Prognostic significance of the extent of cervical involvement by endometrial cancer

Data Set for the Reporting of Endometrial Cancer: Recommendations From the International Collaboration on Cancer Reporting (ICCR)

Endometrial cancer is one of the most common cancers among women. The International Collaboration on Cancer Reporting (ICCR) developed a standardized endometrial cancer data set in 2011, which provided detailed recommendations for the reporting of resection specimens of these neoplasms. A new data set has been developed, which incorporates the updated 2020 World Health Organization Classification of Female Genital Tumors, the Cancer Genome Atlas (TCGA) molecular classification of endometrial cancers, and other major advances in endometrial cancer reporting, all of which necessitated a major revision of the data set. This updated data set has been produced by a panel of expert pathologists and an expert clinician and has been subject to international open consultation. The data set includes core elements which are unanimously agreed upon as essential for cancer diagnosis, clinical management, staging, or prognosis and noncore elements which are clinically important, but not essential. Explanatory notes are provided for each element. Adoption of this updated data set will result in improvements in endometrial cancer patient care.

Blood Vessel Invasion in Endometrial Cancer Is One of the Mechanisms of Spread to the Cervix

To evaluate the association between type of invaded vessels (blood or lymphatic) and cervical involvement in endometrial cancer (EC). Pathological slides of 93 patients with EC who had vascular space invasion in hematoxylin-eosin staining underwent immunohistochemical assay with CD31 and podoplanin. CD31 and podoplanin were used to identify blood and lymphatic invaded vessels, respectively. Cervical stromal invasion (CSI) was determined in 21 (30%) patients. The rate of CD31-positivity was significantly higher in patients with CSI than without (76.2 and 34.7%, p = 0.001; respectively). Podoplanin-positivity was determined in 47.6 and 81.6% of patients with and without CSI, respectively (p = 0.005). Age, myometrial invasion and the combination of CD31-positivity with podoplanin-negativity were found as independent predictors for CSI. Blood vessel invasion is an important factor for CSI in EC. Blood vessel invasion rather than lymphatic vessel invasion is one of the predominant ways by which EC spreads to the cervix.

Further insight into prognostic factors in endometrial cancer: the new serum biomarker HE4

INTRODUCTION

Endometrial cancer (EC) is one of the most common gynecological cancer worldwide. To date, no good markers are routinely used in clinical practice for prognosis and monitoring. Areas covered: During the last years, an increasing interest in literature has been growing on HE4 (Human epididimis 4). Therefore, we aimed to gather all the evidence reported in literature analysing the potential prognostic value of HE4, compared to the well know tumor's features (histological type and grade, stage of disease, depth of myometrial invasion, lymphovascular space involvement and cervical involvement). Expert commentary: The analysis of data suggests that HE4 seems to have a good performance in prognosis and monitoring of the disease, helping to schedule the appropriste timing of imaging and surgery in a more individualized fashion. However, these findings surely require a validation in a larger cohorts of patients. Probably, in the next five years, prospective randomized trials will be performed to confirm the prognostic role of HE4 in EC and to find a tailored EC management strategy.

Problematic issues in the staging of endometrial, cervical and vulval carcinomas

The International Federation of Gynecology and Obstetrics (FIGO) staging of tumours of the uterine corpus, cervix and vulva was revised in 2009. The greatest impact of the revised staging was on carcinomas of the uterine corpus. Uterine sarcomas are now staged separately. Changes to the staging system for vulvar carcinomas largely reflect the significance of lymph node status. Only minor amendments have been introduced for cervical carcinomas, which remain the only gynaecological tumours to be staged clinically. These revisions, based on recent evidence, require careful, more detailed assessment of several histological parameters at each anatomical site. The present review deals with the evidence and rationale underpinning the revisions, and includes practical guidance on tumour staging. This covers the assessment and measurement of myoinvasion and evaluation of cervical, parametrial, serosal and vaginal involvement in carcinomas of the uterine corpus; the identification and accurate measurement of stromal invasion in cervical and vulvar carcinomas; the assessment of unusual variants of carcinoma at each of these sites; and the assessment of lymph node involvement.

