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Glavy JC, Peterson SL, Strain J, Byrd K, Flint JH. Metastatic Endometrioid Carcinoma Mimicking a Subungual Melanoma. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14494. [PMID: 36361369 PMCID: PMC9653594 DOI: 10.3390/ijerph192114494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/23/2022] [Accepted: 11/01/2022] [Indexed: 06/16/2023]
Abstract
CASE We report a case of a 76-year-old female with a stage IB, grade I endometrioid endometrial carcinoma who presented with right-hip pain and an enlarging black, exophytic, subungual lesion on her right-small-finger distal phalanx. Clinically, the distal phalanx lesion was suspicious for a subungual melanoma; however, advanced imaging suggested metastatic disease, with lesions in the acetabulum, lungs, brain, vulva, and vagina. CONCLUSION Partial amputation of the right, small finger and vulvar biopsies confirmed an endometrial carcinoma. To our knowledge, this is the first described case of endometrial adenocarcinoma metastasis to the phalanx of an upper extremity, mimicking a subungual melanoma.
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Affiliation(s)
- Jena C. Glavy
- Department of OBGYN, Navy Medicine Readiness and Training Command, San Diego, CA 92134, USA
| | - Shian L. Peterson
- Department of Orthopedic Surgery, Navy Medicine Readiness and Training Command, San Diego, CA 92134, USA
| | - Jonathan Strain
- Department of Pathology, Navy Medicine Readiness and Training Command, San Diego, CA 92134, USA
| | - Kevin Byrd
- Department of OBGYN, Navy Medicine Readiness and Training Command, San Diego, CA 92134, USA
| | - James H. Flint
- Department of Orthopedic Surgery, Navy Medicine Readiness and Training Command, San Diego, CA 92134, USA
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Daix M, Angeles MA, Migliorelli F, Kakkos A, Martinez Gomez C, Delbecque K, Mery E, Tock S, Gabiache E, Decuypere M, Goffin F, Martinez A, Ferron G, Kridelka F. Concordance between preoperative ESMO-ESGO-ESTRO risk classification and final histology in early-stage endometrial cancer. J Gynecol Oncol 2021; 32:e48. [PMID: 33908709 PMCID: PMC8192240 DOI: 10.3802/jgo.2021.32.e48] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/22/2021] [Accepted: 02/06/2021] [Indexed: 01/04/2023] Open
Abstract
Objective To evaluate the concordance between preoperative European Society for Medical Oncology (ESMO)-European Society of Gynaecological Oncology (ESGO)-European SocieTy for Radiotherapy and Oncology (ESTRO) risk classification in early-stage endometrial cancer (EC) assessed by biopsy and magnetic resonance imaging (MRI) with this classification based on histology of surgical specimen. Methods This bicentric retrospective study included women diagnosed with early-stage EC (≤stage II) who had a complete preoperative assessment and underwent a surgical management from January 2011 to December 2018. Patients were preoperatively classified into 3 degrees of risk of lymph node (LN) involvement based on biopsy and MRI. Based on final histological report, patients were re-classified using the preoperative classification. Concordance between the preoperative assessment and definitive histology was calculated with weighted Cohen's kappa coefficient. Results A total of 333 women were included and kappa coefficient of preoperative risk classification was 0.49. The risk was underestimated and overestimated in 37% and 10% of cases, respectively. Twenty-nine percent of patients had an incomplete LN staging according to the degree of risk of re-classification. The observed discordance in the risk classification was attributed to MRI in 75% of cases, to biopsy in 18% and in 7% to both (p<0.001). Kappa coefficient for concordance was 0.25 for MRI and 0.73 for biopsy. Conclusion Concordance between preoperative ESMO-ESGO-ESTRO risk classification and final histology is weak. Given that the risk was underestimated in the majority of patients wrongly classified, sentinel LN procedure instead of no LN dissection could be an option offered to preoperative low-risk patients to decrease the indication of second surgery for re-staging and/or to avoid toxicity of adjuvant radiotherapy.
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Affiliation(s)
- Manon Daix
- Department of Surgical Oncology, Institut Universitaire du Cancer de Toulouse - Institut Claudius Regaud, Oncopole, Toulouse, France.,Department of Gynecology, Centre Hospitalier Universitaire, Liège, Belgium.,Department of Gynecology, Centre Hospitalier Chrétien - Mont Légia, Liège, Belgium.
| | - Martina Aida Angeles
- Department of Surgical Oncology, Institut Universitaire du Cancer de Toulouse - Institut Claudius Regaud, Oncopole, Toulouse, France
| | - Federico Migliorelli
- Department of Gynecology, Centre Hospitalier Intercommunal des Vallées de l'Ariège, Saint Jean de Verges, France
| | - Athanasios Kakkos
- Department of Gynecology, Centre Hospitalier Universitaire, Liège, Belgium
| | - Carlos Martinez Gomez
- Department of Surgical Oncology, Institut Universitaire du Cancer de Toulouse - Institut Claudius Regaud, Oncopole, Toulouse, France.,Inserm CRCT, Toulouse, France
| | - Katty Delbecque
- Department of Pathology, Centre Hospitalier Universitaire, Liège, Belgium
| | - Eliane Mery
- Department of Pathology, Institut Universitaire du Cancer de Toulouse - Institut Claudius Regaud, Oncopole, Toulouse, France
| | - Stéphanie Tock
- Department of Gynecology, Centre Hospitalier Chrétien - Mont Légia, Liège, Belgium
| | - Erwan Gabiache
- Department of Medical Imaging, Institut Universitaire du Cancer de Toulouse - Institut Claudius Regaud, Oncopole, Toulouse, France
| | | | - Frédéric Goffin
- Department of Gynecology, Centre Hospitalier Universitaire, Liège, Belgium
| | - Alejandra Martinez
- Department of Surgical Oncology, Institut Universitaire du Cancer de Toulouse - Institut Claudius Regaud, Oncopole, Toulouse, France.,Inserm CRCT, Toulouse, France
| | - Gwénaël Ferron
- Department of Surgical Oncology, Institut Universitaire du Cancer de Toulouse - Institut Claudius Regaud, Oncopole, Toulouse, France.,Inserm CRCT, Toulouse, France
| | - Frédéric Kridelka
- Department of Gynecology, Centre Hospitalier Universitaire, Liège, Belgium
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Koyuncu K, Altın D, Turgay B, Varlı B, Konuralp B, Şükür YE, Taşkın S, Ortaç F. Binary grading may be more appropriate for endometrial cancer. J Turk Ger Gynecol Assoc 2020; 21:163-170. [PMID: 32885922 PMCID: PMC7495132 DOI: 10.4274/jtgga.galenos.2019.2019.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: To elucidate the survival consequences of the prognostic factors for endometrial cancer. Material and Methods: This was a retrospective study of 276 patients diagnosed with endometrial cancer who admitted for staging surgery. The extent of the surgery was determined by clinical staging and preoperative evaluation. The pathology specimens were reassessed by a gynecopathologist. Independent risk factors were revealed for the progression-free survival (PFS), overall survival (OS) and disease-specific survival (DSS) utilizing Kaplan-Meier and “Cox” proportional analysis. Results: The median follow up of the patients was 50 months. Of the 29 patients who died, 15 (5.43%) died because of endometrial cancer. Multivariate analysis revealed that independent risk factors for OS and PFS were stage (p=0.002, 0.002, respectively) and grade 3 (G3) histology (p=0.013, 0.015, respectively). Positive peritoneal cytology was an independent risk factor for OS (p=0.024), but not for PFS (p=0.050). Stage (p=0.005) was found to be the only independent risk factor for DSS. Patients with G1 and G2 histology had a similar and more favorable prognosis than patients with G3 histology. Conclusion: Advanced stage, high-grade tumor and the presence of positive peritoneal cytology were ascertained as independent prognostic factors for endometrial cancer. A binary histological grading system could be simpler and as effective as the current three grade system because grade 1 and 2 patients showed similar prognosis.
