Adjuvant whole abdominopelvic irradiation for high risk endometrial carcinoma

Treatment of node-positive endometrial cancer: chemotherapy, radiation, immunotherapy, and targeted therapy

OPINION STATEMENT

The standard of treatment for node-positive endometrial cancer (FIGO Stage IIIC) in North America has been systemic therapy with or without additional external beam radiation therapy (RT) given as pelvic or extended field RT. However, this treatment paradigm is rapidly evolving with improvements in systemic chemotherapy, the emergence of targeted therapies, and improved molecular characterization of these tumors. The biggest question facing providers regarding management of stage IIIC endometrial cancer at this time is: what is the best management strategy to use with regard to combinations of cytotoxic chemotherapy, immunotherapy, other targeted therapeutics, and radiation that will maximize clinical benefit and minimize toxicities for the best patient outcomes? While clinicians await the results of ongoing clinical trials regarding combined immunotherapy/RT as well as management based on molecular classification, we must make decisions regarding the best treatment combinations for our patients. Based on the available literature, we are offering stage IIIC patients without measurable disease postoperatively both adjuvant chemotherapy and IMRT with carboplatin, paclitaxel, and with or without pembrolizumab/dostarlimab as primary adjuvant therapy. Patients with measurable disease post operatively, high risk histologies, or stage IV disease receive chemoimmunotherapy, and vaginal brachytherapy is added for those with uterine risk factors for vaginal recurrence. In the setting of endometrioid EC recurrence more than 6 months after treatment, patients with pelvic nodal and vaginal recurrence are offered IMRT and brachytherapy without chemotherapy. For measurable recurrence not suitable for pelvic radiation alone, chemoimmunotherapy is preferred as standard of care.

Uterine Neoplasms, Version 1.2023, NCCN Clinical Practice Guidelines in Oncology

Adenocarcinoma of the endometrium (also known as endometrial cancer, or more broadly as uterine cancer or carcinoma of the uterine corpus) is the most common malignancy of the female genital tract in the United States. It is estimated that 65,950 new uterine cancer cases will have occurred in 2022, with 12,550 deaths resulting from the disease. Endometrial carcinoma includes pure endometrioid cancer and carcinomas with high-risk endometrial histology (including uterine serous carcinoma, clear cell carcinoma, carcinosarcoma [also known as malignant mixed Müllerian tumor], and undifferentiated/dedifferentiated carcinoma). Stromal or mesenchymal sarcomas are uncommon subtypes accounting for approximately 3% of all uterine cancers. This selection from the NCCN Guidelines for Uterine Neoplasms focuses on the diagnosis, staging, and management of pure endometrioid carcinoma. The complete version of the NCCN Guidelines for Uterine Neoplasms is available online at NCCN.org.

Systemic therapy for the treatment of endometrial cancer

Introduction: Endometrial cancer (EC) is one of the most frequent gynecological cancers worldwide. The gold standard treatment of EC is most certainly surgery and may very well be the only therapy in the early stages of disease. To improve outcomes in non-early EC, adjuvant therapy is often employed but this is not standardized. Adjuvant options can include radiotherapy, chemotherapy or a combination of both. Adjuvant chemotherapy could be indicated in high-risk stage I and II or advanced stage EC. Several clinical trials are ongoing in an attempt to define the optimal adjuvant treatment. Furthermore, chemotherapy is the front-line therapy in advanced unresectable, metastatic or recurrent endometrial cancer. Areas covered: Herein, the authors review the first-line chemotherapy for the treatment of endometrial cancer and provide their expert perspectives on these therapies. Expert opinion: Chemotherapy is fundamental in advanced/recurrent EC. Further evidence is needed to characterize the role of adjuvant chemotherapy. Future studies should consider genomic and molecular heterogeneities to identify even more efficient tailored therapies.

The addition of paclitaxel to doxorubicin and cisplatin and volume-directed radiation does not improve overall survival (OS) or long-term recurrence-free survival (RFS) in advanced endometrial cancer (EC): A randomized phase III NRG/Gynecologic Oncology Group (GOG) study

OBJECTIVES

To determine if the addition of paclitaxel (P) to cisplatin and doxorubicin (CD) following surgical debulking and volume-directed radiation therapy improved long-term, recurrence-free survival (RFS) and overall survival (OS) in patients with advanced-stage endometrial cancer (EC).

METHODS

Prospective, randomized GOG trial comparing (CD) (50 mg/m²)/(45 mg/m²) +/- (P) (160 mg/m²) following volume-directed radiation and surgery in advanced EC. A Kaplan-Meier (KM) analysis characterized the relationship between treatment arms and the OS outcome, a log-rank test assessed the independence of treatment with the OS outcome, and the treatment effect on estimated OS was determined using a Cox proportional hazards (PH) model stratified by stage. The PH assumption was assessed using a test of interaction between treatment variable and the natural logarithm of survival time. Adverse events, regardless of attribution, were graded.

RESULTS

Since initial publication, 60 deaths occurred, leaving 311 patients alive with 290 (93.8%) recurrence- free. There was no significant decrease in the risk of recurrence or death associated with the CDP treatment regimen stratified for stage (p = 0.14, one-tail). The exploratory analysis for OS and the corresponding homogeneity tests for different effects across subgroups revealed only EFRT and EFRT & GRD status to have significantly different treatment effects (p = 0.027 and p = 0.017, respectively). Second primary malignancies were identified in 17/253 (6.4%) and 19/263 (7.0%) of patients treated with CD and CDP respectively. Breast (2.4%) followed by colon (1%) were the two cancers most frequently diagnosed in this setting.

CONCLUSION

No significant difference between treatment arms was identified. Subgroup analysis both in the initial and current reports demonstrated a trend towards improved RFS and OS in patients treated with CDP and EFRT. This long-term analysis of outcomes also identified the necessity of providing on-going cancer screening to patients enrolled in trials.

Patterns of care and outcomes for women with uterine cancer and ovarian metastases

OBJECTIVE

For women with uterine cancer with metastases isolated to the adnexa (stage IIIA) optimal adjuvant therapy is unknown. We performed a population-based analysis to examine the use of chemotherapy, vaginal brachytherapy, and external beam therapy (in women with stage IIIA uterine cancer.

METHODS

The National Cancer Database was used to identify women with stage IIIA uterine cancer with ovarian metastasis from 2004 to 2012. We explored the use of chemotherapy, vaginal brachytherapy, and external beam therapy over time. Multivariable models were developed to examine factors associated with survival.

RESULTS

We identified 4088 women with uterine cancer and ovarian metastases. Overall, 56.2% of women received chemotherapy. Vaginal brachytherapy was used in 11.1%, while 36.6% received external beam therapy. Five-year survival was 64.7 % (95% CI, 62.9% to 66.5%). In a multivariable model, chemotherapy was associated with a 38% decrease in mortality (HR = 0.62; 95% CI, 0.54 to 0.71). Similarly, both external beam therapy (HR = 0.74; 95% CI, 0.65 to 0.85) and vaginal brachytherapy (HR = 0.67; 95% CI, 0.53 to 0.85) were associated with improved survival. When the cohort was limited to women who received chemotherapy, radiation was associated with improved overall survival (HR 0.74, 95% CI 0.61 to 0.90). There was no difference in survival between the use of external beam therapy and vaginal brachytherapy.

CONCLUSIONS

Chemotherapy was associated with a decrease in mortality in women with endometrial cancer and ovarian metastases. The addition of radiation therapy was associated with improved overall survival, although there was no difference between external beam therapy and vaginal brachytherapy.

Pathological Stage I Endometrial Carcinoma: The Role for Adjuvant Radiotherapy

Background

In order to assess the efficacy of adjuvant radiotherapy in the treatment of pathological stage I endometrial carcinoma, we performed a retrospective analysis of 158 patients with this diagnosis who after surgery were either treated with radiation therapy or only followed from January 1980 through December 1987.

Methods

Patients were divided into two prognostic categories, high and low risk, on the basis of three known predictors of survival: histology, differentiation, and depth of myometrial invasion. All patients underwent total abdominal hysterectomy and bilateral salpingooophorectomy but only the high risk group received radiotherapy as well.

Results

After a median follow up time of 59 months the survival rates of the two groups were similar. The 5-year disease-free survival of the surgery alone group was 92 % compared to 89 % for the postoperative radiotherapy group. Side effects of treatment were minimal.

Conclusions

Postoperative radiation therapy for high risk pathological stage I endometrial carcinoma is an effective adjuvant therapy and confers an excellent prognosis.

