillham CM, Weidner N, Kommoss S, Vandecasteele K, Tomancova V, Creutzberg CL, Nout RA. Brachytherapy quality assurance in the PORTEC-4a trial for molecular-integrated risk profile guided adjuvant treatment of endometrial cancer. Radiother Oncol 2020; 155:160-166. [PMID: 33159971 DOI: 10.1016/j.radonc.2020.10.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/26/2020] [Accepted: 10/26/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The PORTEC-4a trial investigates molecular-integrated risk profile guided adjuvant treatment for endometrial cancer. The quality assurance programme included a dummy run for vaginal brachytherapy prior to site activation, and annual quality assurance to verify protocol adherence. Aims of this study were to evaluate vaginal brachytherapy quality and protocol adherence. METHODS For the dummy run, institutes were invited to create a brachytherapy plan on a provided CT-scan with the applicator in situ. For annual quality assurance, institutes provided data of one randomly selected brachytherapy case. A brachytherapy panel reviewed and scored the brachytherapy plans according to a checklist. RESULTS At the dummy run, 15 out of 21 (71.4%) institutes needed adjustments of delineation or planning. After adjustments, the mean dose at the vaginal apex (protocol: 100%; 7 Gy) decreased from 100.7% to 99.9% and range and standard deviation (SD) narrowed from 83.6-135.1 to 96.4-101.4 and 8.8 to 1.1, respectively. At annual quality assurance, 22 out of 27 (81.5%) cases had no or minor and 5 out of 27 (18.5%) major deviations. Most deviations were related to delineation, mean dose at the vaginal apex (98.0%, 74.7-114.2, SD 7.6) or reference volume length. CONCLUSIONS Most feedback during the brachytherapy quality assurance procedure of the PORTEC-4a trial was related to delineation, dose at the vaginal apex and the reference volume length. Annual quality assurance is essential to promote protocol compliance, ensuring high quality vaginal brachytherapy in all participating institutes.
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Affiliation(s)
- B G Wortman
- Department of Radiation Oncology, Leiden University Medical Centre, The Netherlands.
| | - E Astreinidou
- Department of Radiation Oncology, Leiden University Medical Centre, The Netherlands
| | - M S Laman
- Department of Radiation Oncology, Leiden University Medical Centre, The Netherlands
| | | | | | - H Westerveld
- Department of Radiation Oncology, Amsterdam University Medical Centres, University of Amsterdam, The Netherlands
| | - F Koppe
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, The Netherlands
| | - A Slot
- Radiotherapy Institute Friesland, Leeuwarden, The Netherlands
| | - H A van den Berg
- Department of Radiation Oncology, Catharina Hospital Eindhoven, The Netherlands
| | - M E Nowee
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - S Bijmolt
- Department of Radiation Oncology, University Medical Centre Groningen, The Netherlands
| | - T C Stam
- Department of Radiation Oncology, Haaglanden Medical Centre, Leidschendam, The Netherlands
| | - A G Zwanenburg
- Department of Radiation Oncology, Zwolle, The Netherlands
| | - J W M Mens
- Department of Radiation Oncology, Erasmus MC-Cancer Institute, Rotterdam, The Netherlands
| | | | - A Snyers
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - C M Gillham
- Department of Radiation Oncology, St Luke's Radiation Oncology Network, Dublin 6, Ireland
| | - N Weidner
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University, Germany
| | - S Kommoss
- Department of Women's Health, Tübingen University Hospital, Germany
| | - K Vandecasteele
- Department of Radiation Oncology, Ghent University Hospital, Belgium
| | - V Tomancova
- Department of Clinical Oncology, General Teaching Hospital, First Medical School, Charles University, Prague, Czech Republic
| | - C L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Centre, The Netherlands
| | - R A Nout
- Department of Radiation Oncology, Leiden University Medical Centre, The Netherlands
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Bronsart E, Petit C, Gouy S, Bockel S, Espenel S, Kumar T, Fumagalli I, Maulard A, Ayachy RE, Genestie C, Leary A, Pautier P, Morice P, Haie-Meder C, Chargari C. Evaluation of adjuvant vaginal vault brachytherapy in early stage cervical cancer patients. Cancer Radiother 2020; 24:860-865. [PMID: 33129715 DOI: 10.1016/j.canrad.2020.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/12/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Adjuvant external beam radiotherapy (EBRT) was shown to decrease pelvic relapses in patients with an early stage cervical cancer and intermediate-risk histopathological prognostic factors, at the cost of increased bowel morbidity. We examined the feasibility and results of adjuvant brachytherapy alone as an alternative to EBRT in this situation. PATIENTS AND METHODS Medical records of consecutive patients receiving adjuvant brachytherapy between 1991 and 2018 for an early stage cervical cancer were examined. Patients were included if they presented a pT1a2N0 or pT1b1N0 disease following radical colpohysterectomy. Adjuvant vaginal wall brachytherapy (without EBRT) was indicated because of a tumor size≥2cm and/or presence of lymphovascular space invasion (LVSI). Patients received 60Gy to 5mm of the vaginal wall, through low-dose or pulse-dose rate technique. Patients' outcome was examined for disease control, toxicities and prognostic factors. RESULTS A total of 40 patients were included. Eight patients (20%) had LVSI, 26 patients (65%) had a tumor size≥2cm. With median follow-up time of 42.0 months, 90% of patients were in complete remission and four patients (10%) experienced tumor relapse, all in the peritoneal cavity, and associated with synchronous pelvic lymph node failure in 2/4 patients. No vaginal or isolated pelvic nodal failure was reported. At 5 year, overall survival was 83.6% (CI95%: 67.8-100%) and disease-free survival was 85.1% (CI95%: 72.6-99.9%). In univariate analysis, probability of relapse correlated with tumor size≥3cm (P=0.004). No acute or late toxicity grade more than 2 was reported. CONCLUSION Brachytherapy alone was a well-tolerated adjuvant treatment for selected patients with intermediate risk factors. The risk of relapse in patients with tumor size≥3cm was however high, suggesting that EBRT is more appropriate in this situation.