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Affiliation(s)
- Kazibe Koyuncu
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Duygu Altın
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Batuhan Turgay
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Bulut Varlı
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Bahar Konuralp
- Clinic of Obstetrics and Gynecology, University of Health Sciences Turkey, Tepecik Traning and Research Hospital, İzmir, Turkey
| | - Yavuz Emre Şükür
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Salih Taşkın
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Fırat Ortaç
- Department of Obstetrics and Gynecology, Ankara University Faculty of Medicine, Ankara, Turkey
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The brave new world of endometrial cancer : Future implications for adjuvant treatment decisions. Strahlenther Onkol 2020; 196:963-972. [PMID: 32430662 DOI: 10.1007/s00066-020-01632-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 05/04/2020] [Indexed: 01/20/2023]
Abstract
PURPOSE For many decades, endometrial cancer (EC) has been considered as a homogenous tumor entity with good prognosis. The currently valid risk stratification considers clinical and pathological factors. Treatment recommendations differ considerably from country to country. MATERIALS AND METHODS The Cancer Genome Atlas (TCGA) Research Network has shown that ECs should be reclassified into four novel molecular prognostic groups, with the potential of changing adjuvant management of EC patients: ultra-mutated, hyper-mutated, copy-number low, and copy-number high. Clinical examples are shown, and the available literature has been highlighted. The European Society of Gynaecological Oncology (ESGO) guideline for endometrial cancer takes the new classification system into consideration for adjuvant treatment decisions and will be published this year. RESULTS In the near future, we expect new treatment recommendations that may differ considerably from the clinicopathologically driven recommendations on the basis of our deeper insight and better understanding of molecular markers in endometrial cancer. The PORTEC 4a study is the only recruiting study which randomizes patients to adjuvant or no adjuvant treatment on the basis of the aforementioned new classification system. CONCLUSION The aim of the new classification is a more personalized adjuvant radio(chemo)therapy decision and better oncologic outcomes or avoidance of overtreatment.
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Yilmaz E, Gurocak S, Melekoglu R, Koleli I, Faydali S, Temelli O, Yar T. The Effect of Prognostic Factors and Adjuvant Radiotherapy on Survival in Patients with High-Grade Early-Stage Endometrial Cancer: A Retrospective Clinical Study. Med Sci Monit 2019; 25:2811-2818. [PMID: 30992424 PMCID: PMC6482868 DOI: 10.12659/msm.913740] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND This retrospective clinical study aimed to investigate the effect of prognostic factors and adjuvant radiotherapy in patients with high-grade early-stage endometrial cancer on overall survival (OS) and disease-free survival (DFS). MATERIAL AND METHODS The medical records of patients diagnosed with high-grade, early stage (I or II) endometrial adenocarcinoma who had received adjuvant radiotherapy after surgery were reviewed. RESULTS Seventy-nine patients included 39 patients (49.4%) with stage II endometrial cancer, 25 patients (31.6%) with histologic grade 3 tumors, and 47 patients (59.5%) with endometrial cancer showing lymphovascular space invasion (LVSI). There were 45 patients (57.0%) who received external pelvic radiotherapy with an average dose of 46.0 Gy (range, 11.2-50.4 Gy), and 34 patients (43.0%) received vaginal brachytherapy (VBT) with an average dose of 21.5 Gy (range, 10-36 Gy). Multivariate analysis showed that tumor stage (HR, 4.066; 95% CI, 1.227-13.467; p=0.022) and histologic grade (HR, 16.652; 95% CI, 4.430-62.589; p<0.001) were independent predictors for OS. Increased serum CA-125 levels (HR, 1.136; 95% CI, 0.995-1.653; p=0.047) and histologic grade (HR, 3.236; 95% CI, 1.107-15.156; p=0.015) were independent predictors for DFS. Adjuvant radiotherapy was not found to be significantly associated with improved OS (HR, 1.259; 95% CI, 0.518-3.058; p=0.612) or DFS (HR, 1.056; 95% CI, 0.994-1.123; p=0.078). CONCLUSIONS This retrospective study showed that in high-grade early-stage endometrial cancer treated with postoperative adjuvant radiotherapy, independent predictors for OS were tumor stage and grade. Adjuvant radiotherapy was not associated with improved OS or DFS.