Trends in Survival of Patients With Uterine Serous Carcinoma From 1988 to 2011: A Population-Based Study

Objective

Our study used the Surveillance, Epidemiology, and End Result database to determine if the changes in treatment paradigm observed over the last 2 decades have improved outcomes in patients with uterine serous carcinoma (USC).

Methods

Women with USC were identified using the Surveillance, Epidemiology, and End Result database from 1988 to 2011 (n = 8230) and grouped into 3 cohorts (1988–1997, 1998–2004, and 2005–2011). Disease-specific survival and overall survival were estimated. Kaplan-Meier survival curves and Cox regression models were used.

Results

Disease-specific survival (59 vs 94 months vs not reached;P< 0.001) and overall survival (31 vs 37 vs 45 months;P< 0.001) improved over time. In univariable analyses, only those with stage I–III and those who reside in the Western or Central regions were noted to have improvement over time. In multivariable analyses when adjusting for age, race, marital status, stage, geographic location, cancer-related surgery, extent of lymphadenectomy, and adjuvant radiation, patients who received the diagnosis during 2005 to 2011 were 22% less likely to die of uterine cancer (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.70–0.87;P< 0.001) and 17% less likely to die of any cause (HR, 0.83; 95% CI, 0.76–0.90;P< 0.0001) compared with patients who received a diagnosis during 1988–1997. Similarly, patients who received a diagnosis during 1998–2004 were 15% less likely to die of uterine cancer (HR, 0.85; 95% CI, 0.77–0.94;P= 0.0015) and 10% less likely to die of any cause (HR, 0.90; 95% CI, 0.83–0.97;P= 0.0048) compared with patients who received a diagnosis during 1988–1997.

Conclusions

Changes in treatment trends for USC over the last 2 decades have resulted in an improvement in outcome especially those with stage I–III disease.

Pelvic insufficiency fracture (PIF) incidence in patients treated with intensity-modulated radiation therapy (IMRT) for gynaecological or anal cancer: single-institution experience and review of the literature

OBJECTIVE

To summarize the results of pelvic insufficiency fracture (PIF) incidence in patients with anal or gynaecological cancer treated by pelvic intensity-modulated radiation therapy (IMRT).

METHODS

The clinical and morphological (CT and/or pelvic MRI) characteristics of patients treated by IMRT at our institution between 2007 and 2014 were analyzed. The global incidence of PIF after external beam radiotherapy and the impact of tumour site (gynaecological or anal cancer) were determined. A dosimetric study was then performed to compare patients with and without pelvic fracture.

RESULTS

341 patients were treated by IMRT for gynaecological or anal cancer between 2007 and 2014. 15 patients experienced at least 1 pelvic fracture after external beam radiotherapy, corresponding to an overall incidence of 4.4%. Age and menopausal status were correlated with an increased fracture risk (p = 0.0274 and p < 0.0001, respectively). The site of the primary tumour (gynaecological or anal canal) was not associated with an excess fracture risk. The median maximum dose received at the fracture site was 50.3 Gy (range: 40.8-68.4 Gy).

CONCLUSION

The incidence of pelvic fracture after IMRT is low, but is higher after the age of 50 and in patients who are postmenopausal. Pre-treatment evaluation of bone density by bone densitometry and phosphorus-calcium assessment could be useful prior to the management of these patients. Advances in knowledge: Pelvic fractures are a frequent complication after radiotherapy. The influence of IMRT and clinical characteristics were evaluated in this study.

The effect of cell type on surgico-pathologic risk factors in endometrial cancer

OBJECTIVE

In this study the effect of histologic subtype as a surgicopathologic risk factor in endometrial cancer is evaluated.

MATERIAL AND METHODS

We evaluated 182 patients who underwent systematic lymphadenectomy up to the level of the renal vessels and at least 15 lymph nodes were dissected from the pelvic area and 10 lymph nodes from the para-aortic area. investigation of whether endometrioid and aggressive cell types (serous papillary cell and clear cell) affect the distribution of surgicopathologic risk factors among endometrial cancer cases was carried out.

RESULTS

Patients in the aggressive cell type group were older and the tumor size was significantly smaller. There was no difference between the two groups for the total number of dissected lymph nodes except for the external iliac area. Although the difference is not statistically significant, the total number of lymph nodes dissected in the aggressive group was less (54.3 vs 62.9, p=0.067) than that of the endometrioid cell type group. While the incidence of pelvic lymph node metastasis in the aggressive group was 59.1% the incidence was 15.6% in the endometrioid cell type group (p>0.001). The possibility of lymph node metastasis for aggressive cell type endometrial carcinoma in the para-aortic area was twice the endometrioid cell type group. It was found that the presence and type (stromal/glandular) of cervical invasion, depth of myometrial invasion and presence of lymphovascular space invasion were not affected by cell type.

CONCLUSION

Aggressive cell types significantly increase the adnexial and lymph node metastasis in endometrial cancer.

No cookie-cutter oncology: individualized treatment approaches for women with corpus endometrial cancer

Endometrial adenocarcinoma is the most common gynecologic malignancy and, for the majority of patients who present with stage I (approximately 70%) or stage II ( approximately 10%) disease, 5-year overall survival rates approach 85%. However, the complicated mix of medical comorbidities, the broad spectrum of techniques and treatment modalities and controversial clinical trial outcomes makes treating this heterogeneous group of patients unique and challenging. Similar management controversies exist and, when one factors in histologic variability, no flow-chart treatment algorithm can be easily constructed. This article will discuss data from key clinical trials, consider the role of routine lymphadenectomy as a component of surgical staging, discuss the heterogeneity of stage III patients in both presentation and response to treatment, review options for medically inoperable patients and reflect on current and upcoming protocols.

A randomized phase III trial in advanced endometrial carcinoma of surgery and volume directed radiation followed by cisplatin and doxorubicin with or without paclitaxel: A Gynecologic Oncology Group study

OBJECTIVES

After surgical debulking and volume-directed irradiation of the pelvis/para-aortic lymph nodes, treatment was randomized to compare recurrence-free survival (RFS) and toxicity between two chemotherapy regimens for the treatment of women with advanced stage endometrial carcinoma.

METHODS

Treatment was randomized between 6 cycles of cisplatin [C] (50 mg/m(2)) and doxorubicin [D] (45 mg/m(2)) with or without paclitaxel [P] (160 mg/m(2)). Initially in paclitaxel treated patients and, after May 2002, all patients received granulocyte growth factor with each cycle.

RESULTS

Of 659 patients enrolled following surgery, 552 eligible patients were randomized to chemotherapy after irradiation. Accrual closed to Stage IV patients in June, 2003. Approximately 80% completed six cycles of chemotherapy. Three deaths resulted from bowel complications and one death was due to renal failure. Hematologic adverse events, sensory neuropathy and myalgia, were more frequent and severe in the paclitaxel arm (p<0.01) which was confirmed by Quality of Life assessments. Percentage of patients alive and recurrence-free at 36 months was 62% for CD vs. 64% for CDP. The hazard of recurrence or death relative to the CD arm stratified by stage is 0.90 (95% CI is 0.69 to 1.17, p=0.21, one-tail). However, in subgroup analysis, CDP was associated with a 50% reduction in the risk of recurrence or death among patients with gross residual disease (95% CI: 0.26 to 0.92). Stage, residual disease, histology/grade, positive para-aortic node and cytology, pelvic metastases and age were significantly associated with RFS.

CONCLUSION

The addition of paclitaxel to cisplatin and doxorubicin following surgery and radiation was not associated with a significant improvement in RFS but was associated with increased toxicity.

Present status and future direction of clinical trials in advanced endometrial carcinoma

Endometrial adenocarcinoma is staged surgically, and advanced endometrial carcinoma is considered to be FIGO stage III and IV. The Gynecologic Oncology Group (GOG) has come a long way in developing new strategies in the management of advanced endometrial carcinoma. Combining surgery, radiation, and chemotherapy, the 5-year survival has improved to between 40-60% in newly diagnosed advanced endometrial carcinoma. Recent findings in GOG184 indicate that multiple risk factors noted at the time of surgical staging could lead to concurrent clinical trials that could be completed expeditiously rather than a subsequent ten year long phase III trial including all the various risk subgroups of patients. This review is a focus on the accomplishments of the GOG in advanced endometrial carcinoma with an emphasis on future challenges.

Omission of lymphadenectomy is possible for low-risk corpus cancer

AIM

The objective of this study is to ascertain whether omission of lymphadenectomy is possible when endometrial cancer is considered low-risk based on intraoperative pathologic indicators.