Endocervical involvement in endometrial adenocarcinoma is not prognostically significant and the pathologic assessment of the pattern of involvement is not reproducible

OBJECTIVES

Since 1988, cervical gland involvement and stromal invasion defined stage IIA and stage IIB endometrial carcinoma. In 2009, FIGO changed the criteria for stage II disease to include only those with cervical stromal invasion. We wished to: 1) assess the reproducibility of pathologists to distinguish patterns of cervical spread, and 2) determine the prognostic significance of cervical involvement.

METHODS

Slides from 46 women with cervical involvement by endometrial adenocarcinoma were scored for 5 patterns of involvement by 6 experienced pathologists to determine reproducibility. To assess prognostic significance, 206 patients with FIGO 1988 stage II adenocarcinoma formed the study population with matched FIGO stage I controls.

RESULTS

At least 5 of the 6 pathologists agreed that the cervix was involved in the 46 cases. The reproducibility for cervical gland involvement and endocervical stromal invasion was slight (kappas of 0.15 and 0.28). The survival with any type of cervical involvement was not significantly different from that of matched stage I controls (p=0.18). The 5year recurrence-free survival rates were 84% for FIGO 1988 stage I, 73% for stage IIA, and 82% for stage IIB (FIGO 2009 stage II).

CONCLUSIONS

Pathologists reliably recognize cervical involvement by endometrial carcinoma. However, reproducibility for the determination of pattern of cervical spread by experienced pathologists is too low to be of clinical utility. Women with spread of carcinoma to the cervix do not have a significantly lower survival than matched stage I controls. Cervical spread should not be the basis for determination of stage II disease.

[Current TNM/FIGO classification for cervical and endometrial cancer as well as malignant mixed müllerian tumors. Facts and background]

Numerous recent studies of endometrial and cervical carcinomas as well as malignant mixed müllerian tumors (MMMT) of the uterus have made a revision of the FIGO/TNM classification necessary, effective as of January 1st, 2010. There will be a new subclassification of carcinoma of the uterine cervix with proximal vaginal infiltration, using the same cut-off for the tumor extension as used for stage FIGOIB/T1b (≤/>4 cm), resulting in stage FIGO IIA1/T2a1 and FIGO IIA2/T2a2. In endometrial carcinoma, the previous FIGO IA/pT1a and FIGO IB/pT1b will be merged to FIGO IA/pT1a. The former category FIGO IC/T1c will be changed into FIGO IB/T1b. The category FIGO IC/pT1c will not longer been used. Additionally, there will be no separate classification for the involvement of the endocervical glands by endometrial carcinoma. This feature will be incorporated in stage FIGO I/T1 disease. The new category FIGO II/T2 will be defined as endocervical stromal involvement. There will be a new category, termed T3c/IIIC, which includes regional lymph node involvement. Stage T3c1/IIIC1 will be defined as pelvic lymph node involvement and stage T3c2/IIIC2 para-aortal lymph node involvement with or without pelvic lymph node disease. In the TNM system, regional lymph node involvement can alternatively be classified as N1. The MMMT will be staged like endometrial carcinoma.

[Changes in the TNM classification of gynecological tumors]

Based on the results of clinical and histomorphological studies in recent years, a revision of the TNM classification of malignant tumours of the female genital organs became necessary. Vulvar cancer saw the most significant changes. In the T1 category the new system recognises tumour size and its relation to the infiltration of adjacent structures by the tumour. The number of positive regional lymph nodes has also been included in the new staging system. For cervical cancer, there is a new subdivision of the category T2a depending on tumour size with a breakpoint of ≤ 4 cm versus > 4 cm and a subdivision into T2a1 und T2a2. In endometrial cancer, the previous pT1a and pT1b were merged to pT1a. The former category T1c has changed into T1b. The category pT1c is no longer used. For the first time, there is a TNM classification system for uterine sarcomas.