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Affiliation(s)
- Ercan Yilmaz
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Inonu, Malatya, Turkey
| | - Simay Gurocak
- Department of Radiation Oncology, Faculty of Medicine, University of Inonu, Malatya, Turkey
| | - Rauf Melekoglu
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Inonu, Malatya, Turkey
| | - Isil Koleli
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Inonu, Malatya, Turkey
| | - Simge Faydali
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Inonu, Malatya, Turkey
| | - Oztun Temelli
- Department of Radiation Oncology, Faculty of Medicine, University of Inonu, Malatya, Turkey
| | - Tuba Yar
- Gynecology and Obstetrics Clinic, Adana Seyhan State Hospital, Adana, Turkey
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Marnitz S, Köhler C, Gharbi N, Kunze S, Jablonska K, Herter J. Evolution of adjuvant treatment in endometrial cancer-no evidence and new questions? Strahlenther Onkol 2018; 194:965-974. [PMID: 30112692 DOI: 10.1007/s00066-018-1339-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 07/12/2018] [Indexed: 01/23/2023]
Abstract
PURPOSE For endometrial cancer (EC), clinical and pathological risk factors are taken to triage patients and estimate their prognosis. Lymph node involvement (pN+), lymphovascular space involvement (LSVI), grading, age of the patients, and T classification are internationally accepted parameters for treatment decisions. MATERIALS AND METHODS Studies on adjuvant radiation, chemotherapy, and chemoradiation are discussed against the background of risk stratification and clinical decision-making in early-to-advanced stage endometrial cancer. Recent publications on adjuvant treatment in high-risk disease and its implications for the patients with regard to expected oncologic benefit and treatment-related toxicity are discussed. RESULTS Surgery is the mainstay of treatment of EC patients. Well-differentiated tumors and early disease (FIGO IA) should be followed up without further treatment. In FIGO I stage without risk factors, VBT remains the standard treatment after surgery. FIGO I, II patients with one or more risk factors (MI ≥ 50%, Grading[G]3, age >60 years, LVSI) benefit from external beam radiotherapy (EBRT) in terms of survival. There are no data of acceptable quality demonstrating that chemotherapy is superior to radiation in locally advanced carcinomas. Therefore, even in locally advanced disease (FIGO III, IV), EBRT remains the standard of care after surgery. EBRT contributes to the very low rate of local relapses and better DFS in these patients and should not be replaced by chemotherapy only. Whether and which subgroups of patients benefit from an additional (concomitant and/or adjuvant) chemotherapy in terms of disease-free survival remains a controversial issue. The recently published PORTEC-3 trial could not create clear evidence. With a high rate of isolated tumors cells and micrometastases in the specimens, the increasing use of unvalidated sentinel concepts in endometrial cancer raises more questions with regard to indications for adjuvant treatment. In the future, integrated genomic characterization of tumors might be helpful for treatment individualization in the adjuvant setting.
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Affiliation(s)
- S Marnitz
- Medical Faculty, Department of Radiation Oncology, CyberKnife- and Radiation Therapy, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| | - C Köhler
- Department of Special Operative and Oncologic Gynaecology, Asklepios-Clinic Hamburg, Hamburg, Germany
| | - N Gharbi
- Medical Faculty, Department of Radiation Oncology, CyberKnife- and Radiation Therapy, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - S Kunze
- Medical Faculty, Department of Radiation Oncology, CyberKnife- and Radiation Therapy, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - K Jablonska
- Medical Faculty, Department of Radiation Oncology, CyberKnife- and Radiation Therapy, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - J Herter
- Medical Faculty, Department of Radiation Oncology, CyberKnife- and Radiation Therapy, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
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McAlpine J, Leon-Castillo A, Bosse T. The rise of a novel classification system for endometrial carcinoma; integration of molecular subclasses. J Pathol 2018; 244:538-549. [PMID: 29344951 DOI: 10.1002/path.5034] [Citation(s) in RCA: 143] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 12/21/2017] [Accepted: 12/27/2017] [Indexed: 12/24/2022]
Abstract
Endometrial cancer is a clinically heterogeneous disease and it is becoming increasingly clear that this heterogeneity may be a function of the diversity of the underlying molecular alterations. Recent large-scale genomic studies have revealed that endometrial cancer can be divided into at least four distinct molecular subtypes, with well-described underlying genomic aberrations. These subtypes can be reliably delineated and carry significant prognostic as well as predictive information; embracing and incorporating them into clinical practice is thus attractive. The road towards the integration of molecular features into current classification systems is not without obstacles. Collaborative studies engaging research teams from across the world are working to define pragmatic assays, improve risk stratification systems by combining molecular features and traditional clinicopathological parameters, and determine how molecular classification can be optimally utilized to direct patient care. Pathologists and clinicians caring for women with endometrial cancer need to engage with and understand the possibilities and limitations of this new approach, because integration of molecular classification of endometrial cancers is anticipated to become an essential part of gynaecological pathology practice. This review will describe the challenges in current systems of endometrial carcinoma classification, the evolution of new molecular technologies that define prognostically distinct molecular subtypes, and potential applications of molecular classification as a step towards precision medicine and refining care for individuals with the most common gynaecological cancer in the developed world. Copyright © 2018 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Jessica McAlpine
- Department of Obstetrics and Gynaecology, The University of British Colombia, Vancouver, Canada
| | - Alicia Leon-Castillo
- Department of Pathology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - Tjalling Bosse
- Department of Pathology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
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A new short daily brachytherapy schedule in postoperative endometrial carcinoma. Preliminary results. Brachytherapy 2016; 16:147-152. [PMID: 28029590 DOI: 10.1016/j.brachy.2016.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 09/22/2016] [Accepted: 10/03/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the preliminary results of vaginal-cuff relapses (VCR) and complications of a short brachytherapy (BT) schedule in postoperative endometrial carcinoma. METHODS AND MATERIALS From September 2011 to December 2014, 102 patients were treated with postoperative BT for endometrial carcinoma. Seventy-four patients received a single 7 Gy dose after external beam irradiation (Group 1), and 28 intermediate-risk patients received three daily fractions of 6 Gy (Group 2). The dose was prescribed at 5 mm from the applicator surface. Toxicity was prospectively evaluated after the objective late effects of normal tissues-subjective, objective, management, analytic scores for vagina and RTOG scores for rectum and bladder. STATISTICS χ2 and Student's t tests. RESULTS The mean followup was 28.85 months (9.6-58.5) in Group 1 and 31.19 months (7.7-62.3) in Group 2. No VCR was found during followup. Late toxicity: vagina toxicity was developed in 24.32% of the patients in Group 1 (G1-G2) and in 21.4% in Group 2 (G1-G2 but 1 G3). Rectal toxicity appeared in only 2.7% of patients in Group 1 (G1). Neither Group 1 nor Group 2 presented late bladder toxicity. No differences were found in late toxicity between Groups 1 and 2. CONCLUSIONS The present short BT schedule was safe in relation to VCR and late toxicity for the followup period studied. These results are similar to those of two larger previous schedules performed in our center in relation to the same point of followup.