PATIENT AND METHODS

A total of 128 patients were deemed to be low-risk based on intraoperative evaluation, including frozen-section determination of grade and myometrial invasion. We divided these 128 patients into 2 groups, the total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) with lymphadenectomy (LA group, n=68) and the TAH-BSO without lymphadenectomy (non-LA group, n=60) group. The only adjuvant treatment used was chemotherapy, and the decision to use chemotherapy was based on stage, grade, or lymphovascular space involvement. A retrospective review of the medical records was performed, and disease-free survival (DFS), overall survival (OS), operative time, estimated blood loss during operation, percentage of transfusion requirement, incidence of post-operative leg lymphedema and post-operative deep vein thrombosis were evaluated.

RESULTS

The 5-year DFS and OS rates were 95.6% and 98.5% in the LA group, and 98.3% and 98.3% in the non-LA group, respectively, and were not significantly different. In the LA group, pelvic lymph node metastasis was observed in only 1 case. In the LA group, blood loss during operation, percentage of transfusion requirement and the incidence of post-operative leg lymphedema were significantly higher than those in the non-LA group.

CONCLUSION

Lymphadenectomy did not provide a significant survival advantage in the patients with low-risk corpus cancer. Additionally, some peri- and post-operative morbidities and complications were increased by the addition of lymphadenectomy. The present findings suggest that lymphadenectomy should be limited for low-risk corpus cancer.

Paclitaxel/carboplatin versus cyclophosphamide/adriamycin/cisplatin as postoperative adjuvant chemotherapy for advanced endometrial adenocarcinoma

AIM

There is no standard chemotherapy regimen for patients with advanced endometrial adenocarcinoma. In our hospital, a cyclophosphamide/adriamycin/cisplatin (CAP) regimen was commonly used as adjuvant chemotherapy. However, since October 1999 a paclitaxel/carboplatin regimen has been substituted for CAP. To evaluate the antitumor activity and toxic effects of those regimens, we retrospectively reviewed cases that were treated in our hospital.

METHODS

Twenty-eight patients who underwent surgery and had histologically confirmed advanced endometrial adenocarcinoma, International Federation of Gynecology and Obstetrics stage III/IV, received combination chemotherapy. Treatment consisted of cisplatin, adriamycin and cyclophosphamide (CAP group, n = 16), or paclitaxel and carboplatin (paclitaxel/carboplatin group, n = 12). The response rate (RR), progression-free survival (PFS), overall survival (OS), and toxicities were evaluated.

RESULTS

In the CAP group, complete response (CR) was observed in six patients and partial response (PR) in three, for an RR of 64.3%. In the paclitaxel/carboplatin group, CR was observed in five and PR in two, for an RR of 77.8%. The 3-year PFS and OS rates were 50.0% and 75.0% in the paclitaxel/carboplatin group, and 37.5% and 50.0% in the CAP group, respectively, and there was no significant difference between the two groups. National Cancer Institute Common Toxicity Criteria grade 3-4 thrombocytopenia and gastrointestinal toxicities occurred significantly less frequently in the paclitaxel/carboplatin group (0% and 16.7%) than in the CAP group (31.3% and 68.8%) (P = 0.0389 and P = 0.0062).

CONCLUSIONS

We conclude that paclitaxel/carboplatin is a promising regimen which could be substituted for CAP, with major activity and a highly acceptable toxicity profile for the treatment of advanced endometrial adenocarcinomas.

Randomized Phase III Trial of Whole-Abdominal Irradiation Versus Doxorubicin and Cisplatin Chemotherapy in Advanced Endometrial Carcinoma: A Gynecologic Oncology Group Study

Purpose

To compare whole-abdominal irradiation (WAI) and doxorubicin-cisplatin (AP) chemotherapy in women with stage III or IV endometrial carcinoma having a maximum of 2 cm of postoperative residual disease.

Patients and Methods

Four hundred twenty-two patients were entered onto this trial. Of 396 assessable patients, 202 were randomly allocated to receive WAI, and 194 were allocated to receive AP. Irradiation dosage was 30 Gy in 20 fractions, with a 15-Gy boost. Chemotherapy consisted of doxorubicin 60 mg/m2 and cisplatin 50 mg/m2 every 3 weeks for seven cycles, followed by one cycle of cisplatin.

Results

Most patient and tumor characteristics were well balanced. The median patient age was 63 years; 50% had endometrioid tumors. Median follow-up time was 74 months. The hazard ratio for progression adjusted for stage was 0.71 favoring AP (95% CI, 0.55 to 0.91; P < .01). At 60 months, 50% of patients receiving AP were predicted to be alive and disease free when adjusting for stage compared with 38% of patients receiving WAI. The stage-adjusted death hazard ratio was 0.68 (95% CI, 0.52 to 0.89; P < .01) favoring AP. Moreover, at 60 months and adjusting for stage, 55% of AP patients were predicted to be alive compared with 42% of WAI patients. Greater acute toxicity was seen with AP. Treatment probably contributed to the deaths of eight patients (4%) on the AP arm and five patients (2%) on the WAI arm.

Conclusion

Chemotherapy with AP significantly improved progression-free and overall survival compared with WAI. Nevertheless, further advances in efficacy and reduction in toxicity are clearly needed.

Whole abdominal radiotherapy in the adjuvant treatment of patients with stage III and IV endometrial cancer: a gynecologic oncology group study

OBJECTIVE

To evaluate toxicity, survival, and recurrence-free interval in women with loco-regionally advanced endometrial carcinoma treated with postoperative whole abdominal radiation therapy.

METHODS

Whole abdominal irradiation with pelvic plus or minus para-aortic boost was initiated within 8 weeks of total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic washings, and selective pelvic and para-aortic node sampling in eligible, consenting patients.

RESULTS

Of 180 evaluable patients entered on the study with surgically staged III and IV endometrial carcinoma maximally debulked to less than 2 cm, 77 had typical endometrial adenocarcinoma and 103 had high-risk histology, either papillary serous or clear cell carcinoma. Patients with typical endometrial adenocarcinoma were significantly younger and had significantly fewer poorly differentiated cancers. Proportionally, there were twice as many non-Whites with high-risk histologies as non-Whites with typical endometrial adenocarcinoma. Forty-five percent of patients with typical endometrial adenocarcinomas had positive pelvic nodes compared to 51% of those with high-risk histologies. Both histologic groups had similar distribution for performance status, para-aortic node positivity, site and extent of disease, and International Federation of Gynecology and Obstetrics (FIGO) stage. The frequency of severe or life-threatening adverse effects among 174 patients evaluable for radiation toxicity included 12.6% with bone marrow depression, 15% GI, and 2.2% hepatic toxicity. The recurrence-free survival rates were 29% and 27% (at 3 years) for the typical endometrial adenocarcinoma and high-risk histologies, respectively. The survival rates were 31% and 35%, respectively. No patient with gross residual disease survived.

CONCLUSION

Whole abdominal irradiation in maximally resected advanced endometrial carcinoma has tolerable toxicity, and it is suggested that the outcome may be improved by this adjunctive treatment in patients with completely resected disease.

Papillary serous carcinoma—A less radio-sensitive subtype of endometrial cancer

OBJECTIVE

To explore factors that determine the response of endometrial cancer to radiation therapy. Such factors may influence treatment outcome and yield predictive information about individual patients and their tumors.

METHODS

A retrospective study of the complete pathologic response (pCR) rates in the hysterectomy specimens of patients, who had undergone pre-operative radiotherapy for > or = Stage II biopsy-proven endometrial carcinoma, was performed. 62 patient records were reviewed with respect to patient characteristics, tumor stage, histological grade and subtype, radiation technique and dose, and presence or absence of pCR in the post-operative hysterectomy specimen.

RESULTS

24 of 62 specimens exhibited a pCR. The only significant factor with respect to pCR was presence of uterine papillary serous carcinoma (UPSC). None of the seven cases of UPSC displayed a pCR (P = 0.036 Fischer's exact test), despite not differing from the non-UPSC cases in any other tumor, treatment, or patient factors. No factors were found that separated non-UPSC cases with a pCR from those without.

CONCLUSIONS

These data suggest an intrinsic radioresistance within UPSC, which may have implications for future treatment strategies. UPSC has documented genetic aberrations that may account for this, although its true radiosensitivity has yet to be quantitated directly. Future studies should focus on the molecular basis of its response to radiation. The reasons for the heterogeneous response of non-UPSC has yet to be elucidated and should also be investigated.