Endometrial endometrioid adenocarcinoma of the uterine corpus involving the cervix: some cases probably represent independent primaries

The majority of endometrial endometrioid adenocarcinomas involving the cervix have tumor morphology that is similar in the endometrium and the endocervix. There are, however, some cases in which the morphology of the tumor in the endocervix is different from the endometrial carcinoma, in which it is more invasive than the endometrial carcinoma, or in which invasion only occurs in the endocervix while there is no or only minimal myometrial invasion. The goal of this study was to investigate whether tumors involving the endometrium and the endocervix are similar or 2 independent primaries by hematoxylin and eosin stain, immunohistochemistry (IHC), human papillomavirus (HPV) DNA in situ hybridization, RNA reverse transcriptase in situ polymerase chain reaction (PCR) analyses to reveal HPV, and DNA clonality studies. We selected 14 cases of endometrial endometrioid adenocarcinomas involving the cervix with complete pathology material available from the years between 1968 and 2004. Immunohistochemical studies for vimentin, carcinoembryonic antigen, estrogen receptor, progesterone receptor, and p16 were performed in 12 cases; HPV DNA/RNA analyses in 4 cases; and clonality studies in 9 cases. The patients' ages ranged from 42 to 81 years (mean: 62 y). Follow-up information was obtained in 11 patients. Histologic features varied between the tumors in the endometrium and the endocervix in 8 cases, and 5 of these cases had uniform, dilated glands having a microcystic appearance in the cervix. In 6 cases, the tumors in the endometrium and the endocervix had similar histologic features. The immunohistochemical studies showed some differences between the endometrial and endocervical adenocarcinomas in 8 of the 12 cases, independent of differing or similar histologic features. HPV testing in 4 of the cases (3 with similar and 1 with different histology) yielded similar results in the endometrium and endocervix: 2 cases were negative, 1 was positive and 1 was equivocal for HPV DNA/RNA analyses. Clonality studies showed differences between the adenocarcinoma in the endometrium and the endocervix in 7 cases, including 5 cases with different histologic appearances; 2 cases had similar loss of heterozygosity patterns. In conclusion, as suggested by clonality studies, coexisting endometrial and endocervical carcinomas with different histologic features are most likely independent neoplasms. Endometrial and endocervical carcinomas that have similar appearances can represent either the same neoplasm or independent primaries. Clonality tests may help determine their relationship. IHC studies may not be helpful for synchronous endometrial and endocervical tumors, especially those of endometrioid type. It is possible that IHC identifies cell differentiation, rather than site of origin. HPV studies are important to identify endocervical tumors associated with high-risk HPV. However, endometrial tumors involving the cervix and endocervical tumors unrelated to HPV are both negative for high-risk HPV.

FIGO staging of endometrial adenocarcinoma: a critical review and proposal

The optimal staging of tumors would reflect their biology and patterns of spread, permit accurate prognostication, and facilitate therapeutic decision-making. The last revision of the International Federation of Obstetricians and Gynecologists (FIGO) staging of uterine corpus tumors was in 1988, and it represented the transition from a clinical to a surgico-pathologic system. With 20 years of experience, we can now review the accuracy, reproducibility, and utility of this system. Pathologists are in a unique position to study each of these characteristics, comment on their ability to apply the criteria in daily practice, and offer suggestions to further improve the FIGO system. This paper selectively reviews some of the more problematic aspects of the current FIGO system, including the following: the distinction of tumors confined to the endometrium from those which are superficially myoinvasive; the method and utility of histologic grading of endometrial adenocarcinoma; the utility and reproducibility of the diagnosis of cervical epithelial and stromal invasion; the striking heterogeneity within and among stage III A, B, and C tumors and their differing prognostic significance. It concludes with recommendations for changes in a future revision of the FIGO staging of endometrial carcinoma.