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Can we shorten the overall treatment time in postoperative brachytherapy of endometrial carcinoma? Comparison of two brachytherapy schedules. Radiother Oncol 2015; 116:143-8. [DOI: 10.1016/j.radonc.2015.06.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 06/12/2015] [Accepted: 06/13/2015] [Indexed: 11/22/2022]
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Solmaz U, Mat E, Dereli ML, Turan V, Tosun G, Dogan A, Sanci M, Ozdemir IA, Pala EE. Lymphovascular space invasion and positive pelvic lymph nodes are independent risk factors for para-aortic nodal metastasis in endometrioid endometrial cancer. Eur J Obstet Gynecol Reprod Biol 2015; 186:63-7. [PMID: 25638600 DOI: 10.1016/j.ejogrb.2015.01.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 01/03/2015] [Accepted: 01/13/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Para-aortic lymph node dissemination in endometrioid endometrial cancer is uncommon, and systematic para-aortic lymph node dissection increases morbidity. The purpose of this study was to identify a subgroup of endometrioid endometrial cancer patients who did not require para-aortic lymphadenectomy. STUDY DESIGN All patients who had undergone surgery for endometrioid endometrial cancer between 1 January 1995 and 31 December 2012 were retrospectively reviewed. Patients with higher risk factors for nodal metastasis and inadequate lymphadenectomy were excluded. Para-aortic lymph node dissemination was defined as nodal metastasis when pelvic and para-aortic lymph node dissection was performed, when para-aortic lymph node recurrence occurred after negative para-aortic lymph node dissection or when para-aortic lymph node dissection was not performed. Multivariate logistic regression models were used to identify the pathological features as predictors for para-aortic lymphatic dissemination. RESULTS A total of 827 patients were assessed, 516 (62.4%) of whom underwent pelvic and para-aortic lymph node dissection. Sixty-seven (13%) patients (37 with only pelvic, 26 with pelvic and para-aortic, and 4 with only para-aortic metastasis) had positive lymph nodes in the pelvic and para-aortic lymph node dissection group. Multivariate analysis confirmed positive pelvic nodes (odds ratio 20.58; p<0.001) and lymphovascular space invasion (odds ratio 8.10; p=0.022) as independent predictors of para-aortic lymphatic dissemination. When these two factors were absent (in 83% of patients), the predicted probability of para-aortic lymph node metastasis was 0.1%. CONCLUSION Positive pelvic nodes and lymphovascular space invasion are highly associated with para-aortic lymph node metastasis. These markers may be useful for identifying those patients who require para-aortic lymph node dissection.
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Affiliation(s)
- Ulas Solmaz
- Department of Gynecologic Oncology, Tepecik Training and Research Hospital, Izmir, Turkey.
| | - Emre Mat
- Department of Gynecologic Oncology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Murat Levent Dereli
- Department of Obstetrics and Gynecology, Tavas State Hospital, Denizli, Turkey
| | - Volkan Turan
- Department of Gynecologic Oncology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Gokhan Tosun
- Department of Gynecologic Oncology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Askin Dogan
- Department of Gynecologic Oncology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Muzaffer Sanci
- Department of Gynecologic Oncology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - I Aykut Ozdemir
- Department of Gynecologic Oncology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Emel Ebru Pala
- Department of Pathology, Tepecik Training and Research Hospital, Izmir, Turkey
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Ward KK, McHale MT. Uterine Corpus Cancers. Gynecol Oncol 2015. [DOI: 10.1007/978-1-4939-1976-5_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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El-Hadaad HA, Wahba HA, Gamal AM, Dawod T. Adjuvant Pelvic Radiotherapy vs. Sequential Chemoradiotherapy for High-Risk Stage I-II Endometrial Carcinoma. Cancer Biol Med 2012; 9:168-71. [PMID: 23691474 PMCID: PMC3643665 DOI: 10.7497/j.issn.2095-3941.2012.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Accepted: 07/06/2012] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To explore if the addition of adjuvant chemotherapy with paclitaxel and carboplatin to radiotherapy confers an advantage for overall survival (OAS), and progression free survival (PFS); to assess the incidence of relapses over standard pelvic radiotherapy; and to evaluate the related toxicity in high-risk stage I-II endometrial carcinoma. METHODS Medical records were reviewed to identify high-risk stage I-II endometrial carcinoma cases treated in the Clinical Oncology and Nuclear Medicine department between 2002 and 2008 with adjuvant radiotherapy alone (arm I) (57 patients) or with sequential carboplatin (AUC5-6) and paclitaxel (135-175 mg/m(2)) with radiotherapy (arm II) (51 patients). Radiotherapy was performed through the four-field box technique at doses of 45-50 Gy (1.8 Gy/day × 5 days/week). RESULTS The toxicity was manageable and predominantly hematologic with a grade 3 neutropenia and thrombocytopenia in 9.8% and 6% of the patients in arm I and arm II, respectively, without febrile neutropenia. All patients experienced hair loss. Chemoradiotherapy arm was associated with a lower incidence rate of relapse (9.8% vs. 22.7%). After a median follow-up period of 48 months, the 5-year OAS and PFS rates for chemoradiotherapy-treated patients were significantly more favorable than those who did not receive chemotherapy (P=0.02 and 0.03, respectively). In arm I, the OAS and PFS rates were 73.7% and 66.7% compared with those in arm II, whose rates were 90.2% and 84.3%. CONCLUSIONS Adjuvant chemoradiation with paclitaxel and carboplatin improved the survival rates and decreased the recurrence rates in patients with high-risk stage I-II endometrial carcinoma. Chemotherapy was associated with an acceptable rate of toxicity. However, a prospective study with a larger number of patients is needed to define a standard adjuvant treatment for high-risk stage I-II endometrial carcinoma.
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Nomograms to predict isolated loco-regional or distant recurrence among women with uterine cancer. Gynecol Oncol 2012; 125:520-5. [DOI: 10.1016/j.ygyno.2012.02.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 02/13/2012] [Accepted: 02/15/2012] [Indexed: 11/16/2022]
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External-beam radiotherapy and/or HDR brachytherapy in postoperative endometrial cancer patients: clinical outcomes and toxicity rates. Radiol Med 2012; 118:311-22. [PMID: 22580814 DOI: 10.1007/s11547-012-0833-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 09/20/2011] [Indexed: 10/28/2022]
Abstract
PURPOSE The objectives of this study were to evaluate local disease control, overall survival (OS), disease-free survival (DFS) and local relapse-free survival (LRFS) in patients with endometrial cancer undergoing adjuvant vaginal brachytherapy (VBT )± external-beam radiotherapy (EBRT). MATERIALS AND METHODS From September 2007 to February 2011, 40 patients with endometrial cancer were retrospectively analysed. Surgery consisted of total hysterectomy and bilateral salpingo-oophorectomy without node dissection (16 patients) or with bilateral pelvic node dissection (24 patients). The stage distribution was as follows: two IA, nine IB, 12 IC, five IIA, eight IIB, two IIIA and two IIIC. Thirty-four patients underwent EBRT and VBT. Six patients received VBT alone. RESULTS Median follow-up was 26 months. The 5-year OS and DFS were 96.4% and 86.9%, respectively. No local recurrence was observed. Four patients presented distant disease (three had lung metastases and one had hepatic node metastases). Acute EBRT-related toxicities were seen in 15 (38%) patients. We recorded late toxicities in 14 patients (35%). There was no evidence of grade 3-4 toxicity. CONCLUSIONS Adjuvant EBRT and/or VBT in patients with endometrial cancer showed good outcomes in terms of local disease control, with an acceptable toxicity profile.