Utility and limitations of abdominal radiotherapy in the management of endometrial carcinomas

OBJECTIVE

The present review analyzes long-term survival, recurrence sites, and toxicity in women with peritoneal spread of endometrial treated with abdominal radiotherapy, in order to provide therapeutic options as a function of disease spread and histology.

METHODS

Retrospective medical record review was performed of 86 patients receiving abdominal radiotherapy for endometrial carcinomas from 1975 to 1995 at the University of Minnesota.

RESULTS

FIGO stage distribution was 54 stage IIIA, 2 stage IIIB, 11 stage IIIC, and 19 stage IVB. Disease-free survivals were 55% at 5 years, 46% at 10 years, and 36% at 20 years. Recurrence rates were 16% for stage IIIA with one peritoneal site, 48% for stage IIIA with multiple peritoneal sites or stage IIIB or stage IIIC, and 72% for stage IVB. With univariate analysis, statistical significance was found for stage, gross peritoneal disease, nodal metastases, histology, concurrent chemotherapy, isolated adnexal spread, grade, angiolymphatic invasion, myometrial invasion, and age. Multivariate analysis found only stage, histology, and age to be significant. Most recurrences were pulmonary or peritoneal. Acute toxicity was acceptable. Six percent of patients required surgical intervention for small bowel obstructions.

CONCLUSIONS

Abdominal radiotherapy confers an excellent prognosis for women with stage IIIA cancers with one site of peritoneal involvement. Lack of randomized trials makes definitive treatment recommendations difficult to provide. Results are less optimal with multiple peritoneal sites of involvement, gross peritoneal spread, or papillary serous/clear cell pathology but a substantial number of such women can be cured as well.

Adjuvant sequential chemotherapy and radiotherapy in uterine papillary serous carcinoma

PURPOSE

To evaluate the efficacy and toxicity of adjuvant combination of sequential chemotherapy followed by radiotherapy in uterine papillary serous carcinoma (UPSC).

METHODS AND MATERIALS

From April 1994 to June 2003, 26 patients (median age 61.7 years, range 46.9-78.4) with UPSC were treated with a platinum-based chemoradiation protocol after definitive surgery. 9 patients were assigned as stage I (35%), 4 were stage II (15%), 11 were stage III (42%), and 2 were stage IV (8%) according to the FIGO staging for gynecological cancers. All patients underwent total hysterectomy, salpingo-oophorectomy, pelvic +/- perioartic lymph nodes dissection/sampling, omentectomy, and peritoneal washing. The adjuvant chemoradiation protocol consists of 4 cycles of platinum-based chemotherapy followed by pelvic irradiation and vaginal vault brachytherapy. In selected stage I patients with no or minimal myometrial invasion, only vault brachytherapy was given after adjuvant chemotherapy.

RESULTS

After a median follow-up of 28 months (range 9-113 months), 14 (54%) patients were alive and free of disease. 12 out of these 14 patients were FIGO stage I/II. 9 patients (35%) had died (8 from distant metastases). The Kaplan-Meier 2-year and 5-year survival estimates were 69.5% and 57%, respectively. Only 4 (15%) patients had pelvic recurrence. None of the patients developed local vault recurrence. The treatment was well tolerated, only 1 patient developed congestive cardiac failure from the chemotherapy and 6 patients had grade 2 peripheral neuropathy on follow-up.

CONCLUSION

In our series of UPSC patients treated with adjuvant chemotherapy followed by radiotherapy, local control can be achieved in a majority of patients. Distant failure remains the major cause of mortality. Further investigations into finding a more effective systemic therapy are required if improvement in outcome for this form of uterine cancer is to be achieved.

Intraperitoneal radioactive phosphorus (32P) and vaginal brachytherapy as adjuvant treatment for uterine papillary serous carcinoma and clear cell carcinoma: a phase II Hoosier Oncology Group (HOG 97-01) study

OBJECTIVE

A phase II study was conducted to evaluate the role of adjuvant intraperitoneal radioactive phosphorus (32P) and vaginal brachytherapy in patients with uterine papillary serous carcinoma (UPSC) and clear cell carcinoma (CCC), after complete surgical staging.

METHODS

Patients were required to have undergone complete surgical staging including maximal surgical resection. Residual < or =3 mm intraperitoneal disease, and pelvic and para-aortic lymph node dissection with negative nodes, were required. A dose of 15 mCi of intraperitoneal 32P was administered within 8 weeks of surgery. Vaginal brachytherapy was delivered using either high dose rate, total dose of 2100 cGy in 3 fractions (700 cGy per fraction prescribed to 0.5 cm depth from the vaginal surface) or low dose rate to 6500 cGy (prescribed to the vaginal surface) in 1-2 fractions.

RESULTS

For the 21 evaluable patients, distribution by FIGO stage was as follows: Stages I-IIB (17), Stages III-IV (4). The median follow-up was 39.6 months (range: 5-63 months). No patients experienced grade 2-4 complications from their adjuvant therapy. Five patients suffered a recurrence: intraperitoneal [n = 2], distal vaginal [n = 2], and one at the surgical scar. Following the 2 distal vagina recurrences early in the trial, the entire length of the vagina was treated with intracavitary brachytherapy. No additional vaginal recurrences were observed. The two-year overall survival, cause-specific survival, and disease-free survival for the entire series were 89.2%, 89.2%, and 79.7%, respectively.

CONCLUSIONS

Adjuvant therapy for UPSC and CCC with intraperitoneal 32P and vaginal brachytherapy after comprehensive surgical staging is feasible, well tolerated, and warrants further study on a larger scale.

Intensity-modulated radiation therapy in gynecologic malignancies

Radiation therapy occupies an important role in the treatment of gynecologic malignancies. Unfortunately, traditional approaches result in the irradiation of large volumes of normal tissues exposing patients to many toxicities and precluding dose escalation in select patients. A novel approach to the planning and delivery of radiation therapy, known as intensity-modulated radiation therapy (IMRT), has been introduced. Unlike conventional approaches, IMRT conforms the prescription dose to the shape of the target in three dimensions, thus sparing the surrounding normal tissues. Multiple studies have demonstrated the clear superiority of IMRT planning in these patients in terms of normal tissue sparing. Promising clinical results have also been published, suggesting that IMRT reduces the incidence of acute and chronic toxicity in these women. Ongoing studies are focusing on tumor control and patient outcome. Although further work is needed, these results suggest that IMRT may represent a major advancement in the planning and delivery of radiation therapy in patients with gynecologic malignancies.

Treatment results of endometrial carcinoma with positive peritoneal washing, adnexal involvement and serosal involvement

AIMS

To review the treatment results of patients with endometrial carcinoma having positive peritoneal washing (PPW), adnexal involvement, uterine serosal involvement, or all three.

MATERIALS AND METHODS

The treatment records of patients who had undergone primary surgery for endometrial cancer without distant metastasis during 1990--2001 at the Department of Clinical Oncology, Tuen Mun Hospital, Hong Kong, were reviewed. Thirty-five patients were found to have involvement of positive PPW, adnexal involvement, uterine serosal involvement, or all three. Seven (20%) of them had gross or microscopic lymph-node metastasis. Thirty-three (94.3%) patients received adjuvant radiotherapy (28 whole-pelvic irradiation [WPI]; five abdominal radiotherapy [WART]). Two patients with solitary ovarian metastasis received chemotherapy, and one with isolated PPW also received adjuvant hormonal therapy. The median follow-up was 50.4 months (range 2.4-151.2 months). Multivariate analysis was carried out using the Cox regression proportional hazards model.

RESULTS

Among the 28 patients with clinical or pathological node-negative disease (International Federation of Gynecology and Obstetrics [FIGO] stage IIIA), only two patients with solitary ovarian metastases developed recurrence. The 5-year actuarial disease-free survival (DFS) rates for the whole group and patients without lymph-node involvement were 77.9% and 91.7%, respectively. Five out of the seven patients with lymph-node involvement developed recurrences. Univariate analysis showed that lymph-node involvement (P < 0.0001) and high-grade disease (P = 0.011) were the significant poor prognostic factors. Multivariate analysis showed that lymph-node involvement was the only significant poor prognostic factor to predict poor 5-year DFS (P = 0.0001). Only one patient (3.7%) who had received WART developed grade 4 toxicity.

CONCLUSIONS

This study showed that good treatment results could be obtained from patients with stage IIIA endometrial carcinoma without clinical or pathological lymph-node involvement after adjuvant radiotherapy, with acceptable late side-effects. The relative prognostic importance of individual IIIA involvement and the optimal adjuvant treatment remain to be determined.