Diffusely Infiltrating Endometrial Carcinomas With No Stromal Response: Report of a Series, Including Cases With Cervical and Ovarian Involvement and Emphasis on the Potential for Misdiagnosis

Endometrial carcinomas, particularly of endometrioid type, can invade the myometrium or cervix without eliciting a stromal desmoplastic or inflammatory response and have been referred to as diffusely infiltrating endometrial carcinomas. This study describes a series of 14 endometrial carcinomas infiltrating as single “naked” glands without a stromal response. The neoplasms consisted of 12 endometrioid carcinomas, 1 mixed endometrioid and clear cell carcinoma, and 1 serous carcinoma. In all cases, there was myometrial invasion without stromal response. Seven cases exhibited cervical stromal involvement and in 2 there was involvement of both ovaries in a similar pattern. Several of the cases were seen in consultation and the pattern of infiltration raised a number of differential diagnoses, both benign and malignant, depending on the site of tumor involvement, including adenomyosis, adenomyoma, primary endocervical glandular lesions, cervical mesonephric remnants, endometriosis or tuboendometrioid metaplasia, and ovarian cortical inclusion cysts. Although this pattern of invasion has been reported previously, it continues to present diagnostic difficulties.

Upstaging based solely on positive peritoneal washing does not affect outcome in endometrial cancer

Surgical staging of endometrial carcinoma includes the collection of peritoneal washings in the abdomen and pelvis. A positive finding upstages patients to International Federation of Gynecology and Obstetrics stage IIIA. However, the prognostic significance of such an upstaging, and thus the justification for the routine performance of this procedure, is unclear. This 5-year retrospective study was conducted to determine the frequency and prognostic significance of upstaging of endometrial carcinoma based solely on positive washings. The cohort for the study was collected by review of pathology reports of all washings that were performed prior to hysterectomies for suspected endometrial carcinomas over a 5-year period (01/1995-12/1999). Cases with positive cytology were selected if there was no grossly apparent intraperitoneal disease, no histologic evidence of extra-uterine tumor and the cases would otherwise have been considered stage I or II (case group). An age-matched control group was selected of stage I and II patients with the same histologic subtypes and negative washings (n=19). Of 220 endometrial carcinomas, peritoneal washing cytology was abnormal in 19 (8.6%) and was solely responsible for upstaging only 10 patients (4.5% of all cases, eight-endometrioid, one-serous, one-mixed; nine stage IA or IB and one stage IIB). Adjuvant therapy was administered in 90% of the case group and 74% of the control group. After a median follow-up of 51 months (case group) and 63 months (control group), we found only a single patient with progression of disease (recurrence, metastases or death) in the control group. It is concluded that abnormal cytology without other evidence of extrauterine disease leads to upstaging of a minority of endometrial carcinoma patients (4.5%), but does not appear to affect their overall outcome. Although this is a small single site study, it raises questions about the value of this procedure in patients with endometrial cancer.

Prognostic parameters of endometrial carcinoma

Endometrial carcinoma is the most common malignant tumor of the female genital tract in the Western world. Approximately 80% of cases are well- to moderately differentiated (endometrioid) adenocarcinomas, which are confined to the uterine corpus at diagnosis, and thus most can be cured. Conversely, high-grade (ie, clear cell and serous) carcinomas account for only 15% to 20% of cases and show marked nuclear atypia. These tumors usually invade the myometrium and may extend beyond the uterus at the time of hysterectomy. In addition to clinical and morphological differences, these 2 groups of endometrial carcinomas differ in their pathogenesis. Whereas prognosis in the latter group is generally poor, the pathologist's role in establishing the outcome in the former group is crucial. Furthermore, it has become progressively apparent that both groups overlap to some extent, making the dualistic model a guideline at best. Over the last 2 decades, several studies have demonstrated the prognostic importance of various key surgical and pathological parameters, including histological type, histological grade, surgical-pathological stage, depth of myometrial invasion, vascular invasion, and cervical involvement. This review presents the most important prognostic factors of endometrial carcinomas from the pathologist's viewpoint, and attempts to clarify existing conflicts in the classification and diagnosis of these tumors.