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Scheithauer HR, Schulz DS, Belka C. Endometrial cancer - reduce to the minimum. A new paradigm for adjuvant treatments? Radiat Oncol 2011; 6:164. [PMID: 22118369 PMCID: PMC3239313 DOI: 10.1186/1748-717x-6-164] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 11/25/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Up to now, the role of adjuvant radiation therapy and the extent of lymph node dissection for early stage endometrial cancer are controversial. In order to clarify the current position of the given adjuvant treatment options, a systematic review was performed. MATERIALS AND METHODS Both, Pubmed and ISI Web of Knowledge database were searched using the following keywords and MESH headings: "Endometrial cancer", "Endometrial Neoplasms", "Endometrial Neoplasms/radiotherapy", "External beam radiation therapy", "Brachytherapy" and adequate combinations. CONCLUSION Recent data from randomized trials indicate that external beam radiation therapy - particularly in combination with extended lymph node dissection - or radical lymph node dissection increases toxicity without any improvement of overall survival rates. Thus, reduced surgical aggressiveness and limitation of radiotherapy to vaginal-vault-brachytherapy only is sufficient for most cases of early stage endometrial cancer.
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Affiliation(s)
- Heike R Scheithauer
- Universitiy of Munich - LMU, Department of Radiation Oncology, Munich, Germany
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Rovirosa A, Ascaso C, Sánchez-Reyes A, Herreros A, Abellana R, Pahisa J, Lejarcegui JA, Biete A. Three or Four Fractions of 4–5 Gy per Week in Postoperative High-Dose-Rate Brachytherapy for Endometrial Carcinoma. Int J Radiat Oncol Biol Phys 2011; 81:418-23. [DOI: 10.1016/j.ijrobp.2010.06.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Revised: 03/16/2010] [Accepted: 06/07/2010] [Indexed: 11/16/2022]
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Dunberger G, Lind H, Steineck G, Waldenström AC, Onelöv E, Avall-Lundqvist E. Loose stools lead to fecal incontinence among gynecological cancer survivors. Acta Oncol 2011; 50:233-42. [PMID: 21231784 DOI: 10.3109/0284186x.2010.535013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Many patients treated with radiotherapy to the pelvic region report a change in bowel habits. Loose stools, urgency and fecal incontinence may have a significant impact on daily life and social functioning. MATERIAL AND METHODS We attempted to follow up 789 women, treated with pelvic radiotherapy for a gynecological cancer during 1991 to 2003 at two departments of gynecological oncology in Sweden. A control group of 478 women from the Swedish Population Registry was also included. As a preparatory study, we made in-depth interviews with 26 women previously treated for gynecological cancer. Based on their narratives, we constructed a study-specific questionnaire including 351 questions and validated it face-to-face. The questionnaire covered questions of physical symptoms originating in the pelvis, demographics, psychological and quality of life factors. In relation to bowel symptoms, 60 questions were asked. RESULTS Six-hundred and sixteen (78%) gynecological cancer survivors and 344 (72%) control women participated. Two-hundred and twenty-six (37%) cancer survivors reported loose stools at least once a week. Eighty-three percent of the survivors with loose stools every day reported defecation urgency with fecal leakage, compared to 20% of cancer survivors without loose stools. Cancer survivors with loose stools at least once a week were 7.7 times more likely to suffer from defecation urgency with fecal leakage (95% CI 4.4-13.3) compared to those who had loose stools once a month or less. In order to avoid loose stools affected survivors with loose stools often skipped meals (13%), made an active choice of food (47%) and preferentially used prescribed medication (36%). DISCUSSION There is a relation between loose stools and defecation urgency with fecal leakage among long-term gynecological cancer survivors treated with pelvic radiotherapy. Targeting loose stools can possibly help survivors to decrease frequency of fecal leakage.
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Affiliation(s)
- Gail Dunberger
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden.
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Moreau-Claeys MV, Brunaud C, Hoffstetter S, Buchheit I, Peiffert D. [High dose rate vaginal brachytherapy in endometrial cancer after surgery]. Cancer Radiother 2011; 15:169-75. [PMID: 21237693 DOI: 10.1016/j.canrad.2010.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Revised: 07/30/2010] [Accepted: 09/28/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE This study aimed at analyzing the evolution and type of recurrence in patients treated for stage I endometrial carcinomas, in order to define the respective roles of adjuvant radiotherapy and brachytherapy. PATIENTS AND METHODS This monocentric retrospective study was conducted at Centre Alexis-Vautrin, Nancy, France, between January 1995 and December 2000 on all the patients surgically treated for an endometrial cancer, and then treated with high dose rate vaginal brachytherapy. The brachytherapy was delivered in two or three fractions of 7 Gy at 5 mm from the applicator. RESULTS In the good prognosis group, the specific and overall survivals at 5 years were respectively 96.5 and 94.2% with no local recurrence demonstrated. In the intermediate prognostic group, the specific and overall survivals at 5 years were respectively 88 and 85%, with six locoregional recurrences observed among those who did not undergo lymphadenectomy; the overall survival at 5 years was significantly decreased in the absence of external radiation. In the group of poor prognosis (stages II and III), the specific survival at 5 years was respectively 72.8 and 67 %, and the overall survival at 5 years 66.7 and 56.4%. CONCLUSION Results for local control and survival as well as for tolerance were good. So we have decided to deliver high rate brachytherapy for all intermediate or poor prognosis patients and we have abandoned pelvic radiotherapy for good prognosis tumours (stages IA: no myometrium invasion with grade 3 and >50% of myometrium invasion with grades 1 and 2), whatever the lymph nodes surgery they had. We now propose pelvic radiotherapy only for intermediate prognosis tumours (such as IA>50% of myometrium invasion with grade 3 and IB stages), if patients did not have any lymphatic surgery, or for bad prognosis tumours.
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Affiliation(s)
- M-V Moreau-Claeys
- Département de curiethérapie, centre Alexis-Vautrin, Vandœuvre-lès-Nancy, France.