The role of abdominal-pelvic radiotherapy in the management of uterine papillary serous carcinoma

PURPOSE

To evaluate the role of abdominal-pelvic radiotherapy (APR) as adjuvant treatment for uterine papillary serous carcinoma (UPSC).

METHODS AND MATERIAL

The medical records database at the Toronto-Sunnybrook Regional Cancer Centre identified 121 patients with the diagnosis of UPSC between 1980 and 2001. Fifty-nine patients received APR as adjuvant treatment. A retrospective chart review was done to evaluate recurrence rates, sites of failure, and treatment toxicity.

RESULTS

Of 59 patients who received APR, 30 had advanced-stage disease (Stage III or IV). Eleven had complete surgical staging. Median follow-up was 71 months. Twenty-five of 59 (42%) recurred, with a median time to relapse of 50 months. Five-year disease-free survival was 43%, and 5-year overall survival was 45%. Of the 25 who recurred, only 3 experienced a sole failure outside the irradiated volume. Thirteen women had their treatment interrupted or discontinued because of toxicity.

CONCLUSIONS

This single-institution study reveals that there is a high recurrence rate despite APR, especially among patients with advanced stage disease, and the majority of recurrences continue to be within the irradiated volume. The role of APR remains undefined in early disease but its effectiveness is questionable in advanced disease. Innovative strategies are needed to improve outcome in these patients.

Patterns of failure after the multimodality treatment of uterine papillary serous carcinoma

PURPOSE

Uterine papillary serous carcinoma (UPSC) is an aggressive variant of endometrial carcinoma. The majority of patients with clinical Stage I UPSC are found to have extrauterine disease at the time of surgery. Most authors report survival rates of 35-50% for Stage I-II and 0-15% for Stage III and IV UPSC. Surgical treatment as the sole therapy for patients with Stage I-IV UPSC is unacceptable because of high recurrence rates. Chemotherapy, radiotherapy, or both have been added after surgery in an attempt to improve survival. However, the survival benefit to patients from such multimodality therapy remains uncertain. This study analyzes the patterns of failure in patients with FIGO Stages I-IV UPSC treated by multimodality therapy.

METHODS AND MATERIALS

Forty-two women with FIGO Stages I-IV UPSC who were treated by multimodality therapy were analyzed retrospectively between 1988 and 1998. Data were obtained from tumor registry, hospital, and radiotherapy chart reviews, operative notes, pathology, and chemotherapy flow sheets. All the patients underwent staging laparotomy, peritoneal cytology, total abdominal hysterectomy and salpingo oophorectomy, pelvic and para-aortic lymph node sampling, omentectomy, and cytoreductive surgery, when indicated followed by radiotherapy and/or chemotherapy. Therapy consisted of external beam radiation therapy in 11 patients (26%), systemic chemotherapy in 20 (48%), and both radiotherapy and chemotherapy in 11 (26%). The treatments were not assigned in a randomized fashion. The dose of external beam radiation therapy ranged from 45-50.40 Gy (median 45). Of the 31 patients (74%) who received chemotherapy, 18 received single-agent (58%), whereas 13 received multiagent chemotherapy (42%).

RESULTS

Median follow-up for all patients was 19 months (range 4-72). Median follow-up for the surviving patients was 36 months (range 21-72). Their median age was 65 years. Six patients (14%) had Stage I, 8 patients (19%) had Stage II, 10 (24%) had Stage III, and 18 (43%) had Stage IV disease. Twenty-nine patients (69%) had suffered recurrence at the time of last follow-up. The actuarial failure rate at 2 and 5 years was 58% and 67%, respectively. The majority of the patients (19/29) recurred in the abdomen, vagina, or pelvis (66%). Metastases outside the abdomen were much less common as the first site of failure (17%). Twenty-five patients (60%) had died at the time of reporting; the observed survival rate at 2 years and 5 years was 52% and 43%, respectively.

CONCLUSIONS

Our data suggest that, after multimodality therapy of FIGO Stage I-IV UPSC, most patients developed abdominopelvic (locoregional) failure, and the great majority of the failures occurred in the abdomen, vagina, and pelvis (66%). Abdominopelvic failure as a component of distant failure occurred in an additional 5 patients (17%). Distant failure alone occurred in 17% of the patients.We propose that future studies should combine whole abdominal radiotherapy (WART) with pelvic and vaginal boosts, in addition to chemotherapy for FIGO Stage I-IV UPSC, especially in patients with minimal residual disease, to attempt to improve the dismal prognosis of patients with UPSC.

Improved outcome at 10 years for serous-papillary/clear cell or high-risk endometrial cancer patients treated by adjuvant high-dose whole abdomino-pelvic irradiation

PURPOSE

The aim of the study was to evaluate the 10-year treatment outcome of utilizing adjuvant high-dose whole abdominal irradiation (WAPI technique) with a pelvic/vaginal boost in patients with stage I-III endometrial carcinoma at high risk for intra-abdominopelvic recurrence, including serous-papillary and clear cell histologies.

MATERIAL AND METHODS

In a prospective nonrandomized trial, 132 patients were treated with adjuvant WAPI between November 1981 and October 2001. Forty-three patients (32%) were 1998 FIGO stage I-II and 89 (68%) were stage III. Pathological features included the following: 66 (52%) with deep myometrial invasion, 50 (38%) with positive peritoneal cytology, 89 (67%) with high-grade lesions, 25 (19%) with positive pelvic/para-aortic lymph nodes, and 58 (45%) with serous-papillary or clear cell histology.

RESULTS

The mean follow up was 6.4 years (range 0.6-16.1). For the entire group, the 5- and 10-year cause-specific survival (CSS) was 77 and 72%, whereas the disease-free survival (DFS) was 55 and 45%. When stratified by histology the 5- and 10-year CSS for adenocarcinoma was 75 and 70%, while serous-papillary/clear cell was 80 and 74% (P = 0.314). The 5- and 10-year DFS for adenocarcinoma was 59 and 49%, whereas serous-papillary/clear cell was 49 and 38% (P = 0.563). For surgical stages I-II, the 5-year CSS was 83% for adenocarcinoma and 89% for serous-papillary (P = 0.353). For stage III, it was 73 and 62% (P = 0.318), respectively. Forty-six patients (35%) relapsed. The first site of failure was the abdomen/pelvis in 27/46 (59%). When stratified by histologic variant, 34% of patients with adenocarcinoma and 41% with serous-papillary developed recurrent disease. In multivariate regression analysis only advancing age was of prognostic significance for CSS (P = 0.025) and DFS (P = 0.026). Chronic grade 3/4 GI toxicity was seen in 14%, and 2% of patients developed grade 3 renal toxicity.

CONCLUSION

High-dose adjuvant WAPI is very effective treatment with excellent 10-year results for stage I-III endometrial carcinoma with risk factors for intra-abdominopelvic recurrence, including serous-papillary or clear cell histology. The low long-term complication rate with high CSS makes high-dose WAPI the treatment of choice for these patients with significant comorbidities.

Whole abdomen radiotherapy for patients with peritoneal dissemination of endometrial adenocarcinoma

PURPOSE

No standard, universally accepted therapy exists for patients with adenocarcinoma of the endometrium with peritoneal dissemination. We report mature outcomes of selected patients with this uncommon pattern of spread treated with whole abdomen radiotherapy (RT).

METHODS AND MATERIALS

A retrospective review was undertaken of all patients with a diagnosis of endometrial cancer referred to the Radiologic Associates of Sacramento Medical Group between January 1, 1988 and October 1, 1999. Eleven patients were identified who had surgically proven peritoneal dissemination (peritoneal seeding) treated with whole abdomen RT as the sole cytotoxic therapy after operative cytoreduction. Ten patients had International Federation of Obstetrics and Gynecology (1988) Stage IV disease at diagnosis, and one had peritoneal dissemination at the time of initial recurrence after hysterectomy for Stage I disease. RT was administered to the whole abdomen using 10-MV photons in fractions of 1.0 or 1.5 Gy. A cumulative dose of 30 Gy was given in all patients, with shielding used to reduce the dose to the liver and kidneys. Partial abdominal volumes (pelvis plus paraaortic nodes) received supplementary dose at 1.5-1.8 Gy/fraction to bring the cumulative dose within the limited volumes to 46.2-54 Gy.