The long-term survival of women with surgical stage II endometrioid type endometrial cancer

OBJECTIVES

The aim of this study was to evaluate the survival estimates, treatment outcomes, prognostic factors, and recurrence patterns of patients with surgical stage II endometrial cancer.

METHODS

Forty-eight stage II endometrial cancer patients treated between 1982 and 2000 were included. All the patients were subjected to the initial surgical staging procedure consisting of peritoneal cytology, infracolic omentectomy, abdominal hysterectomy (radical or simple), bilateral salpingo-oophorectomy, and complete pelvic-paraaortic lymphadenectomy. Of these 48 patients, 21 (44%) were treated with radical hysterectomy (RH) without adjuvant therapy. The remaining 27 (56%) patients were treated with simple hysterectomy plus adjuvant radiotherapy. With respect to the prognostic factors, no statistically significant difference was found between these two groups. The median follow-up period was 5 years (range, 2-9).

RESULTS

The mean age at the time of diagnosis was 55.8 years (range, 34-75). The 5-year disease-free and overall survival (OS) rates of entire group were 83% and 86%, respectively. These figures for 27 (56%) patients treated with simple hysterectomy plus radiation were 81% and 83%, respectively. For 21 (44%) patients who were treated with radical hysterectomy without adjuvant therapy, the 5-year disease-free and overall survival rates were 85% and 90%, respectively. When these two groups were compared, survival rates were not significantly different from each other (P = 0.60 for disease-free survival and P = 0.46 for overall survival). In multivariate analysis, only the high grade predicted poor survival significantly (P = 0.04). Eight patients (17%) had recurrence: two local, five distant, and one both local and distant. Initial therapeutic approach was not related with the subsequent site of relapse. Two patients with only local failure were successively treated, but all the six patients who had distant component of relapse died within the same year. Surgical morbidity was seen in six (12.5%) patients. No surgical mortality was seen, and no patient developed a major complication directly related to the radical hysterectomy or lymphadenectomy.

CONCLUSIONS

Without adjuvant radiotherapy, initial surgical staging procedure consisting radical hysterectomy and complete pelvic-paraaortic lymphadenectomy achieved excellent survival and minimal morbidity in stage II endometrial cancer. Distant failure was the main problem.

Endometrial endometrioid adenocarcinoma with a deceptive pattern of spread to the uterine cervix: a manifestation of stage IIb endometrial carcinoma liable to be misinterpreted as an independent carcinoma or a benign lesion

The prognosis of endometrial endometrioid adenocarcinoma is determined in part by stage; endocervical stromal involvement (stage IIB) imparts a worsened prognosis. We describe a deceptive pattern of stage IIB disease that mimics a primary endocervical glandular proliferation and may lead to understaging of endometrial endometrioid adenocarcinoma. Fifteen cases of endometrial endometrioid adenocarcinoma with a peculiar pattern of cervical involvement were identified from our consultation files. All cases were referred in consultation because of doubt about the nature of the cervical process and its relation to the corpus tumor; in a few instances, the cervical proliferation was considered possibly benign and in one case was misinterpreted as mesonephric hyperplasia. The patients ranged from 49 to 84 years in age (mean age 64.9 years). There was usually a grossly evident endometrial tumor. The cervix was unremarkable grossly in at least 11 patients. The cervical tumors were composed of variably shaped, often tubular glands with little or no stromal response and mainly invaded as widely spaced glands that often appeared deceptively benign. In 14 cases luminal secretions, mainly eosinophilic, were identified, often leading to consideration of a mesonephric lesion. Ten of the endometrial tumors were grade 1, four grade 2, and one grade 3. One was noninvasive, nine superficially invasive, and five deeply invasive. In four cases myoinvasion had, at least in part, a diffusely infiltrative pattern. The tumors in the cervix showed no in situ component and no definite surface involvement. Continuity with the corpus tumor could be demonstrated in 12 cases. Ten of the cervical tumors invaded more deeply than the endometrial tumor, four invaded to a similar depth, and only one was more superficial than its endometrial counterpart. The cervical and corpus tumors had a similar immunoprofile in nine cases: all were vimentin positive, eight estrogen positive and one negative, four carcinoembryonic antigen negative, and five with focal apical or rare cytoplasmic staining. This immunoprofile in conjunction with routine morphologic similarity between the two tumors and the usual documented continuity between them indicate that the cervical process represents spread from the endometrial endometrioid adenocarcinoma. It is important for both therapeutic and prognostic reasons that the cervical abnormality is not misinterpreted as a benign or malignant primary endocervical glandular process.

