Adjuvant chemotherapy as treatment of high-risk stage I and II endometrial cancer

Prognostic significance of adjuvant chemotherapy in stage I-II endometrial carcinoma patients who underwent lymphadenectomy

BACKGROUND

Endometrial carcinoma, the most common gynecologic carcinoma, has an excellent prognosis post-surgery when diagnosed early. The role of postoperative adjuvant chemotherapy in stages I-II endometrial carcinoma remains controversial. This study assesses the efficacy of adjuvant chemotherapy in improving prognosis for these patients.

METHODS

A retrospective analysis was conducted on 1223 stage I-II endometrial carcinoma patients who underwent surgical treatment including total hysterectomy, bilateral salpingo-oophorectomy, and lymph-node biopsy or dissection across four Jikei University School of Medicine-affiliated facilities between 2001 and 2018. Patients were divided into low intermediate risk (LIR) and high intermediate risk (HIR) groups based on recurrence risk. Propensity score matching adjusted for various covariates was used to compare progression-free survival (PFS) and overall survival (OS) between patients who received adjuvant chemotherapy and those who did not.

RESULTS

The study included 443 eligible patients, with 288 in the LIR group and 155 in the HIR group. Post propensity score matching, no significant difference in PFS or OS was observed between the observation and adjuvant chemotherapy groups within both risk categories. Notably, the 5-year OS for LIR was 97.6% in the observation group and 96.7% in the chemotherapy group; for HIR, the 5-year OS was similarly high with no significant difference.

CONCLUSIONS

The findings suggest that postoperative adjuvant chemotherapy does not significantly contribute to the improvement of recurrence or prognosis in patients with stage I-II endometrial carcinoma who are categorized outside the low-risk group and have no lymph-node metastasis.

Therapeutic Benefit of Systematic Lymphadenectomy in Node-Negative Uterine-Confined Endometrioid Endometrial Carcinoma: Omission of Adjuvant Therapy

Simple Summary

Endometrial cancer is the most common gynecological tract malignancy in developed countries. Extrauterine disease, in particular lymph node metastasis, is an important prognostic factor. Nevertheless, pelvic lymphadenectomy is not considered to have a therapeutic benefit, as it did not improve survival in randomized studies. However, lymphadenectomy may have a therapeutic benefit if adjuvant therapy can be omitted without decreasing oncological outcomes, as the long-term quality of life is maintained by avoiding morbidities associated with adjuvant therapy. In intermediate- and high-risk endometrioid endometrial carcinomas, adjuvant therapy may be safely omitted without decreasing long-term survival by open surgery including systematic pelvic and para-aortic lymphadenectomy when patients are node-negative. Systematic lymphadenectomy may remove undetectable low-volume lymph node metastasis in both pelvic and para-aortic regions, and open surgery may reduce vaginal recurrence even without vaginal brachytherapy. However, lymphadenectomy may not improve survival in elderly patients and patients with p53-mutant tumors.

Abstract

Endometrial cancer is the most common gynecological tract malignancy in developed countries, and its incidence has been increasing globally with rising obesity rates and longer life expectancy. In endometrial cancer, extrauterine disease, in particular lymph node metastasis, is an important prognostic factor. Nevertheless, pelvic lymphadenectomy is not considered to have a therapeutic benefit, as it did not improve survival in randomized studies. However, lymphadenectomy may have a therapeutic benefit if adjuvant therapy can be omitted without decreasing oncological outcomes, as the long-term quality of life is maintained by avoiding morbidities associated with adjuvant therapy. In intermediate- and high-risk endometrioid endometrial carcinomas, adjuvant therapy may be safely omitted without decreasing long-term survival by open surgery including systematic pelvic and para-aortic lymphadenectomy when patients are node-negative. Systematic lymphadenectomy may remove undetectable low-volume lymph node metastasis in both pelvic and para-aortic regions, and open surgery may reduce vaginal recurrence even without vaginal brachytherapy. However, lymphadenectomy may not improve survival in elderly patients and patients with p53-mutant tumors. In this review, I discuss the characteristics of lymph node metastasis, the methods of lymph node assessment, and the therapeutic benefits of systematic lymphadenectomy in patients with intermediate- and high-risk endometrioid endometrial carcinoma.

Adjuvant chemotherapy for stage I high-intermediate risk endometrial carcinoma with lymph-vascular invasion

OBJECTIVE

The goal of this study was to evaluate if addition of adjuvant chemotherapy to radiation therapy improves overall survival in patients with high-intermediate risk stage I endometrial carcinoma with lymphovascular invasion.

METHODS

Patients diagnosed between January 2010 and December 2015 with FIGO (International Federation of Gynecology and Obstetrics) stage I endometrioid endometrial carcinoma with lymphovascular invasion who underwent hysterectomy with lymphadenectomy and met the GOG-99 criteria for high-intermediate risk were identified in the National Cancer Database. Patients who received adjuvant radiotherapy with or without adjuvant chemotherapy (administered within 6 months of surgery) and had at least 1 month of follow-up were selected for further analysis. Overall survival was compared with the log-rank test following stratification by type of radiation treatment. A Cox model was constructed to control for a priori selected confounders.

RESULTS

A total of 2881 patients who met the inclusion criteria were identified; 2417 (83.9%) patients received radiation therapy alone while 464 (16.1%) received chemoradiation. Rate of adjuvant chemotherapy administration was comparable between patients who received vaginal brachytherapy alone (16.2%), and external beam radiation therapy (with or without vaginal brachytherapy) (15.8%), p=0.78. Rate of chemoradiation was higher for patients with grade 3 (28.8%) tumors compared with those with grade 2 (9.9%) and grade 1 (8.3%) tumors, p<0.001. After controlling for confounders for patients receiving external beam radiation, addition of chemotherapy was not associated with improved overall survival (HR 0.90, 95% CI 0.56 to 1.46). For patients receiving vaginal brachytherapy addition of chemotherapy was associated with better overall survival (HR 0.644, 95% CI 0.45 to 0.92). Benefit was limited to patients with grade 3 tumors, p=0.026; 4-year overall survival rate was 81.1% versus 74.9%.