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Affiliation(s)
- E Bronsart
- Department of Radiation Oncology, Gustave-Roussy, Paris-Saclay University, Villejuif, France
| | - C Petit
- Department of Radiation Oncology, Gustave-Roussy, Paris-Saclay University, Villejuif, France
| | - S Gouy
- Department of Gynecologic Surgery, Gustave-Roussy, Villejuif, France
| | - S Bockel
- Department of Radiation Oncology, Gustave-Roussy, Paris-Saclay University, Villejuif, France
| | - S Espenel
- Department of Radiation Oncology, Gustave-Roussy, Paris-Saclay University, Villejuif, France
| | - T Kumar
- Department of Radiation Oncology, Gustave-Roussy, Paris-Saclay University, Villejuif, France
| | - I Fumagalli
- Department of Radiation Oncology, Gustave-Roussy, Paris-Saclay University, Villejuif, France
| | - A Maulard
- Department of Gynecologic Surgery, Gustave-Roussy, Villejuif, France
| | - R El Ayachy
- Department of Radiation Oncology, Gustave-Roussy, Paris-Saclay University, Villejuif, France
| | - C Genestie
- Department of Pathology, Gustave-Roussy, Villejuif, France
| | - A Leary
- Department of Medical Oncology, Gustave-Roussy, Villejuif, France
| | - P Pautier
- Department of Medical Oncology, Gustave-Roussy, Villejuif, France
| | - P Morice
- Department of Gynecologic Surgery, Gustave-Roussy, Villejuif, France
| | - C Haie-Meder
- Department of Radiation Oncology, Gustave-Roussy, Paris-Saclay University, Villejuif, France; GIE Charlebourg, groupe Amethyst, 65, avenue Foch, 92250 La-Garenne-Colombes, France
| | - C Chargari
- Department of Radiation Oncology, Gustave-Roussy, Paris-Saclay University, Villejuif, France; French Military Health Academy, Paris, France; Institut de recherche biomédicale des armées, Brétigny-sur-Orge, France.
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Song J, Le T, Hopkins L, Fung-Kee-Fung M, Jooya A, Lupe K, Gaudet M, Samant R. Treatment of Early Stage High-Risk Endometrioid-Type Endometrial Cancer and Patterns of Disease Relapse: A Retrospective Analysis. Adv Radiat Oncol 2020; 5:910-919. [PMID: 33083653 PMCID: PMC7557164 DOI: 10.1016/j.adro.2020.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/29/2020] [Accepted: 07/15/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose A recently published randomized controlled trial has demonstrated that in patients with endometrial cancer with high-risk features, the addition of chemotherapy to radiation therapy, compared with radiation therapy alone, resulted in a significant improvement in failure-free survival. However, in the study, the effect of chemotherapy was limited to stage III patients, and the benefit was less pronounced in stage I and II patients. Our study aims to investigate the current practice of treatment and clinical outcomes in stage I high-risk endometrioid-type endometrial cancer. Methods and Materials A single-center retrospective study was conducted on patients with stage I high-risk endometrioid-type endometrial cancer without serous or clear cell features who have undergone hysterectomy between 1998 and 2015. Data on patients, tumor, and treatments were collected and correlated with clinical outcomes. Results A total of 1,572 patients with stage I disease were identified and 46 patients who met the inclusion criteria were selected for final analysis. The median age at diagnosis was 63 years (range, 49-86 years) and median follow-up was 5.9 years. Among the entire cohort, 40 (87.0%) patients underwent adjuvant radiation therapy, of which 36 (78.2%) patients underwent external beam radiation therapy and 4 (8.7%) patients underwent vaginal brachytherapy. Two of the 40 patients who received adjuvant radiation therapy also received adjuvant chemotherapy. Six (13.0%) patients received no adjuvant treatment. Of the 46 patients, the cumulative risk of distant recurrence was 19.6%, and only 1 patient (2.2%) recurred within pelvis (perirectal lymph node). Five-year disease-free survival and overall survival rates were 73.1% and 80.1%, respectively. Conclusions Adjuvant radiation therapy in stage I endometrioid-type endometrial cancer patients with high-risk features resulted in high rates of locoregional disease control, and most recurrences occurred at distant sites. Effective systemic therapy may be indicated in this patient population to further reduce the risk of distant relapses and improve survival.