Postoperative irradiation in endometrial cancer: still a matter of controversy

Although endometrial cancer is the most common female malignancy, evidence-based uniform guidelines for postoperative therapy have not been established. The most logical management is adjuvant irradiation tailored to the extent of surgery, the tumour grade, depth of myometrial invasion, degree of lymph node involvement and age of the patient. Currently, the only widely accepted treatment recommendations are no further therapy in low-risk patients who underwent extensive surgical staging, and external beam radiotherapy (EBRT) in high-risk patients. Most authors recommend postoperative application of only one radiotherapy modality: either brachytherapy (BRT) or EBRT, as their routine combination does not clearly improve the outcome but does increase the risk of late complications. A combination of BRT and EBRT should however be considered in patients with stage II disease, for infiltration of the lower uterine segment, vaginal involvement, positive or close surgical margins, capillary space involvement or unfavourable histology. Two recent randomized studies including mostly intermediate-risk patients managed with either extensive surgical staging or total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH&BSO) with or without postoperative EBRT, showed better local control but no survival benefit from adjuvant irradiation. Two ongoing Gynecologic Oncology Group (GOG) studies compare adjuvant chemotherapy with pelvic or abdominal irradiation in patients with high risk of local relapse. The role of adjuvant radiotherapy (EBRT with or without BRT) in high-risk patients as well as the value of lymphadenectomy in patients fit for such surgery is being addressed in a trial co-ordinated by the Medical Research Council. Future studies are warranted to define whether any irradiation should be employed in intermediate-risk patients and which radiotherapy modality should be used in high-risk node-negative patients with stage I tumours (stage Ib grade 3 and all stage Ic). Other issues which should be addressed in future studies include the extent of surgery, the role of systemic therapies, the relevance of novel biologic prognostic factors, salvage therapies after recurrence, cost-benefit analysis and quality of life.

Value of dynamic MR imaging in assessing endometrial carcinoma involvement of the cervix

OBJECTIVE

The purpose of this study was to evaluate endometrial carcinoma involvement of the cervix using dynamic MR imaging compared with T2-weighted and contrast-enhanced T1-weighted MR imaging.

SUBJECTS AND METHODS

In 42 patients with endometrial carcinoma, T2-weighted MR imaging using rapid acquisition with relaxation enhancement, dynamic MR imaging using gradient-echo sequences, and contrast-enhanced T1-weighted MR imaging using spin-echo sequences were performed before treatment. We evaluated patterns of enhancement in the cervix and tumor. In 39 of the 42 patients who underwent surgical treatment, we compared MR imaging findings with histologic results concerning cervical involvement.