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Plataniotis G, Castiglione M. Endometrial cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2010; 21 Suppl 5:v41-5. [DOI: 10.1093/annonc/mdq245] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Systematic pelvic and aortic lymphadenectomy in intermediate and high-risk endometrial cancer: lymph-node mapping and identification of predictive factors for lymph-node status. Eur J Obstet Gynecol Reprod Biol 2010; 149:199-203. [PMID: 20096987 DOI: 10.1016/j.ejogrb.2009.12.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Revised: 11/14/2009] [Accepted: 12/21/2009] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To systematically assess the metastatic pattern of intermediate- and high-risk endometrial cancer in pelvic and para-aortic lymph-nodes and to evaluate risk factors for lymph-node metastases. STUDY DESIGN Between 01/2005 and 01/2009 62 consecutive patients with intermediate- and high-risk endometrial cancer who underwent a systematic surgical staging including pelvic and para-aortic lymphadenectomy were enrolled into this study. Patients' characteristics, histological findings, lymph-node localization and involvement, surgical morbidity and relapse data were analyzed. Univariate analysis was performed to define risk factors for lymph-node metastasis. RESULTS Of the 13 patients (21%) with positive lymph-nodes (N1), 8 (61.5%) had both pelvic and para-aortic lymph-nodes affected, 2 (15.4%) only para-aortic and 3 (23%) only pelvic lymph-node metastases. Overall, 54% of the N1-patients had positive lymph-nodes above the inferior mesenteric artery (IMA) to the level of the renal veins. Univariate analysis revealed lymph vascular space invasion (p-value: <0.001), vascular-space-invasion (p-value: <0.001) and incomplete tumor resection (p-value: 0.008) as significant risk factors for N1-status. Overall and progression-free survival was not significantly different between N1- and N0-patients. CONCLUSIONS Since the proportion of N1-endometrial cancer patients with positive para-aortic lymph-nodes is, at 76%, considerably high, and more than half of them have affected lymph-nodes above the IMA-level, lymphadenectomy for endometrial cancer should be extended up to the renal veins, when indicated. The therapeutic impact of systematic lymphadenectomy on overall and progression-free survival has still to be evaluated in future prospective randomized studies.
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Klopp AH, Jhingran A, Ramondetta L, Lu K, Gershenson DM, Eifel PJ. Node-positive adenocarcinoma of the endometrium: outcome and patterns of recurrence with and without external beam irradiation. Gynecol Oncol 2009; 115:6-11. [PMID: 19632709 DOI: 10.1016/j.ygyno.2009.06.035] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 06/19/2009] [Accepted: 06/24/2009] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate treatment outcomes and patterns of recurrence in patients with node-positive (International Federation of Obstetrics and Gynecology stage IIIC) adenocarcinoma of the uterus without serous or clear cell differentiation. METHODS The records of 71 women who were treated for stage IIIC endometrial adenocarcinoma at our institution between 1984 and 2005 were reviewed. All patients underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy. Fifty patients received definitive pelvic or extended-field radiotherapy with or without systemic therapy (regional RT group). Eighteen received adjuvant systemic platinum-based chemotherapy or hormonal therapy without external beam RT. The median follow-up for patients not dying of disease was 67 months. Survival rates were calculated using the Kaplan-Meier method; differences were assessed using log-rank tests. RESULTS Thirty-nine percent (28/71) of patients had involved paraaortic lymph nodes while 61% (43/71) had only pelvic lymph nodes. Five- and 10-year disease-specific survival (DSS) rates were 63% and 54%, respectively; corresponding overall survival rates were 60% and 47%. Grade was strongly associated with DSS (76% vs 46% at 5 years for low-grade vs high-grade tumors, P=0.004). Cervical or adnexal involvement was associated with decreased DSS, but lymph-vascular space invasion, age, race, body mass index, and number and location of positive nodes were not. Five-year pelvic-relapse-free survival (98% vs 61%, P=0.001), DSS (78% vs 39%, P=0.01), and overall survival (73% vs 40%, P=0.03) were significantly better for the regional RT group than the systemic therapy group. In patients treated without regional RT, the most common site of relapse was the pelvis. DSS was not significantly correlated with number of nodes removed in the regional RT group but was in patients treated without regional RT (P=0.001). CONCLUSIONS Patients treated without regional RT had a high rate of locoregional recurrence. Patients with stage IIIC endometrial adenocarcinoma who underwent surgical staging followed by external beam irradiation had a high rate of cure. Relapses in patients treated with EBRT primarily occurred in patients with grade 3 cancer who may be most likely to benefit from combined-chemoradiation treatment.
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Affiliation(s)
- Ann H Klopp
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
| | - Lois Ramondetta
- Department of Gynecologic Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
| | - Karen Lu
- Department of Gynecologic Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
| | - David M Gershenson
- Department of Gynecologic Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
| | - Patricia J Eifel
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
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Narayan K, Rejeki V, Herschtal A, Bernshaw D, Quinn M, Jobling T, Allen D. Prognostic significance of several histological features in intermediate and high-risk endometrial cancer patients treated with curative intent using surgery and adjuvant radiotherapy. J Med Imaging Radiat Oncol 2009; 53:107-13. [DOI: 10.1111/j.1754-9485.2009.02045.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Kim K, Choi SC, Ryu SY, Kim JW, Kang SB. Major clinical research advances in gynecologic cancer 2008. J Gynecol Oncol 2008; 19:209-17. [PMID: 19471658 PMCID: PMC2676488 DOI: 10.3802/jgo.2008.19.4.209] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Revised: 12/08/2008] [Accepted: 12/09/2008] [Indexed: 11/30/2022] Open
Abstract
In this review, we summarized 14 major clinical advances in gynecology which occurred in 2008. For cervical cancer, clinical impact of HPV vaccine, prognostic value of imaging during radiotherapy, and oncologic/obstetric outcomes of fertility-sparing surgery were chosen. For uterine cancer, optimal method of adjuvant radiotherapy in intermediate-risk patients, extent of lymph node dissection, outcome of robot-assisted staging surgery, new standard chemotherapy regimen for leiomyosarcoma were selected. For ovarian cancer, recent changes in adjuvant therapy, feasibility of neoadjuvant chemotherapy, prediction of optimal secondary cytoreduction, studies on new biomarkers, advances in screening and treatment of women with BRCA mutations were included. For other cancers, the safety of sentinel lymph node dissection in vulvar cancer and chemotherapy regimens for low-risk gestational trophoblastic tumors were reviewed.
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Affiliation(s)
- Kidong Kim
- Department of Obstetrics and Gynecology, Korea Cancer Center Hospital, Korea Institute of Radiological & Medical Sciences, Seoul, Korea
| | - Seok-Cheol Choi
- Department of Obstetrics and Gynecology, Korea Cancer Center Hospital, Korea Institute of Radiological & Medical Sciences, Seoul, Korea
| | - Sang-Young Ryu
- Department of Obstetrics and Gynecology, Korea Cancer Center Hospital, Korea Institute of Radiological & Medical Sciences, Seoul, Korea
| | - Jae Weon Kim
- Department of Obstetrics and Gynecology, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Soon-Beom Kang
- Department of Obstetrics and Gynecology, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Abstract
INTRODUCTION The objective of this study was to evaluate different surgical treatments and radiotherapy on patterns of recurrence and overall survival in patients with endometrioid-type endometrial cancer. MATERIALS AND METHODS The retrospective records of 162 patients with endometrioid endometrial cancer were collected. Patients were surgically treated from 1997 to 2002. Recurrence and survival were analyzed according to patient age, surgical procedure, lymphadenectomy, externalbeam irradiation, brachytherapy, surgical stage, myometrial invasion, and tumor grade. Standard statistical calculations were used. RESULTS Median age was 64 years. Median follow-up was 44 months. Overall, ten patients (5.6%) experienced recurrence and 14 (8.6%) died. With univariate analysis, statistical significance for survival was found for age older than 70 years, tumor grade, myometrial invasion, and stage. Multivariate analysis, however, found only age, stage, and grade to be significant. With univariate analysis, statistical significance for recurrence was found for tumor grade, stage, and external-beam radiotherapy as risk factors. Multivariate analysis found only radiotherapy and brachytherapy to be significant, but in an inverted sense, with brachytherapy having a protective effect. CONCLUSION Our results suggest that brachytherapy protects against recurrence and that neither a surgical approach nor a lymphadenectomy appear to affect recurrence or survival in patients with surgically treated endometrioid endometrial cancer.