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Affiliation(s)
- Jiheon Song
- Division of Radiation Oncology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Tien Le
- Division of Gynecologic Oncology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Laura Hopkins
- Division of Gynecologic Oncology, Saskatoon Cancer Center, Saskatoon, SK, Canada
| | | | - Alborz Jooya
- Division of Radiation Oncology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Krystine Lupe
- Division of Radiation Oncology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Marc Gaudet
- Division of Radiation Oncology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Rajiv Samant
- Division of Radiation Oncology, The Ottawa Hospital, Ottawa, ON, Canada
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Dessources K, Da Cruz Paula A, Pareja F, Stylianou A, Cybulska P, Farmanbar A, Chandarlapaty S, Abu-Rustum NR, Reis-Filho JS, Weigelt B, Mueller JJ. Acquisition of APOBEC Mutagenesis and Microsatellite Instability Signatures in the Development of Brain Metastases in Low-Grade, Early-Stage Endometrioid Endometrial Carcinoma. JCO Precis Oncol 2020; 4:PO.20.00044. [PMID: 33163849 PMCID: PMC7608574 DOI: 10.1200/po.20.00044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2020] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Fresia Pareja
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anthe Stylianou
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Paulina Cybulska
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Amir Farmanbar
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sarat Chandarlapaty
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Jorge S. Reis-Filho
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Britta Weigelt
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
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Mège A, Biau J, Meyer E, Allouache N, Guigo M, Servagi Vernat S. Les essais cliniques en radiothérapie qui ont changé les pratiques 2010–2020. Cancer Radiother 2020; 24:612-622. [DOI: 10.1016/j.canrad.2020.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/02/2020] [Accepted: 06/08/2020] [Indexed: 11/25/2022]
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Arden JD, Gruner MF, Vu CC, Marvin K, Ye H, Nandalur SR, Al-Wahab Z, Gadzinski J, Rakowski JA, Field J, Rosen B, Jawad MS. Outcomes After Salvage Radiation Therapy for Recurrent Endometrial Cancer in Patients With No Prior Adjuvant Therapy: An Institutional Review. Adv Radiat Oncol 2020; 5:1240-1247. [PMID: 33305085 PMCID: PMC7718518 DOI: 10.1016/j.adro.2020.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/25/2020] [Accepted: 08/28/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose After definitive surgery, women with early-stage, low-risk endometrial cancer are observed. However, some will require salvage radiation therapy for recurrence. The purpose of this study was to evaluate our experience using salvage radiation for recurrent endometrial cancer in patients who did not receive upfront adjuvant therapy. Methods and Materials Twenty-eight women with endometrial cancer who had undergone initial definitive hysterectomy without adjuvant therapy developed isolated local or regional recurrence and were treated with salvage radiation in our department from 2004 to 2018. Salvage radiation included whole pelvic radiation, vaginal brachytherapy, or both. Patient and tumor characteristics, treatment details, and toxicities were recorded and analyzed. Results The median time to first recurrence was 1.7 years. First recurrences consisted of local recurrence in 23 patients, regional recurrence in 4, and both in 1. The median times from hysterectomy to first recurrence, local and regional, were 1.2 and 4.0 years, respectively. All patients underwent salvage radiation for management of their first recurrence. The median total equivalent dose in 2 Gy fractions for this treatment was 67.6 Gy (37.5–81.8 Gy). Two second recurrences occurred following salvage treatment, both local recurrence, at 6.5 and 13.5 months after radiation. The 2-year rates of local control, disease-free survival, and overall survival were 93%, 80%, and 88%, respectively. Treatment was well-tolerated, with low rates of gastrointestinal and genitourinary toxicity. Conclusions In this group of patients, salvage radiation therapy for local or regional recurrence of endometrial cancer resulted in excellent control with low rates of acute and chronic toxicities.
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Affiliation(s)
- Jessica D. Arden
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Morgan F. Gruner
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
- Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio
| | - Charles C. Vu
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
- Department of Radiation Oncology, Parkview Cancer Institute, Fort Wayne, Indiana
| | - Kimberly Marvin
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Hong Ye
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Sirisha R. Nandalur
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Zaid Al-Wahab
- Department of Gynecologic Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Jill Gadzinski
- Department of Gynecologic Oncology, Beaumont Health System, Royal Oak, Michigan
| | | | - Jayson Field
- Department of Gynecologic Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Barry Rosen
- Department of Gynecologic Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Maha Saada Jawad
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
- Corresponding author: Maha Saada Jawad, MD
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Aoki Y, Kanao H, Wang X, Yunokawa M, Omatsu K, Fusegi A, Takeshima N. Adjuvant treatment of endometrial cancer today. Jpn J Clin Oncol 2020; 50:753-765. [PMID: 32463094 DOI: 10.1093/jjco/hyaa071] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 01/15/2020] [Accepted: 04/30/2020] [Indexed: 01/22/2023] Open
Abstract
Endometrial cancer frequently occurs in post-menopausal women, and the endometrium is a well-known site of cancer affecting women. Endometrial cancer is found with genital bleeding and often at an early stage. However, there are some risks of recurrence after hysterectomy. As a medical treatment after the diagnosis of endometrial cancer, appropriate adjuvant therapy is considered to lead to a decrease in the rate of recurrence and improvement of prognosis according to the determination of the cancer stage from the surgical and histopathological results. In this review, we describe post-operative adjuvant therapy administered for endometrial cancer and advanced disease, focusing on chemotherapy, radiation therapy and the combination of both. These treatments are divided according to the risk of recurrence as based primarily on the reported evidence.
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Affiliation(s)
- Yoichi Aoki
- Department of Gynecologic Oncology, Cancer Institute Hospital, Tokyo, Japan
| | - Hiroyuki Kanao
- Department of Gynecologic Oncology, Cancer Institute Hospital, Tokyo, Japan
| | - Xipeng Wang
- Department of Gynecology and Obstetrics, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mayu Yunokawa
- Department of Gynecologic Oncology, Cancer Institute Hospital, Tokyo, Japan
| | - Kohei Omatsu
- Department of Gynecologic Oncology, Cancer Institute Hospital, Tokyo, Japan
| | - Atsushi Fusegi
- Department of Gynecologic Oncology, Cancer Institute Hospital, Tokyo, Japan.,Department of Perinatal and Women's Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nobuhiro Takeshima
- Department of Gynecologic Oncology, Cancer Institute Hospital, Tokyo, Japan
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Elledge CR, Beriwal S, Chargari C, Chopra S, Erickson BA, Gaffney DK, Jhingran A, Klopp AH, Small W, Yashar CM, Viswanathan AN. Radiation therapy for gynecologic malignancies during the COVID-19 pandemic: International expert consensus recommendations. Gynecol Oncol 2020; 158:244-253. [PMID: 32563593 PMCID: PMC7294297 DOI: 10.1016/j.ygyno.2020.06.486] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/10/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To develop expert consensus recommendations regarding radiation therapy for gynecologic malignancies during the COVID-19 pandemic. METHODS An international committee of ten experts in gynecologic radiation oncology convened to provide consensus recommendations for patients with gynecologic malignancies referred for radiation therapy. Treatment priority groups were established. A review of the relevant literature was performed and different clinical scenarios were categorized into three priority groups. For each stage and clinical scenario in cervical, endometrial, vulvar, vaginal and ovarian cancer, specific recommendations regarding dose, technique, and timing were provided by the panel. RESULTS Expert review and discussion generated consensus recommendations to guide radiation oncologists treating gynecologic malignancies during the COVID-19 pandemic. Priority scales for cervical, endometrial, vulvar, vaginal, and ovarian cancers are presented. Both radical and palliative treatments are discussed. Management of COVID-19 positive patients is considered. Hypofractionated radiation therapy should be used when feasible and recommendations regarding radiation dose, timing, and technique have been provided for external beam and brachytherapy treatments. Concurrent chemotherapy may be limited in some countries, and consideration of radiation alone is recommended. CONCLUSIONS The expert consensus recommendations provide guidance for delivering radiation therapy during the COVID-19 pandemic. Specific recommendations have been provided for common clinical scenarios encountered in gynecologic radiation oncology with a focus on strategies to reduce patient and staff exposure to COVID-19.