RESULTS

Enhancement of the cervical epithelium was greater than that of the tumor and cervical stroma on dynamic MR imaging in most patients. In assessing cervical involvement, the accuracy of T2-weighted, dynamic, and contrast-enhanced T1-weighted MR imaging was 85%, 95%, and 90%, respectively; no statistically significant difference was observed. False-positive cases on T2-weighted MR imaging were correctly identified as having no cervical involvement on dynamic MR imaging using the finding of continuous enhancement of the cervical epithelium. We found this finding to be reliable in assessing tumor involvement of the cervix.

CONCLUSION

We believe that, in combination with T2-weighted MR imaging sequences, dynamic MR imaging is useful in assessing endometrial carcinoma involvement of the cervix.

Parametrial spread in patients with endometrial carcinoma undergoing radical hysterectomy

The objective of this paper is to study parametrial involvement in patients with endometrial carcinoma undergoing radical hysterectomy. We reviewed indications for surgery, pathology findings, and outcome of a series of 24 patients with endometrial carcinoma who underwent radical hysterectomy. The uterus, cervix and parametrial tissue were processed as step-serial sections. Histologically, 16 patients (67%) had carcinoma involving the cervix. Two of these patients (8%) had frank histologic parametrial involvement and four (17%) had disease extending to the transitional zone of the cervix. Parametrial involvement was continuous and seen only in patients with involvement of the cervical stroma. Six patients (25%) had pelvic node metastases. With a median follow-up of 53 months (range 2-140), four patients (17%) developed recurrences (all within 24 months). Twelve patients (50%), including one of the two with parametrial invasion, were free of disease for 5 years or longer. We conclude that direct parametrial extension can occur in locally advanced endometrial cancer. Radical hysterectomy with lymphadenectomy can be an adequate operation for such patients.

Surgery followed by radiotherapy in endometrial cancer: analysis of survival and patterns of failure

We performed a retrospective evaluation of survival and patterns of failure in 317 consecutive endometrial cancer patients treated between 1974 and 1991 with surgery and adjuvant radiotherapy. Two hundred and forty seven patients (78%) had FIGO stage I disease, 30 (9%) - stage II, 35 (11%) - stage III and 5 (2%) - stage IV. Both low dose rate brachytherapy (BRT) and external beam radiation (EBRT) were applied in 247 patients (78%), only BRT in 49 (15%), and only EBRT in 21 (7%). Median follow-up was 7.3 years. Five-year overall survival was 75%, and five-year disease free survival was 81%. Both overall and disease free survival rates were correlated with stage (P = 0.001 and P = 0.000, respectively). Recurrence occurred in 70 patients (22%): 11 (3.5%) in the pelvis, 51 (16%) outside the pelvis and 6 (2%) both in- and outside the pelvis. Independent risk factors for local recurrence included older age (P = 0.03) and variant histologic subtypes (P = 0.039), whereas independent risk factors for distant spread were stage (P = 0.000) and older age (P = 0.011). Normalized Total Dose (the sum of EBRT and BRT doses, based on linear-quadratic equation), type of radiotherapy regimen, overall radiotherapy time and surgery-to-radiotherapy interval did not correlate with the risk of relapse. Severe early and late radiotherapy complications were observed in 21 (7%) and 35 patients (11%), respectively. In view of the relatively low risk of exclusive pelvic recurrences and the high rate of severe late radiotherapy complications, indications for postoperative radiotherapy and its scheme should be verified. A relatively high rate of extrapelvic recurrences calls for effective systemic adjuvants to surgery. Further definition of high risk patients is warranted in order to tailor postoperative therapy to the prognostic factors and to increase the therapeutic index of management of endometrial cancer.

Accuracy of preoperative histology and macroscopic assessment of cervical involvement in endometrial carcinoma

OBJECTIVE

To compare the diagnostic accuracy between the preoperatively and macroscopically established determination of cervical involvement in endometrial carcinoma.

STUDY DESIGN

During the period 1987 to 1991, 154 patients with endometrial cancer were evaluated in a retrospective blind manner with the objective of assessing the diagnostic accuracy of the preoperative (prehysterectomy curettage) and the macroscopic (sectioned surgical specimen) determination of th involvement of the cervix. The results were compared with histological findings of the hysterectomy specimen (gold standard).