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Kuoppala T, Mäenpää J, Tomas E, Puistola U, Salmi T, Grenman S, Lehtovirta P, Fors M, Luukkaala T, Sipilä P. Surgically staged high-risk endometrial cancer: Randomized study of adjuvant radiotherapy alone vs. sequential chemo-radiotherapy. Gynecol Oncol 2008; 110:190-5. [DOI: 10.1016/j.ygyno.2008.03.020] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2008] [Revised: 03/14/2008] [Accepted: 03/29/2008] [Indexed: 10/22/2022]
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Prospective assessment of lymphatic dissemination in endometrial cancer: a paradigm shift in surgical staging. Gynecol Oncol 2008; 109:11-8. [PMID: 18304622 DOI: 10.1016/j.ygyno.2008.01.023] [Citation(s) in RCA: 556] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Revised: 01/16/2008] [Accepted: 01/17/2008] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To prospectively assess pelvic and para-aortic lymph node metastases in endometrial cancer with lymphatic dissemination, emphasizing the examination of para-aortic metastases relative to the inferior mesenteric artery (IMA). METHODS Over 36 months, 422 consecutive patients were managed by predefined surgical guidelines differentiating low-risk patients from patients at risk for dissemination requiring systematic lymphadenectomy. Low risk was defined as grade 1 or 2 endometrioid type with myometrial invasion (MI) < or = 50% and primary tumor diameter (PTD) < or = 2 cm. Pelvic and para-aortic lymph nodes were submitted separately, with nodes identified from all 8 pelvic and 4 para-aortic node-bearing basins. Surgical quality assessments examined median node counts (primary surrogate for quality) and nodes harvested above and below the IMA and excised gonadal veins (secondary surrogates). RESULTS Lymphadenectomy was not required in 27% of patients (all low risk) and in 33% (n=112) of endometrioid cases. However, 22 patients (20%) of this latter cohort had lymphadenectomy and all lymph nodes were negative. Sixty-three (22%) of 281 patients undergoing lymphadenectomy had lymph node metastases: both pelvic and para-aortic in 51%, only pelvic in 33%, and isolated to the para-aortic area in 16%. Therefore, 67% of patients with lymphatic dissemination had para-aortic lymph node metastases. Furthermore, 77% of patients with para-aortic node involvement had metastases above the IMA, whereas nodes in the ipsilateral para-aortic area below the IMA and ipsilateral common iliac basin were declared negative in 60% and 71%, respectively. Gonadal veins were excised in 25 patients with para-aortic node metastases; 7 patients (28%) had documented metastatic involvement of gonadal veins or surrounding soft tissue. CONCLUSIONS The high rate of lymphatic metastasis above the IMA indicates the need for systematic pelvic and para-aortic lymphadenectomy (vs sampling) up to the renal vessels. The latter should include consideration of excision of the gonadal veins. Conversely, lymphadenectomy does not benefit patients with grade 1 and 2 endometrioid lesions with MI < or = 50% and PTD < or = 2 cm.
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Radiotherapy of endometrial carcinoma: Who needs to be irradiated? ARCHIVE OF ONCOLOGY 2008. [DOI: 10.2298/aoo0802010e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Due to gynecological oncology general strategy and everyday aspiration for individual approach to malignant tumors, guidelines in treatment approach are not finally established, and they are controversial in some demands with age of the patients. If we look general treatment strategy approach to invasive endometrial cancer it is proved that operative treatment is priority and base line of treating endometrial carcinoma I and II clinical stage (FIGO) if there is general conditions for surgery, allowing complicated treatment in this age. Previous experience are showing that decision about application of therapy procedures in treatment of endometrial carcinoma every case have to has individual approach, regarding all known prognostic criteria: clinical stage, histological type, myometrial infiltration, lymph-vascular space involvement, size of the tumor and its localiza?tion, depth of myometrial infiltration, invading of serosa, cervix and adnexa, present of hormonal tissue receptors, information about lymph node: number, size and size of the biggest metastases, data about both extra nodular expansion of tumor and peritoneal cytology. The use of postoperative radiotherapy should be limited to group of patients with highly enough risk of locoregional recurrence (15% and more) as risk warranty of morbidity connected to radiological treatment. Therefore, the goal of postoperative radiotherapy appliance is to achieve maximum locoregional disease control and survival without relapse. New Radiotherapy (RT) techniques, Conformal Radiotherapy (CFRT) and Intensity Modulated radiotherapy (IMRT), reduce the risk of complications, especially for patients with multimodal treatment.
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Bakkum-Gamez JN, Gonzalez-Bosquet J, Laack NN, Mariani A, Dowdy SC. Current issues in the management of endometrial cancer. Mayo Clin Proc 2008; 83:97-112. [PMID: 18174012 DOI: 10.4065/83.1.97] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Endometrial cancer (EC) remains the most common gynecologic malignancy in the United States. It is expected to become more common as the prevalence of obesity, one of the most common risk factors for EC, increases worldwide. The 2 main histologic subcategories of EC, endometrioid and nonendometrioid EC, show unique molecular aberrations and are responsible for markedly disparate clinical behaviors. The primary treatment of EC is surgery, ie, hysterectomy, removal of the adnexa, and pelvic and para-aortic lymphadenectomy, either via laparotomy or endoscopic techniques. Adjuvant therapy is necessary for patients at high risk of recurrence and consists of vaginal brachytherapy, teletherapy, systemic chemotherapy, or some combination thereof. Multi-institutional trials are in progress in this country and in Europe to better define optimal adjuvant treatment for subsets of patients, as well as the role of surgical staging in reducing both overuse and underuse of radiation therapy. Hormonal therapy is an option for some young women with EC who wish to preserve fertility. This review summarizes the diagnosis and management of EC and discusses current controversies and upcoming investigations pertaining to EC staging and adjuvant treatment.