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Affiliation(s)
- Christen R Elledge
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Hillman Cancer Center, Pittsburgh, PA, USA
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Kharghar, Navi Mumbai, India
| | - Beth A Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William Small
- Department of Radiation Oncology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - Catheryn M Yashar
- Department of Radiation Oncology, University of California San Diego, San Diego, CA, USA
| | - Akila N Viswanathan
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Sapienza LG, Ning MS, de la Pena R, McNew LK, Jhingran A, Georgeon L, Rasool N, Gomes MJL, Abu-Isa E, Baiocchi G. Outcomes and toxicity after salvage radiotherapy for vaginal relapse of endometrial cancer. Int J Gynecol Cancer 2020; 30:1535-1541. [PMID: 32376738 DOI: 10.1136/ijgc-2020-001281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 04/03/2020] [Accepted: 04/17/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Studies of salvage radiotherapy in locally recurrent endometrial cancer remain limited. The aim of this study was to evaluate the efficacy of salvage radiotherapy for vaginal relapse of endometrial cancer and to explore prognostic factors associated with outcomes. METHODS We evaluated 30 patients treated with salvage external-beam radiotherapy and/or vaginal brachytherapy for vaginal relapses of endometrial cancer between 2009 and 2018. The inclusion criteria were: pathologically-confirmed recurrence; loco-regional relapse (in absence of distant metastases); and salvage treatment including external-beam radiotherapy and/or vaginal brachytherapy. Outcomes were evaluated via Kaplan-Meier, with the log-rank test employed to compare differences among various groups and identify prognostic factors. RESULTS 30 patients developed vaginal recurrence at a median time of 20.6 months (range 2-219) post-hysterectomy. The most common site of recurrence was the vaginal apex (60%), followed by the distal vagina (10%). Salvage radiotherapy entailed combination external-beam radiotherapy and vaginal brachytherapy (n=24) or single modality treatment (n=6), along with concurrent chemotherapy in 20 cases. At a median follow-up of 4.4 years (range 0.1-130) post-radiotherapy, the 5 year rates of local control, regional control, metastasis-free interval, disease-free interval, and overall survival were 89%, 91.5%, 75.5%, 69%, and 83%, respectively. Factors associated with improved disease-free interval included: endometrioid histology (p=0.03), isolated vaginal relapse (p=0.003), late recurrence (>9 months) (p=0.007), and combined modality radiotherapy (p=0.001). The only factor associated with overall survival was isolated vaginal relapse (in the absence of other recurrent disease) (p=0.02). Regarding toxicity, 18% of patients experienced acute grade ≥3 events (most commonly gastrointestinal). The 5 year rates of rectal bleeding, small bowel obstruction, and pelvic fracture were 31%, 18%, and 13%, respectively. CONCLUSIONS Salvage radiotherapy imparts excellent loco-regional control for vaginal relapses of endometrial cancer and should entail combination external-beam radiotherapy and vaginal brachytherapy. Patients should be closely monitored for late gastrointestinal toxicity following salvage radiotherapy.
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Affiliation(s)
- Lucas Gomes Sapienza
- Radiation Oncology, Baylor College of Medicine, Houston, Texas, USA .,Internal Medicine, Ascension Providence Hospital, Southfield, Michigan, USA
| | - Matthew S Ning
- Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Rosinda de la Pena
- Gynecologic Oncology, Ascension Providence Hospital, Southfield, Michigan, USA
| | | | - Anuja Jhingran
- Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Larissa Georgeon
- Michigan State University College of Human Medicine, East Lansing, Michigan, USA
| | - Nabila Rasool
- Gynecologic Oncology, Ascension Providence Hospital, Southfield, Michigan, USA
| | - Maria José Leite Gomes
- Radiation Oncology, Hospital Federal dos Servidores do Estado (HSFE-RJ), Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eyad Abu-Isa
- Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Glauco Baiocchi
- Gynecologic Oncology, AC Camargo Cancer Center, Sao Paulo, São Paulo, Brazil
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Cai S, Zhang H, Chen X, Wang T, Lu J, Liu X, Zhang G. MR volumetry in predicting the aggressiveness of endometrioid adenocarcinoma: correlation with final pathological results. Acta Radiol 2020; 61:705-713. [PMID: 31564116 DOI: 10.1177/0284185119877331] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Magnetic resonance (MR) has been widely used in predicting the aggressiveness of endometrioid adenocarcinoma. However, the diagnostic value of the MR volume of the lesion has been controversial. Purpose To determine whether the whole-lesion MR volume measurement could be used as a better predictor for evaluating the aggressiveness of endometrioid adenocarcinoma. Material and Methods In this retrospective study, we include 357 patients with pathologically demonstrated endometrioid adenocarcinoma at our institution between 1 January 2013 and 31 December 2018. Whole-lesion MR volume was calculated on sagittal T2-weighted images with ITK-SNAP software on a personal computer. Results According to the receiver operating characteristics curve analysis, whole-lesion MR volume has the competitive advantage in evaluating deep myometrial invasion compared with the frozen results, generating area under the curve (AUC) values of 0.751 vs. 0.834 ( P = 0.0629, Z = 1.860). The AUC of tumor maximum diameter, simple tumor volume, and whole-lesion MR volume in predicting deep myometrial invasion was 63.8%, 67.6%, and 75.1%, respectively. Conclusion Whole-lesion MR volume is a good diagnostic tool for prediction of deep myometrial invasion, lymph node metastasis, and lymphovascular invasion. MR volumetry could reflect the aggressiveness of endometrioid adenocarcinoma more accurately than traditional lesion measurements.