RESULTS

Four patients developed progressive cancer within 13 months of completion of whole abdomen RT. One additional patient died of hepatic venoocclusive disease (radiation hepatitis) 15 months after RT without evidence of cancer recurrence. Five patients were alive and clinically cancer free 55, 129, 131, 134, and 178 months after RT completion. One patient died of unrelated causes 79 months after treatment completion.

CONCLUSION

Abdominal RT, in doses compatible with the acute and late tolerance of normal tissues, can eradicate small deposits of disseminated, intraperitoneal endometrial cancer. Currently, our patient selection criteria include limited peritoneal dissemination at diagnosis permitting complete surgical clearance (<1 mm residual) of visible and palpable disease, Grade 1 or 2 histologic features, lack of demonstrable extraabdominal metastasis, and absence of major medical contraindications.

Ten-year outcome including patterns of failure and toxicity for adjuvant whole abdominopelvic irradiation in high-risk and poor histologic feature patients with endometrial carcinoma

PURPOSE

To evaluate the long-term results of treatment using adjuvant whole abdominal irradiation (WAPI) with a pelvic/vaginal boost in patients with Stage I-III endometrial carcinoma at high risk of intra-abdominopelvic recurrence, including clear cell (CC) and serous-papillary (SP) histologic features.

METHODS AND MATERIALS

In a prospective nonrandomized trial, 119 patients were treated with adjuvant WAPI between November 1981 and April 2000. All patients were analyzed, including those who did not complete therapy. The mean age at diagnosis was 66 years (range 39-88). Thirty-eight patients (32%) had 1989 FIGO Stage I-II disease and 81 (68%) had Stage III. The pathologic features included the following: 64 (54%) with deep myometrial invasion, 48 (40%) with positive peritoneal cytologic findings, 69 (58%) with high-grade lesions, 21 (18%) with positive pelvic/para-aortic lymph nodes, and 44 (37%) with SP or CC histologic findings.

RESULTS

The mean follow-up was 5.8 years (range 0.2-14.7). For the entire group, the 5- and 10-year cause-specific survival (CSS) rate was 75% and 69% and the disease-free survival (DFS) rate was 58% and 48%, respectively. When stratified by histologic features, the 5- and 10-year CSS rate for adenocarcinoma was 76% and 71%, and for serous papillary/CC subtypes, it was 74% and 63%, respectively (p = 0.917). The 5- and 10-year DFS rate for adenocarcinoma was 60% and 50% and was 54% and 37% serous papillary/CC subtypes, respectively (p = 0.498). For surgical Stage I-II, the 5-year CSS rate was 82% for adenocarcinoma and 87% for SP/CC features (p = 0.480). For Stage III, it was 75% and 57%, respectively (p = 0.129). Thirty-seven patients had a relapse, with the first site of failure the abdomen/pelvis in 14 (38%), lung in 8 (22%), extraabdominal lymph nodes in 7 (19%), vagina in 6 (16%), and other in 2 (5%). When stratified by histologic variant, 32% of patients with adenocarcinoma and 30% with the SP/CC subtype developed recurrent disease. Most failures for either histologic group occurred within the abdominopelvic region. However, one-third of the adenocarcinoma recurrences were in the lung. Multivariate regression analysis (age, surgical stage, grade, myometrial invasion, histologic type, lymph node status, and peritoneal cytology) demonstrated age (p = 0.019) and surgical stage (p = 0.036) to be of prognostic significance for CSS; age (p = 0.036) was the only significant prognostic factor for DFS. Grade 1-2 gastrointestinal and hematologic acute toxicities were common. Asymptomatic bibasilar scarring on chest X-ray and mild elevation of liver enzymes were seen in almost 50% of the patients. Even though chronic toxicities were less frequent, 12% developed Grade 3-4 gastrointestinal and 2% Grade 3 renal toxicities.

CONCLUSION

Adjuvant WAPI is very effective treatment with excellent 10-year results for Stage I-III endometrial carcinoma with risk factors for intra-abdominopelvic recurrence, including SP or CC histologic variants, deep myometrial invasion, high grade, nodal involvement, and positive peritoneal cytology. The low long-term complication rate with high CSS rate makes WAPI the treatment of choice for these patients with significant comorbidities.

Outcome of endometrial carcinoma patients with involvement of the uterine serosa

OBJECTIVE

The goal of this work was to evaluate the outcome of endometrial carcinoma patients undergoing primary surgery who have serosal involvement (SI).

METHODS

Between 1980 and 1998, 562 women underwent primary surgery for endometrial cancer at the University of Chicago. Thirty-nine were noted to have SI. FIGO stages were IIIA (19), IIIB (1), IIIC (7), and IV (12). Of the 19 IIIA patients, 15 had solitary SI. Twenty-six patients received pelvic radiation therapy (RT) with or without vaginal brachytherapy (VB). One patient received whole-abdomen radiation therapy, and 13, adjuvant chemotherapy. Solitary SI patients received pelvic RT with or without VB as their sole adjuvant therapy. Disease-free survivals (DFSs) were estimated using the method of Kaplan and Meier and prognostic factors were analyzed by the log-rank test.

RESULTS

With a median follow-up of 30.3 months, the 5-year actuarial DFS of the entire group was 28.9%. Factors correlated with disease recurrence included tumor stage (P = 0.003) and lymph node involvement (P = 0.04). In addition, patients with solitary SI had a better 5-year DFS (41.5% vs 20%, P = 0.04) than patients with SI plus other extrauterine sites. Relapse occurred in 23 women overall and in 7 of 15 solitary SI patients. The most common site of disease recurrence was distant both in the entire group and in the solitary SI patients. While abdominal recurrences were common in the entire group, they were infrequent in solitary SI patients.

CONCLUSION

Endometrial carcinoma patients with SI have a high rate of relapse and a poor outcome. Even when patients have extrauterine disease limited to SI, the outcome is relatively unfavorable. Nonetheless, our results demonstrate the need to distinguish patients with solitary SI and those with SI plus other extrauterine disease sites.

Significant pelvic recurrence in high-risk pathologic stage I--IV endometrial carcinoma patients after adjuvant chemotherapy alone: implications for adjuvant radiation therapy

OBJECTIVE

To evaluate the risk of pelvic recurrence (PVR) in high-risk pathologic Stage I--IV endometrial carcinoma patients after adjuvant chemotherapy alone.

METHODS

Between 1992 and 1998, 43 high-risk endometrial cancer patients received adjuvant chemotherapy. All patients underwent primary surgery consisting of total abdominal hysterectomy and bilateral salpingo-oophorectomy. No patients received preoperative radiation therapy (RT). Regional lymph nodes and peritoneal cytology were sampled in 62.8% and 83.7% of cases, respectively. Most patients had Stage III--IV disease (83.7%) or unfavorable histology tumors (74.4%). None had evidence of extra-abdominal disease. All patients received 4-6 cycles of chemotherapy as the sole adjuvant therapy, consisting primarily of cisplatin and doxorubicin. Recurrent disease sites were divided into pelvic (vaginal, nonvaginal) and extrapelvic (para-aortic, upper abdomen, liver, and extra-abdominal). Median follow-up was 27 months (range, 2--96 months).

RESULTS

Twenty-nine women (67.4%) relapsed. Seventeen (39.5%) recurred in the pelvis and 23 (55.5%) in extrapelvic sites. The 3-year actuarial PVR rate was 46.5%. The most significant factors correlated with PVR were cervical involvement (CI) (p = 0.01) and adnexal (p = 0.05) involvement. Of the 17 women who developed a PVR, 8 relapsed in the vagina, 3 in the nonvaginal pelvis, and 6 in both. The 3-year vaginal and nonvaginal PVR rates were 37.8% and 26%, respectively. The most significant factor correlated with vaginal PVR was CI (p = 0.0007). Deep myometrial invasion (p = 0.02) and lymph nodal involvement (p = 0.03) were both correlated with nonvaginal PVR. Nine of the 29 relapsed patients (31%) developed PVR as their only (6) or first site (3) of recurrence. Factors associated with a higher rate of PVR (as the first or only site) were CI and Stage I--II disease.

CONCLUSIONS

PVR is common in high-risk pathologic Stage I-IV endometrial cancer patients after adjuvant chemotherapy alone. These results support the continued use of locoregional RT in patients undergoing adjuvant chemotherapy. Further studies are needed to test the addition of chemotherapy to locoregional RT.

Surgery and postoperative radiation therapy in FIGO Stage IIIC endometrial carcinoma

OBJECTIVE

To determine the outcome, pattern(s) of failure, and optimal treatment volume in Stage IIIC endometrial carcinoma patients treated with surgery and postoperative radiation therapy (RT).