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Affiliation(s)
- Jamie N Bakkum-Gamez
- Division of Gynecologic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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Johnson N, Cornes P. Survival and recurrent disease after postoperative radiotherapy for early endometrial cancer: systematic review and meta-analysis. BJOG 2007; 114:1313-20. [PMID: 17803718 DOI: 10.1111/j.1471-0528.2007.01332.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To clarify the effect of postoperative (adjuvant) external-beam pelvic radiotherapy (EBRT) for different grades of early endometrial cancer. SEARCH STRATEGY Meta-analysis of data from randomised trials stratified by histological risk factors supported by cohort studies. SELECTION CRITERIA Cochrane methodology. DATA Seven randomised trials were identified. Five were eligible for meta-analysis. Homogeneity was confirmed (I2 < 25%). MAIN OUTCOME MEASURES Survival, site of recurrence and added complications. MAIN RESULTS EBRT after hysterectomy for low-risk disease increases the odds of death (OR for overall survival 0.71; 95% CI 0.52-0.96). EBRT does not appear to alter survival for intermediate-risk cancers (stage ICG1/2 and IBG3) (OR 0.97; 95% CI 0.69-1.35). In contrast, EBRT offers a significant disease-free survival advantage for high-risk cancer (OR 1.76; 95% CI 1.07-2.89). The survival advantage benefits one in ten women. The definition of high risk is variable across studies but focuses on ICG3 (deeply invasive, poorly differentiated) tumours. Pelvic EBRT reduces the risk of pelvic recurrent disease in all types of invasive endometrial cancer (OR 0.27; 95% CI 0.16-0.44), but local recurrence may respond to salvage treatment. The risk of distant metastasis appears to be increased significantly by prophylactic EBRT (OR 1.58; 95% CI 1.07-2.35), but this might be because pelvic relapse in untreated women alters reporting of metastatic disease. AUTHORS' CONCLUSIONS Adjuvant EBRT should not be used for low- (IA, IBG1) or intermediate-risk (IBG2) cancer, but it is associated with a 10% survival advantage for high-risk (stage ICG3) endometrial cancer. This challenges the role of a staging lymphadenectomy.
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Affiliation(s)
- N Johnson
- Department of Gynaecologic Oncology, Royal United Hospital, Bath, UK.
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Maggi R, Lissoni A, Spina F, Melpignano M, Zola P, Favalli G, Colombo A, Fossati R. Adjuvant chemotherapy vs radiotherapy in high-risk endometrial carcinoma: results of a randomised trial. Br J Cancer 2006; 95:266-71. [PMID: 16868539 PMCID: PMC2360651 DOI: 10.1038/sj.bjc.6603279] [Citation(s) in RCA: 302] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2006] [Revised: 06/19/2006] [Accepted: 06/19/2006] [Indexed: 11/16/2022] Open
Abstract
Patients with high-risk endometrial carcinoma (stage IcG3, IIG3 with myometrial invasion >50%, and III) receive adjuvant therapy after surgery but it is not clear whether radiotherapy (RT) or chemotherapy (CT) is better. We randomly assigned 345 patients with high-risk endometrial carcinoma to adjuvant CT (cisplatin (50 mg m(-2)), doxorubicin (45 mg m(-2)), cyclophosphamide (600 mg m(-2)) every 28 days for five cycles, or external RT (45-50 Gy on a 5 days week(-1) schedule). The primary end points were overall and progression-free survival. After a median follow-up of 95.5 months women in the CT group as compared with the RT group, had a no significant hazard ratio (HR) for death of 0.95 (95% confidence interval (CI), 0.66-1.36; P = 0.77) and a nonsignificant HR for event of 0.88 (95% CI, 0.63-1.23; P = 0.45). The 3, 5 and 7-year overall survivals were 78, 69 and 62% in the RT group and 76, 66 and 62% in the CT group. The 3, 5 and 7-year progression-free survivals were, respectively, 69, 63 and 56 and 68, 63 and 60%. Radiotherapy delayed local relapses and CT delayed metastases but these trends did not achieve statistical significance. Overall, both treatments were well tolerated. This trial failed to show any improvement in survival of patients treated with CT or the standard adjuvant radiation therapy. Randomised trials of pelvic RT combined with adjuvant cytotoxic therapy compared with RT alone are eagerly awaited.
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Affiliation(s)
- R Maggi
- Clinica ‘L. Mangiagalli’, Università degli Studi di Milano, Milano, Italy
| | - A Lissoni
- Ospedale ‘San Gerardo’, Università degli Studi Milano ‘Bicocca’, Monza, Italy
| | - F Spina
- Clinica ‘L. Mangiagalli’, Università degli Studi di Milano, Milano, Italy
| | - M Melpignano
- Azienda Ospedaliero-Universitaria di Parma, Università degli Studi di Parma, Italy
| | - P Zola
- Ospedale Mauriziano ‘Umberto I’, Università degli Studi di Torino, Italy
| | - G Favalli
- Ospedali Civili di Brescia, Università degli Studi di Brescia, Italy
| | | | - R Fossati
- Department of Oncology, Istituto ‘Mario Negri’, Via Eritrea 62, 20157 Milano, Italy
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Zuurendonk LD, Smit RA, Mol BWJ, Feijen HWH, de Graaff J, Sykora D, de Winter KAJ, vd Wurff A, Snijders MPML, Kruitwagen RFPM. Routine pelvic lymphadenectomy in apparently early stage endometrial cancer. Eur J Surg Oncol 2006; 32:450-4. [PMID: 16546343 DOI: 10.1016/j.ejso.2006.02.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2005] [Accepted: 02/09/2006] [Indexed: 11/30/2022] Open
Abstract
AIMS Controversial issues with respect to the treatment of patients with endometrial cancer include indications for lymphadenectomy and adjuvant radiotherapy. PATIENT AND METHODS Between 1998 and 2004 all women with endometrial cancer stage I were included (n = 335). They all underwent total abdominal hysterectomy and bilateral salpingo-oöphorectomy. Two hundred and thirty-seven women also had a pelvic lymphadenectomy. When pelvic lymphadenectomy was performed, radiotherapy was administered only to patients with lymph-node metastases. Otherwise, adjuvant radiotherapy was based on the presence of risk factors. RESULTS Eleven patients had lymph-node metastases. The overall absolute and relative survival-estimate at 5 years was 85.0 and 93.7%, respectively. Loco-regional recurrence was 8.5%. In the group with pelvic lymphadenectomy and negative lymph nodes these rates were 88.2, 93.9 and 5.6%, respectively. In 58 patients without any of the risk factors tumour grade III, deep myometrial invasion, or age > or =60 years, no lymph-node metastases were found. CONCLUSION In patients with endometrial cancer FIGO stage I without risk-factors, a phenomenon which occurs in about 25% of patients with clinical stage I endometrial cancer, a lymphadenectomy can be omitted. In other patients, the debate regarding the optimal treatment will remain.
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Affiliation(s)
- L D Zuurendonk
- Department of Obstetrics and Gynaecology, St Elisabeth Hospital Tilburg, Tilburg, The Netherlands
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