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Affiliation(s)
- Shulei Cai
- Department of Radiology, Obstetrics and Gynecology Hospital, Fudan University, Fudan, PR China
| | - He Zhang
- Department of Radiology, Obstetrics and Gynecology Hospital, Fudan University, Fudan, PR China
| | - Xiaojun Chen
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Fudan, PR China
| | - Tianping Wang
- Department of Radiology, Obstetrics and Gynecology Hospital, Fudan University, Fudan, PR China
| | - Jiaqi Lu
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Fudan, PR China
| | - Xuefen Liu
- Department of Radiology, Obstetrics and Gynecology Hospital, Fudan University, Fudan, PR China
| | - Guofu Zhang
- Department of Radiology, Obstetrics and Gynecology Hospital, Fudan University, Fudan, PR China
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AlHilli M, Amarnath S, Elson P, Rybicki L, Dowdy S. Impact of vaginal brachytherapy on survival in stage I endometrioid endometrial carcinoma. Int J Gynecol Cancer 2020; 30:789-796. [PMID: 32184268 DOI: 10.1136/ijgc-2019-001182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 02/23/2020] [Accepted: 03/05/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate trends in use of radiation therapy and its impact on overall survival in low- and high-grade stage I endometrioid endometrial carcinoma. METHODS Patients with stage I endometrial cancer who underwent hysterectomy from 2004 to 2013 were identified through the National Cancer Database and classified as: stage IA G1/2, stage IA G3, stage IB G1/2, and stage IB G3. Trends in use of vaginal brachytherapy and external beam radiation therapy were assessed. Overall survival was measured from surgery and estimated using the Kaplan-Meier method. The effect of radiation therapy on overall survival was assessed within each stage/grade group using Cox proportional hazards analysis in propensity-matched treatment groups. RESULTS A total of 132 393 patients met inclusion criteria, and 81% of patients had stage IA and 19% had stage IB endometrial cancer. Adjuvant therapy was administered in 18% of patients: 52% received vaginal brachytherapy, 30% external beam radiation therapy, and 18% chemotherapy ±radiation therapy. External beam radiation therapy use decreased from 9% in 2004 to 4% in 2012, while vaginal brachytherapy use increased from 8% to 14%. Stage IA G1/2 patients did not benefit from either external beam radiation therapy or vaginal brachytherapy, while administration of vaginal brachytherapy improved overall survival in stage IB G1/2 compared with no treatment (p<0.0001). In stage IB G1/2 and stage IA G3, vaginal brachytherapy was superior to external beam radiation therapy (p=0.0004 and p=0.004, respectively). Stage IB G3 patients had improved overall survival with either vaginal brachytherapy or external beam radiation therapy versus no treatment but no difference in overall survival was seen between vaginal brachytherapy and external beam radiation therapy (p=0.94). CONCLUSIONS The delivery of adjuvant radiation therapy in patients with stage IA G1/2 endometrial carcinoma is not associated with improvement in overall survival. Patients with stage IB G1/2 and G3 as well as stage IA G3 are shown to benefit from improved overall survival when adjuvant radiation therapy is administered. These findings demonstrate potential opportunities to reduce both overtreatment and undertreatment in stage I endometrial cancer patients.
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Affiliation(s)
- Mariam AlHilli
- Subspeciality Care for Women's Health, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sudha Amarnath
- Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul Elson
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lisa Rybicki
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sean Dowdy
- Gynecologic Surgery, Mayo Clinic, Rochester, New York, USA
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Zhang Y, Ascaso C, Herreros A, Sánchez J, Sabater S, Pino MD, Li Y, Gómez G, Torné A, Biete A, Rovirosa Á. Postoperative endometrial carcinoma treated with external beam irradiation plus vaginal-cuff brachytherapy. Is there a dose relationship with G2 vaginal complications? Rep Pract Oncol Radiother 2020; 25:227-232. [PMID: 32042274 PMCID: PMC7000548 DOI: 10.1016/j.rpor.2020.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 01/10/2020] [Indexed: 01/26/2023] Open
Abstract
AIM To analyse the possible relationship between the EQD2(α/β=3Gy) at 2 cm3 of the vagina and late toxicity in vaginal-cuff-brachytherapy (VBT) after external-beam-irradiation (EBRT) for postoperative endometrial carcinoma (EC). MATERIALS AND METHODS From 2014 to 2016, 62 postoperative EC patients were treated with EBRT + VBT. The median EBRT dose was 45 Gy (44 Gy-50.4 Gy). VBT involved a single 7 Gy dose. Toxicity was prospectively evaluated using the RTOG score for the rectum and bladder and the objective LENT-SOMA criteria for the vagina. EQD2(α/β = 3Gy) at 2 cm3 of the most exposed part of the vagina was calculated by the sum of the EBRT + VBT dose. Statistics: Boxplot, Student's t and Chi-square tests and ROC curves. RESULTS Mean follow-up: 39.2 months (15-68). Late toxicity: bladder:0 patient; rectum:2 patients-G1; Vagina: 26 patients-17G1, 9G2; median EQD2(α/β=3Gy) at 2 cm3 in G0-G1 patients was 70.4 Gy(SD2.36), being 72.5 Gy(SD2.94) for G2p. The boxplot suggested a cut-point identifying the absence of G2: 100 % of G2p received >68 Gy, ROC curves showed an area under the curve of 0.72 (sensitivity of 1 and specificity of 0.15). CONCLUSIONS Doses >68 Gy EQD2(α/β=3Gy) at 2 cm3 to the most exposed area of the vagina were associated with late G2 vaginal toxicity in postoperative EC patients treated with EBRT + VBT suggesting a very good dose limit to eliminate the risk of G2 late toxicity. The specificity obtained indicates the need for prospective analyses.