METHODS

Between 1983 and 1998, 30 Stage IIIC endometrial carcinoma patients were treated with primary surgery and postoperative RT at the University of Chicago. All underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, sampling of pelvic lymph nodes (PLN), and peritoneal cytology. All were noted to have PLN involvement. Para-aortic lymph nodes (PALN) were sampled in 26 cases, and were positive in 14 cases (54%). Twenty women received whole-pelvic RT (WPRT) and 10 (WPRT), plus paraortic RT (extended-field RT, EFRT). One EFRT patient also underwent concomitant whole-abdominal RT (WART). Adjuvant vaginal brachytherapy (VB) was delivered in 10, chemotherapy in 5, and hormonal therapy in 7 patients.

RESULTS

At a median follow-up of 32 months, the actuarial 5-year disease-free and cause-specific survivals of the entire group were 33.9% and 55.8%, respectively. Overall, 16 women (53%) relapsed. Sites of failure included the pelvis (23%), abdomen (13%), PALN (13%), and distant (40%). Of the 7 pelvic failures, 4 were vaginal (3 vaginal only). Patients treated with VB had a trend to a lower vaginal recurrence rate (0/10 vs. 4/20, p = 0.12) than those not receiving VB. All 4 PALN failures were in women treated with WPRT (2 negative, 1 unsampled, and 1 positive PALN). None of the 10 EFRT patients (2 negative, 8 positive PALN) recurred in the PALN. No patient developed an isolated abdominal recurrence. Two patients developed significant RT sequelae: chronic diarrhea in 1 patient treated with WPRT and VB, and small bowel obstruction in 1 patient treated with EFRT.

CONCLUSION

FIGO Stage IIIC disease comprises a small percentage of endometrial carcinoma patients but carries a poor prognosis. Our failure pattern suggests that the optimal adjuvant RT volume is EFRT, even in women with negative PALN sampling. VB should also be administered to improve local control. The low rate of abdominal recurrence does not support the routine use of WART in these women. Given the predominance of failure in distant sites, attention should be focused on the development of systemic chemotherapy protocols.

Prognosis for papillary serous carcinoma of the endometrium after surgical staging

BACKGROUND

To investigate the pattern of failure and the prognosis following pathological staging for uterine papillary serous carcinoma (UPSC).

PATIENTS AND METHODS

A retrospective review was conducted of 22 patients with UPSC, treated between 1989 and 1998 at a single institution. All patients were surgically staged. Two patients with advanced disease received chemotherapy only. Two patients with early-stage disease were followed without further treatment. Eighteen patients received postoperative irradiation; eight patients received whole abdominal irradiation (WART), and the remaining 10 patients, pelvic irradiation (PRT). In addition, seven of these patients received vaginal cuff irradiation with low-dose-rate or high-dose-rate brachytherapy. Toxicity, pattern of failure, and survival were evaluated and compared to the literature.

RESULTS

Seven patients (32%) developed distant metastases, three out of seven (42%) after WART. Four out of seven patients who had distant metastases died from disease progression during subsequent chemotherapy. All patients with distant metastases had locally advanced-stage disease at presentation (six stage III, one stage IV). Four patients with pelvic recurrences developed concurrent (2) and subsequent (2) distant metastases. Three patients had isolated distant metastases. No patient with early stage-disease (stage I and II) died from disease progression.

CONCLUSION

Pathological staging should be performed for all patients with UPSC to determine the prognosis as well as to tailor the treatment. The role of abdominal irradiation in the treatment of UPSC is yet to be determined; however, such an approach may not be necessary for the control of disease for patients with early-stage (I and II) disease. Patients with locally advanced-stage (stage III) disease are at risk of local regional failures and distant metastases despite WART. Therefore, the benefit of WART for advanced-stage disease is also questionable. Paclitaxel-based chemotherapy is currently being investigated in this setting.

Radiation therapy in endometrial cancer

The role of radiation in endometrial cancer, especially in the adjuvant setting, is controversial. Factors that influence radiotherapy recommendations include surgical considerations, pathological findings, potential sites of disease recurrence and the practice philosophies of the individual physician. It has been demonstrated that adjuvant radiotherapy following primary surgery significantly improves pelvic tumour control, but has no measurable impact on overall survival in an unselected patient population. Studies to date have been hampered by the inclusion of patients with a wide spectrum of prognostic features; this may decrease the likelihood of observing greater benefit in discriminate subsets at higher risk of relapse. Further trials are required to define clinical prognosis more precisely and to investigate the role of radiation in higher-risk patients. In the meantime, we propose guidelines for radiotherapy in endometrial cancer which serve as bases for discussion and collaboration among physicians and as platforms for future study and progress.

Adenocarcinoma of the endometrium treated with combined irradiation and surgery: study of 437 patients

PURPOSE

To identify prognostic factors and treatment toxicity in a series of operable endometrial adenocarcinomas.

METHODS AND MATERIALS

Between November 1971 and October 1992, 437 patients (pts) with endometrial carcinoma, staged according to the 1988 FIGO staging system (225 Stage IB, 107 Stage IC, 4 Stage IIA, 35 Stage IIB, 30 Stage IIIA, 6 Stage IIIB, and 30 Stage IIIC), underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy without (n = 140) or with (n = 297) pelvic lymph node dissection. The chronology of adjuvant RT was not randomized and depended on the usual practices of the surgical teams. Seventy-nine pts (Group I) received preoperative low-dose-rate uterovaginal brachytherapy (mean dose [MD]: 57 Gy). Three hundred fifty-eight pts (Group II) received postoperative RT. One hundred ninety-six pts received low-dose-rate vaginal brachytherapy alone (MD: 50 Gy). One hundred fifty-eight pts had external beam pelvic RT (MD: 46 Gy) followed by low-dose-rate vaginal brachytherapy (MD: 17 Gy). Four pts had external beam pelvic RT alone (MD: 47 Gy). The mean follow-up from the beginning of treatment was 128 months.

RESULTS

The 10-year disease-free survival rate was 86%. From 57 recurrences, only 12 were isolated locoregional recurrences. The independent factors decreasing the probability of disease-free survival were as follows: histologic type (clear-cell carcinoma, p = 0.038), largest histologic tumor diameter >3 cm (p = 0.015), histologic grade (p = 0.008), myometrial invasion > 1/2 (p = 0.005), and 1988 FIGO staging system (p = 9.10(-8)). In Group II, the addition of external beam pelvic RT did not seem to independently improve vaginal or pelvic control. The postoperative complication rate was 7%. The independent factors increasing the risk of postoperative complications were stage FIGO (p = 0.02) and pelvic lymph node dissection (p = 0.011). The 10-year rate for Grade 3 and 4 late radiation complications according to the LENT-SOMA scoring system was 3.1%. External beam pelvic RT independently increased the rate for Grade 3 and 4 late complication (RR: 5.6, p = 0.0096).

CONCLUSION

Postoperative external beam pelvic RT increases the risk of late radiation complications. After surgical and histopathologic staging with pelvic lymph node dissection, in subgroup of "intermediate-risk" patients (Stage IA Grade 3, IB-C and II), postoperative vaginal brachytherapy alone is probably sufficient to obtain a good therapeutic index. Results for patients with Stage III tumor are not satisfactory.

Extended surgical staging for uterine papillary serous carcinoma: survival outcome of locoregional (Stage I-III) disease

OBJECTIVE

The aim of this study was to evaluate survival outcome in patients with locoregional uterine papillary serous carcinoma (UPSC) after extended surgical staging (ESS).

METHODS

All patients diagnosed with FIGO Stage I-III UPSC undergoing ESS (vertical incision, peritoneal cytology, TAH/BSO, omental biopsy, lymph node sampling, peritoneal biopsy) between 1/1/89 and 12/31/98 were identified retrospectively from the tumor registry database. Pathologic features predictive of regional extrauterine spread were evaluated using the log-rank test. The Kaplan-Meier method was used to generate survival curves, and median survival determinations were compared using the log-rank test or the proportional hazards regression model.