RESULTS

Preoperative pre-hysterectomy curettage established a sensitivity of 38% and a specificity of 91% whereas the macroscopic findings (gross appearance) confirmed a sensitivity of 50% and a specificity of 95%. A prevalence of 17% for cervical involvement was found. In patients with cervical involvement diagnosed on pre-hysterectomy curettage, a positive predictive value of 45% and negative predictive value of 88% were established. A positive predictive value of 68% and a negative predictive value of 90% resulted from the judgement of the cervical gross appearance.

CONCLUSIONS

We conclude that the cervical involvement of endometrial carcinoma diagnosed on pre-hysterectomy tissue is less predictive than the judgement of the intraoperative gross appearance of the cervix.

Endometrial cancer

Carcinoma of the uterine corpus (endometrial cancer) remains the gynecologic malignant disease with the highest annual prevalence in the United States. The most common histologic type is adenocarcinoma, although more aggressive variants (e.g., papillary serous carcinoma and clear cell carcinoma) have been identified. Risk factors that are strongly associated with the development of endometrial cancer include tamoxifen therapy, obesity, and stimulation from unopposed estrogen (from exogenous sources or endogenously secreting ovarian tumors). The current staging system of the International Federation of Gynecology and Obstetrics is based on surgical-pathologic findings. Survival has been directly correlated with tumor stage in this staging system. The cornerstone of therapy is total abdominal hysterectomy with bilateral salpingo-oophorectomy. Pelvic and para-aortic lymphadenectomy may provide additional prognostic information but probably does not confer a therapeutic advantage. Moreover, such nodal dissections predispose to the development of complications, especially in women who subsequently receive pelvic irradiation. Other than surgical treatment, irradiation is the single most active therapy for endometrial carcinoma. In fact, some women who are not candidates for hysterectomy because of medical contra-indications can be cured with radiation alone. Adjuvant therapy following hysterectomy is based on patient- and tumor-related features that provided prognostic information for incidence and pattern of recurrence. Adjuvant treatment usually includes pelvic irradiation for selected patients. Current investigational strategies are directed at the role of whole-abdomen irradiation, extended-field irradiation, and systemic chemotherapy. The most active systemic agents include cisplatin, doxorubicin, paclitaxel, and progestins.

The justification for a surgical staging system in endometrial carcinoma

Three hundred and one patients with endometrial carcinoma who were surgically staged and treated postoperatively with irradiation at the Fox Chase Cancer Center or the Hospital of the University of Pennsylvania were retrospectively substaged by the 1988 FIGO staging system. For pathological stage I endometrial carcinoma, FIGO substage (IA/IB vs. IC) in addition to depth by thirds (< or = 2/3 vs. > 2/3), grade (1 or 2 vs. 3), age (< or = 60 vs. > 60), and type of postoperative irradiation (vaginal alone vs. external +/- vaginal) were predictive for 5-year cause-specific survival in univariate analysis. For all pathological stages, excluding IIIB and IV endometrial carcinoma, FIGO stage (I or II vs. III) in addition to depth by thirds (< or = 2/3 vs. > 2/3), grade (1 or 2 vs. 3), age (< or = 60 vs. > 60), and type of postoperative irradiation (vaginal alone vs. external +/- vaginal) were predictive for 5-year cause-specific survival in univariate analysis. Clinical stage (I vs. II or III) was not a significant predictor of outcome in univariate analysis. Multivariate analysis of the above factors revealed FIGO stage in addition to grade, age and depth by thirds to be independent predictors of outcome. In conclusion, the FIGO surgical staging system better predicts outcome compared with the prior clinical staging system, although the FIGO substaging needs refinement. Grade, age, and depth by thirds are equally important prognostic factors in addition to FIGO stage and can add to the predictive value of the current FIGO staging system.