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Affiliation(s)
- Yaowen Zhang
- Fonaments Clinics Dpt. University of Barcelona, 08036 Barcelona, Spain
- Radiation Oncology Dpt. Hospital Clinic Universitari, 08036, Barcelona, Spain
| | - Carlos Ascaso
- Fonaments Clinics Dpt. University of Barcelona, 08036 Barcelona, Spain
| | - Antonio Herreros
- Fonaments Clinics Dpt. University of Barcelona, 08036 Barcelona, Spain
- Radiation Oncology Dpt. Hospital Clinic Universitari, 08036, Barcelona, Spain
| | - Joan Sánchez
- Economics Dpt. Hospital Clinic Universitari, 08036, Barcelona, Spain
| | - Sebastia Sabater
- Radiation Oncology Dpt. Hospital General Universitario de Albacete, 02006 Albacete, Spain
| | - Marta del Pino
- Gynecological Cancer Unit. Hospital Clinic Universitari, 08036 Barcelona, Spain
| | - Yan Li
- Fonaments Clinics Dpt. University of Barcelona, 08036 Barcelona, Spain
- Radiation Oncology Dpt. Hospital Clinic Universitari, 08036, Barcelona, Spain
| | - Gabriela Gómez
- Radiation Oncology Dpt. Hospital Clinic Universitari, 08036, Barcelona, Spain
- Radiation Oncology Dpt. Instituto Nacional de Cancerología, Ciudad de México, Mexico
| | - Aureli Torné
- Gynecological Cancer Unit. Hospital Clinic Universitari, 08036 Barcelona, Spain
| | - Albert Biete
- Fonaments Clinics Dpt. University of Barcelona, 08036 Barcelona, Spain
- Radiation Oncology Dpt. Hospital Clinic Universitari, 08036, Barcelona, Spain
- Gynecological Cancer Unit. Hospital Clinic Universitari, 08036 Barcelona, Spain
| | - Ángeles Rovirosa
- Fonaments Clinics Dpt. University of Barcelona, 08036 Barcelona, Spain
- Radiation Oncology Dpt. Hospital Clinic Universitari, 08036, Barcelona, Spain
- Gynecological Cancer Unit. Hospital Clinic Universitari, 08036 Barcelona, Spain
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ElMajjaoui S, Ismaili N, Benjaafar N. COVID-19, Brachytherapy, and Gynecologic Cancers: a Moroccan Experience. SN COMPREHENSIVE CLINICAL MEDICINE 2020; 2:1035-1038. [PMID: 32838167 PMCID: PMC7360376 DOI: 10.1007/s42399-020-00402-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 07/08/2020] [Indexed: 11/30/2022]
Abstract
The treatment of gynecological cancers is the main activity of brachytherapy units. However, during COVID-19 pandemic, precautions should be done in order to reduce the spread of the virus while maintaining all chances to recovery for all patients (Radiother Oncol 148, 227-228, 2020). Despite the extent of the pandemic in our country, limited data are available to establish recommendations with a sufficient level of evidence (Radiother Oncol 148, 227-228, 2020). More recently, the American Brachytherapy Society published some clarifications in this regard and international expert consensus recommendations of radiation therapy for gynecologic malignancies during the COVID-19 pandemic were published (https://www.americanbrachytherapy.org/about-abs/abs-news/abs-statement-on-coronavirus/, Gynecol Oncol 15, 2020). In this commentary, we sought to share the procedures adopted for the management of gynecological cancer patients during COVID-19 pandemic in our brachytherapy unit.
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Affiliation(s)
- Sanaa ElMajjaoui
- grid.31143.340000 0001 2168 4024Department of Radiotherapy, National Institute of Oncology, Mohammed V University, Rabat, Morocco
| | - Nabil Ismaili
- grid.501379.90000 0004 6022 6378Department of Medical Oncology, Cheick Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco
| | - Noureddine Benjaafar
- grid.31143.340000 0001 2168 4024Department of Radiotherapy, National Institute of Oncology, Mohammed V University, Rabat, Morocco
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LVSI positive and NX in early endometrial cancer: Surgical restaging (and no further treatment if N0), or adjuvant ERT? Gynecol Oncol 2019; 156:243-250. [PMID: 31703813 DOI: 10.1016/j.ygyno.2019.09.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/12/2019] [Accepted: 09/14/2019] [Indexed: 12/20/2022]
Abstract
Early endometrial cancer has an overall survival of greater than 80% (1). One of the poor prognostic factors that may be associated with the 20% who do not survive 5 years is the presence of lymphovascular space invasion (LVSI). LVSI is associated with increased nodal metastasis and decreased progression free survival (PFS) and overall survival (OS). (2-8). Therefore, unstaged, LVSI positive early endometrial cancer requires additional management with either completion of staging with lymphadenectomy or adjuvant radiation. We focus on reviewing the management of natural history and management of early endometrial cancer followed by the prognostic impact of LVSI, management options and recommendations.
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Li R, Shinde A, Han E, Lee S, Beriwal S, Harkenrider M, Kamrava M, Chen YJ, Glaser S. A proposal for a new classification of "unfavorable risk criteria" in patients with stage I endometrial cancer. Int J Gynecol Cancer 2019; 29:1086-1093. [PMID: 31474587 DOI: 10.1136/ijgc-2019-000264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/16/2019] [Accepted: 04/22/2019] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Randomized trials describe differing sets of high-intermediate risk criteria. OBJECTIVE To use the National Cancer Database to compare the impact of radiation therapy in patients with stage I endometrial cancer meeting different criteria, and define a classification of "unfavorable risk." METHODS Patients with stage I endometrial cancer between January 2010 and December 2014 were identified in the National Cancer Database and stratified into two cohorts: (1) patients meeting Gynecologic Oncology Group (GOG)-99 criteria only for high-intermediate risk, but not Post-Operative Radiation Therapy in Endometrial Carcinoma (PORTEC)-1 criteria and (2) those meeting PORTEC-1 criteria only. High-risk stage I patients with both FIGO stage IB (under FIGO 2009 staging) and grade 3 disease were excluded. In each cohort, propensity score-matched survival analyses were performed. Based on these analyses, we propose a new classification of unfavorable risk. We then analyzed the association of adjuvant radiation with survival, stratified by this classification. RESULTS We identified 117,272 patients with stage I endometrial cancer. Of these, 11,207 patients met GOG-99 criteria only and 5,920 patients met PORTEC-1 criteria only. After propensity score matching, adjuvant radiation therapy improved survival (HR=0.73; 95% CI 0.60 to 0.89; p=0.002) in the GOG-99 only cohort. However, there was no benefit of adjuvant radiation (HR=0.89; 95% CI 0.69 to 1.14; p=0.355) in the PORTEC-1 only cohort. We, therefore, defined unfavorable risk stage I endometrial cancer as two or more of the following risk factors: lymphovascular invasion, age ≥70, grade 2-3 disease, and FIGO stage IB. Adjuvant radiation improved survival in stage I patients with adverse risk factors (HR=0.74; 95% CI 0.68 to 0.80; p<0.001), but not in other stage I patients (HR=1.02; 95% CI 0.91 to 1.15; p=0.710; p interaction <0.001). CONCLUSION Our study showed that adjuvant radiation was associated with an overall survival benefit in patients meeting GOG-99 criteria only; however, no survival benefit was seen in patients meeting PORTEC-1 criteria only. We propose a definition of unfavorable risk stage I endometrial cancer: ≥2 risk factors from among lymphovascular invasion, age ≥70, grade 2-3 disease, and FIGO stage IB disease.