RESULTS

Twenty-six patients with locoregional UPSC were identified: FIGO Stage I (n = 11), Stage II (n = 7), and Stage III (n = 8). The median age at diagnosis was 66 years. Preoperative endometrial pathology correctly identified the presence of UPSC in 76.9% of cases. The only pathologic feature found to be predictive of regional extrauterine spread (Stage III) was myometrial invasion > or =50% (P = 0.028). Adjuvant radiation therapy (RT) was administered to 6/18 patients with Stage I/II disease and 5/8 patients with Stage III disease. Platinum-based chemotherapy was administered to 5 patients with Stage III disease. All recurrences of Stage I/II disease were located within the pelvis (16.7%). For Stage III disease, all recurrences occurred at distant sites (42.9%). The median follow-up time for surviving patients was 39.0 months (mean = 45.0 months). For all patients, the overall 5-year survival rate was 61.2%. According to FIGO stage, the overall 5-year survival rates were Stage I, 81.8%; Stage II, 64.3%; and Stage III, 31.3%. No significant differences were detected in the risk of death by stage, although there was a trend toward worse survival with Stage III disease: Stage I hazard ratio [HR] = 1.00, Stage II HR = 1.68, 95% confidence interval [CI] = 0.23-12.03, Stage III HR = 3.63, 95% CI = 0.65-20.12.

CONCLUSIONS

Patients with locoregional UPSC following ESS have a more favorable prognosis than previously thought. The additional information provided by ESS facilitates the selection of adjuvant therapy. Whole pelvic RT is recommended for patients with Stage I/II disease. Pathologic Stage III disease portends a significant risk of distant recurrence. For these patients, administration of adjuvant chemotherapy should be considered in addition to directed RT.

Treatment of high-risk uterine cancer with whole abdominopelvic radiation therapy

PURPOSE

To evaluate the treatment outcomes in patients with optimally debulked Stage III and IV endometrial adenocarcinoma (ACA) or Stages I-IV uterine papillary serous (UPSC) or clear cell (CCC) carcinoma of the uterus, treated postoperatively with whole abdominopelvic irradiation (WAPI).

METHODS AND MATERIALS

Between 1979 and 1998, 48 patients received postoperative WAPI at our institution. Twenty-two patients had FIGO Stage III or Stage IV ACA and 26 patients had FIGO Stages I-IV UPSC or CCC. The median dose was 30 Gy to the upper abdomen and 49.8 Gy to the pelvis. Mean follow-up was 37 months (2.4-135 months).

RESULTS

The 3-year estimated disease-free survival (DFS) and overall survival (OS) rates for the entire group were 60% and 77%, respectively. Patients with ACA had 3-year DFS and OS of 79% and 89%, respectively, compared with 47% and 68% in the UPSC/CCC group. Early-stage patients (I and II) with UPSC/CCC had 3-year DFS and OS of 87% compared with 32% and 61% in those with advanced (Stage III and IV) disease. The 3-year actuarial major complication rate was 7%, with no treatment-related deaths. All 4 failures in the ACA group were extra-abdominal and 6 of the 11 in the UPSC/CCC group had an extra-abdominal component. Age and UPSC/CCC histology were significant prognostic factors for DFS and OS. In addition, stage and number of extrauterine sites of disease were significant predictors for DFS in UPSC/CCC.

CONCLUSION

WAPI is a safe, effective treatment for patients with optimally debulked advanced-stage uterine ACA or early-stage UPSC/CCC. Survival was significantly worse in advanced-stage UPSC/CCC patients. We recommend future trials of WAPI with concurrent, or subsequent systemic therapy in patients with advanced-stage UPSC or CCC.

The role of radiotherapy for high-risk endometrial cancer

High-risk endometrial cancer comprises an uncommon group of tumors, which includes pathological stage III adenocarcinoma and all stages of papillary serous carcinoma. Optimal management of this class of malignant female genital neoplasms is surgical resection, including debulking of any gross abdominopelvic disease. This article analyzes the literature concerning the use of adjunctive radiotherapy. The data presented suggest that postoperative whole abdominal radiotherapy may improve outcome in selected subsets of patients within this high-risk group. Future clinical investigations will greatly benefit from the anticipated published results of two completed prospective cooperative group clinical trials that involve whole abdominal irradiation.

Effect of grade on disease-free survival and overall survival in FIGO stage I adenocarcinoma of the endometrium

OBJECTIVE

To analyse the effect of differentiation on disease-free survival (DFS) and overall survival (OS) in patients with stage I adenocarcinoma of the endometrium.

PATIENTS AND METHODS

From 1979 to 1995, 350 patients with FIGO stage IA-IC with well (G1), moderately (G2) or poorly (G3) differentiated tumors were treated with surgery and high dose-rate brachytherapy with or without external radiation. Median age was 65 years (39-86 years).

RESULTS

The 5-year DFS was 88+/-3% for the G1 tumors, 77+/-4% for the G2 tumors, and 67+/-7% for the G3 tumors (P=0.0049). With regard to the events contributing to DFS, the 5-year cumulative percentage of local relapse was 4.6% for the G1 tumors, 9.0% for the G2 tumors, and 4.6% (P=0.027) for the G3 tumors. Cumulative percentage of metastasis was 1.4, 6.3 and 7.2% (P<0.001), respectively, whereas percentages of death were 6.0, 7.9 and 20.7% (P<0.001). The 5-year OS was 91+/-3, 83+/-4 and 76+/-7%, respectively (P=0.0018). In terms of multivariate hazard ratios (HR), the relative differences between the three differentiation groups correspond to an increase of 77% of the risk of occurrence of either of the three events considered for the DFS (HR=1.77, 95% CI [0.94-3.33]), (P=0.078) for the G2 tumors and of 163% (HR=2.63, 95% CI [1.27-5.43]), (P=0.009) for the G3 tumors with respect to the G1 tumors. The estimated relative hazards for OS are, respectively, in line with those for DFS: HR=1.51 (P=0.282) for the G2 tumors; and HR=3.37 (P=0.003) for the G3 tumors.

CONCLUSION

Patients with grade 1 tumors are those least exposed to either local relapse, metastasis, or death. In contrast patients with grade 2 tumors seem to be at higher risk of metastasis, whereas patients with grade 3 tumors appear at higher risk of death. Since we have looked at the first of three competing events (local relapse, metastasis and death), this suggests that patients with grade 3 tumors probably progress to death so fast that local relapse, if any, cannot be observed.

FIGO stage IIIC endometrial carcinoma with metastases confined to pelvic lymph nodes: analysis of treatment outcomes, prognostic variables, and failure patterns following adjuvant radiation therapy

OBJECTIVES

This study was undertaken to evaluate the prognostic significance of isolated positive pelvic lymph nodes on survival and to analyze other prognostic variables, overall survival, and failure patterns in surgically staged endometrial carcinoma patients with positive pelvic lymph nodes and negative para-aortic lymph nodes following radiation therapy (RT).

METHODS

Between January 1, 1987, and December 31, 1997, 782 women underwent primary treatment for uterine cancer at Indiana University Medical Center. Through a review of the medical records, we identified 58 patients with pathologic stage IIIA, 27 patients with pathologic stage IIIB, and 77 patients with pathologic stage IIIC endometrial carcinoma. Patients with pathologically positive or unsampled para-aortic lymph nodes and patients who received preoperative radiation therapy were excluded, leaving a study group of 17 patients with nodal metastases confined to pelvic lymph nodes. Thirteen patients received adjuvant pelvic RT using AP-PA or four-field technique. A median dose of 5040 cGy was delivered. Four patients received whole abdominal irradiation (WAI) delivering a median dose of 3000 cGy. Two patients received vaginal cuff boosts of 1000 and 3560 cGy to 0.5 cm from the vaginal surface mucosa via Cs-137 brachytherapy. Two patients also received adjuvant chemotherapy (cis-platinum and doxorubicin) and/or hormonal therapy (megestrol acetate). Disease-free and overall survivals were estimated using the Kaplan-Meier method of statistical analysis and prognostic variables were analyzed using the log-rank test.

RESULTS

With a median follow-up of 51 months the actuarial 5-year disease-free survival was 81% and the actuarial 2-year and 5-year overall survival rates were 81 and 72%, respectively. Univariate analysis revealed that positive peritoneal cytology in conjunction with positive pelvic lymph nodes imparts a greater risk of recurrence and decreased overall survival. There were no pelvic and/or upper abdominal failures, but there were recurrences in the para-aortic lymph nodes (two patients) and distantly (two patients).

CONCLUSION

Surgery followed by postoperative pelvic RT is a viable treatment option for pathologically staged stage IIIC endometrial carcinoma with disease confined to the pelvic lymph nodes. Failures in the para-aortic region suggest a possible role for extended-field RT. Patients with positive peritoneal cytology in conjunction with nodal metastasis fared poorly with pelvic RT. Studies evaluating the efficacy of WAI are ongoing. Finally, substages within FIGO stage IIIC are recommended in an effort to better understand and define treatment strategies which might be appropriate for these patients.