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Affiliation(s)
- Richard Li
- Radiation Oncology, City of Hope Medical Center, Duarte, California, USA
| | - Ashwin Shinde
- Radiation Oncology, City of Hope Medical Center, Duarte, California, USA
| | - Ernest Han
- Gynecologic Oncology, City of Hope Medical Center, Duarte, California, USA
| | - Stephen Lee
- Gynecologic Oncology, City of Hope Medical Center, Duarte, California, USA
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania, USA
| | - Matthew Harkenrider
- Radiation Oncology, Stritch School of Medicine; Loyola University Chicago, Maywood, Illinois, USA
| | - Mitchell Kamrava
- Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Yi-Jen Chen
- Radiation Oncology, City of Hope Medical Center, Duarte, California, USA
| | - Scott Glaser
- Radiation Oncology, City of Hope Medical Center, Duarte, California, USA
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Brooks RA, Fleming GF, Lastra RR, Lee NK, Moroney JW, Son CH, Tatebe K, Veneris JL. Current recommendations and recent progress in endometrial cancer. CA Cancer J Clin 2019; 69:258-279. [PMID: 31074865 DOI: 10.3322/caac.21561] [Citation(s) in RCA: 253] [Impact Index Per Article: 50.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Endometrial cancer is the most common gynecologic cancer in the United States, and its incidence is rising. Although there have been significant recent advances in our understanding of endometrial cancer biology, many aspects of treatment remain mired in controversy, including the role of surgical lymph node assessment and the selection of patients for adjuvant radiation or chemotherapy. For the subset of women with microsatellite-instable, metastatic disease, anti- programmed cell death protein 1 immunotherapy (pembrolizumab) is now approved by the US Food and Drug Administration, and numerous trials are attempting to build on this early success.
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Affiliation(s)
- Rebecca A Brooks
- Associate Professor, Department of Gynecologic Oncology, The University of Chicago, Chicago, IL
- Dr. Brooks is now the Associate Professor and Chief of the Division of Gynecologic Oncology, University of California Davis School of Medicine, Davis, CA
| | - Gini F Fleming
- Professor of Medicine and Director, Medical Oncology Breast Program, Department of Medical Oncology, The University of Chicago, Chicago, IL
| | - Ricardo R Lastra
- Assistant Professor, Department of Pathology, The University of Chicago, Chicago, IL
| | - Nita K Lee
- Assistant Professor of Obstetrics and Gynecology, Department of Gynecologic Oncology, The University of Chicago, Chicago, IL
| | - John W Moroney
- Associate Professor of Obstetrics and Gynecology, Department of Gynecologic Oncology, The University of Chicago, Chicago, IL
| | - Christina H Son
- Assistant Professor, Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL
| | - Ken Tatebe
- Resident, Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL
| | - Jennifer L Veneris
- Instructor of Medicine, Division of Gynecologic Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
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Reboux PA, Azaïs H, Canova CH, Bendifallah S, Ouldamer L, Raimond E, Hudry D, Coutant C, Graesslin O, Touboul C, Collinet P, Bricou A, Huchon C, Daraï E, Ballester M, Lévêque J, Lavoué V, Koskas M, Uzan C, Canlorbe G. Impact of vaginal brachytherapy in intermediate and high-intermediate risk endometrial cancer: a multicenter study from the FRANCOGYN group. J Gynecol Oncol 2019; 30:e53. [PMID: 31074238 PMCID: PMC6543117 DOI: 10.3802/jgo.2019.30.e53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 11/26/2018] [Accepted: 01/09/2019] [Indexed: 11/30/2022] Open
Abstract
Objective According to recent European Society of Medical Oncology, European Society of Gynaecological Oncology and European Society of Radiotherapy and Oncology guidelines, adjuvant vaginal brachytherapy (VB) is optional in patients with intermediate risk (IR) and high-intermediate risk (HIR) endometrial cancer (EC). The aim of this French retrospective, multicenter study was to assess the impact of VB in these groups on local recurrence rate, local recurrence-free survival (RFS) and overall survival (OS). Methods Data of 191 patients with IR and HIR EC who underwent primary surgery with or without VB and no other adjuvant treatment between 2000 and 2016 were extracted from the FRANCOGYN database. Rate of local recurrence, OS and local RFS in these two groups were compared using the Kaplan-Meier method. Results The number of patients with IR and HIR EC were 118 and 73 respectively. VB was used in 92 patients in IR group and 43 in HIR group. Median follow-up was 22 months. In the HIR group, the local recurrence rate was significantly higher in the no adjuvant therapy group in comparison with the VB group (16.7% and 0% respectively, p=0.02). There was also a significant improvement in local RFS (p=0.01) in VB group. In IR EC, there is no significant difference on local recurrence rate (4.2% and 3.2%, respectively, p=1.00) or local RFS (p=0.54) between the two groups. Conclusions VB is an efficient adjuvant treatment for patients with HIR EC. VB is not associated with an improvement of RFS or OS in IR EC patient.
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Affiliation(s)
- Pierre Alain Reboux
- Department of Gynecological and Breast Surgery and Oncology, Pitié-Salpêtrière University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Institut Universitaire de Cancérologie (IUC), Paris, France
| | - Henri Azaïs
- Department of Gynecological and Breast Surgery and Oncology, Pitié-Salpêtrière University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Institut Universitaire de Cancérologie (IUC), Paris, France
| | - Charles Henry Canova
- Department of Radiation Oncology, Pitié-Salpêtrière University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Paris, France
| | - Sofiane Bendifallah
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Institut Universitaire de Cancérologie (IUC), Paris, France.,INSERM UMR_S_938, "Cancer Biology and Therapeutics", Centre de Recherche Saint-Antoine (CRSA), Sorbonne University, Paris, France
| | - Lobna Ouldamer
- Department of Gynecology, Centre Hospitalier Universitaire de Tours, Tours, France; INSERM U1069, Université François-Rabelas, Tours, France
| | - Emilie Raimond
- Department of Obstetrics and Gynaecology, Institute Alix de Champagne University Hospital, Reims, France
| | - Delphine Hudry
- Center de Lutte Contre le Cancer Georges François Leclerc, Dijon, France
| | - Charles Coutant
- Center de Lutte Contre le Cancer Georges François Leclerc, Dijon, France
| | - Olivier Graesslin
- Department of Obstetrics and Gynaecology, Institute Alix de Champagne University Hospital, Reims, France
| | - Cyril Touboul
- Department of Obstetrics and Gynaecology, Centre Hospitalier Intercommunal, Créteil, France
| | - Pierre Collinet
- Department of Obstetrics and Gynaecology, Centre Hospitalier Régional Universitaire, Lille, France
| | - Alexandre Bricou
- Department of Gynaecology and Obstetrics, Jean Verdier University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), University Paris 13, Bondy, France
| | - Cyrille Huchon
- Department of Gynaecology and Obstetrics, Centre Hospitalier Intercommunal, Poissy, France
| | - Emile Daraï
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Institut Universitaire de Cancérologie (IUC), Paris, France
| | - Marcos Ballester
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Institut Universitaire de Cancérologie (IUC), Paris, France
| | - Jean Lévêque
- CHU de Rennes, Service de Gynécologie, Hopital Sud, Université de Rennes 1, Rennes, France
| | - Vincent Lavoué
- CHU de Rennes, Service de Gynécologie, Hopital Sud, Université de Rennes 1, Rennes, France.,INSERM 1242, Oncogenesis, Stress and Signaling, CRLC Eugène Marquis, Rennes, France
| | - Martin Koskas
- Division of Gynecologic Oncology, Bichat University Hospital, Paris, France
| | - Catherine Uzan
- Department of Gynecological and Breast Surgery and Oncology, Pitié-Salpêtrière University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Institut Universitaire de Cancérologie (IUC), Paris, France.,INSERM UMR_S_938, "Cancer Biology and Therapeutics", Centre de Recherche Saint-Antoine (CRSA), Sorbonne University, Paris, France
| | - Geoffroy Canlorbe
- Department of Gynecological and Breast Surgery and Oncology, Pitié-Salpêtrière University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Institut Universitaire de Cancérologie (IUC), Paris, France.,INSERM UMR_S_938, "Cancer Biology and Therapeutics", Centre de Recherche Saint-Antoine (CRSA), Sorbonne University, Paris, France.
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50
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Ager BJ, Francis SR, Do OA, Huang YJ, Soisson AP, Dodson MK, Werner TL, Sause WT, Grant JD, Gaffney DK. Do vaginal recurrence rates differ among adjuvant vaginal brachytherapy regimens in early-stage endometrial cancer? Brachytherapy 2019; 18:453-461. [PMID: 31005603 DOI: 10.1016/j.brachy.2019.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/22/2019] [Accepted: 03/01/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE We sought to retrospectively examine clinical outcomes for three adjuvant vaginal high-dose-rate (HDR) brachytherapy regimens after hysterectomy for early-stage endometrial cancer. METHODS Included were women of all ages from two independent hospital systems diagnosed with Stage I-II endometrial cancer of any grade between 2000 and 2016 who underwent hysterectomy followed by adjuvant vaginal cylinder HDR brachytherapy with either 7.0 Gy × 3 fractions prescribed to 0.5 cm vaginal depth, 6.5 Gy × 3 fractions prescribed to 0.5 cm vaginal depth, or 6.0 Gy × 5 fractions prescribed to the vaginal surface. Outcomes included vaginal recurrence (VR), pelvic recurrence, distant recurrence, locoregional recurrence, recurrence-free survival, and overall survival. RESULTS Of the 348 women, 45 (13%) received 7.0 Gy × 3 fractions, 259 (74%) received 6.5 Gy × 3 fractions, and 44 (13%) received 6.0 Gy × 5 fractions. Women receiving 5-fraction brachytherapy were more likely to be younger with a higher performance status. At a median follow-up of 4.5 years, VR rates were 2.2%, 0.8%, and 4.5%, respectively. Multivariate analysis revealed no significant differences in the risks for VR among brachytherapy regimens. Risks for VR, pelvic recurrence, distant recurrence, locoregional recurrence, recurrence-free survival, and overall survival did not differ between propensity score-matched five- and 3-fraction brachytherapy cohorts. CONCLUSIONS VR rates after hysterectomy and adjuvant vaginal brachytherapy for early-stage endometrial cancer were low and not significantly different by HDR dose fractionation.
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Affiliation(s)
- Bryan J Ager
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Samual R Francis
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Olivia A Do
- Population Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Y Jessica Huang
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Andrew P Soisson
- Department of Obstetrics and Gynecology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Mark K Dodson
- Department of Obstetrics and Gynecology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Theresa L Werner
- Department of Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - William T Sause
- Department of Radiation Oncology, Intermountain Medical Group, Intermountain Healthcare, Salt Lake City, UT
| | - Jonathan D Grant
- Department of Radiation Oncology, Intermountain Medical Group, Intermountain Healthcare, Salt Lake City, UT
| | - David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT.
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