CONCLUSIONS

In patients with high-intermediate risk FIGO stage I endometrioid endometrial carcinoma and lymphovascular invasion, addition of chemotherapy to radiation therapy was associated with a survival benefit for patients with grade 3 tumors receiving vaginal brachytherapy.

Adjuvant Chemotherapy versus Radiotherapy in High-risk, Early-stage Endometrioid Endometrial Carcinoma

OBJECTIVE

The present study was designed to evaluate the effects of adjuvant chemotherapy (CT) vs. radiotherapy (RT, alone or combined with CT) on the prognosis of patients with high-risk, early-stage (stage I and stage II) endometrioid endometrial carcinoma.

METHODS

This single-center retrospective clinical study was conducted in Union Hospital, Tongji Medical College, Huazhong University of Science and Technology between 2010 and 2019. In the present study, endometrioid endometrial carcinoma patients, who underwent total hysterectomy and bilateral salpingo-oophorectomy followed by postoperative adjuvant CT or RT (alone or combined with CT), and were diagnosed with stage IA grade 2/3 with lymph-vascular space invasion (LVSI), and stage IB with two or more uterine risks, including old age, histological grade 2 or 3, LVSI and stage II, were included. According to the postoperative adjuvant therapy, all eligible patients were divided into two groups: CT group and RT (RT±CT) group. The primary objective was to investigate overall survival (OS) and disease-free survival (DFS) between the CT and RT groups. Grade 3 or worse adverse events were also presented in the present study.

RESULTS

A total of 145 eligible patients were included. Among these patients, 97 patients underwent adjuvant CT and 48 patients underwent adjuvant RT (RT±CT). The median follow-up was 47.2 months, and the five-year OS rate was 92.7% in the CT group and 88.6 % in the RT group [hazard ratio (HR): 0.81, 95% confidence interval (CI): 0.22-2.99). The 5-year DFS rate for the two groups was 85.7% and 80.2%, respectively (HR: 0.82, 95% CI: 0.33-2.05). The cumulative incidence of local-regional disease recurrence at 60 months of follow-up was 6.2% in the CT group and 6.3% in the RT group (HR=1.11; 95%CI: 0.28-4.35). The cumulative incidence of distant recurrence at 60 months of follow-up was 5.2% in the CT group and 10.4% in the RT group (HR=0.65; 95%CI: 0.19-2.24). Both groups of patients were well-tolerant, and the only grade 3 or worse adverse events were neutropenia and thrombocytopenia.

CONCLUSION

There was no difference in efficacy for adjuvant CT or adjuvant RT (RT±CT) in high-risk, early-stage endometrioid endometrial carcinoma. CT exhibited a trend of reducing the distant relapse, although there was no significant difference, when compared with adjuvant RT (RT±CT).

Treatment of Early Stage High-Risk Endometrioid-Type Endometrial Cancer and Patterns of Disease Relapse: A Retrospective Analysis

Purpose

A recently published randomized controlled trial has demonstrated that in patients with endometrial cancer with high-risk features, the addition of chemotherapy to radiation therapy, compared with radiation therapy alone, resulted in a significant improvement in failure-free survival. However, in the study, the effect of chemotherapy was limited to stage III patients, and the benefit was less pronounced in stage I and II patients. Our study aims to investigate the current practice of treatment and clinical outcomes in stage I high-risk endometrioid-type endometrial cancer.

Methods and Materials

A single-center retrospective study was conducted on patients with stage I high-risk endometrioid-type endometrial cancer without serous or clear cell features who have undergone hysterectomy between 1998 and 2015. Data on patients, tumor, and treatments were collected and correlated with clinical outcomes.

Results

A total of 1,572 patients with stage I disease were identified and 46 patients who met the inclusion criteria were selected for final analysis. The median age at diagnosis was 63 years (range, 49-86 years) and median follow-up was 5.9 years. Among the entire cohort, 40 (87.0%) patients underwent adjuvant radiation therapy, of which 36 (78.2%) patients underwent external beam radiation therapy and 4 (8.7%) patients underwent vaginal brachytherapy. Two of the 40 patients who received adjuvant radiation therapy also received adjuvant chemotherapy. Six (13.0%) patients received no adjuvant treatment. Of the 46 patients, the cumulative risk of distant recurrence was 19.6%, and only 1 patient (2.2%) recurred within pelvis (perirectal lymph node). Five-year disease-free survival and overall survival rates were 73.1% and 80.1%, respectively.

Conclusions

Adjuvant radiation therapy in stage I endometrioid-type endometrial cancer patients with high-risk features resulted in high rates of locoregional disease control, and most recurrences occurred at distant sites. Effective systemic therapy may be indicated in this patient population to further reduce the risk of distant relapses and improve survival.

Modeling Endometrial Cancer: Past, Present, and Future

Endometrial cancer is the most common type of cancer of the female reproductive tract. Although prognosis is generally good for patients with low-grade and early-stage diseases, the outcomes for high-grade and metastatic/recurrent cases remain poor, since traditional chemotherapy regimens based on platinum and taxanes have limited effects. No targeted agents have been approved so far, although several new drugs have been tested without striking results in clinical trials. Over the last decades, many efforts have been made towards the establishment and development of preclinical models, aiming at recapitulating the structural and molecular determinants of the disease. Here, we present an overview of the most commonly used in vitro and in vivo models and discuss their peculiar features, describing their main applications and the value in the advancement of both fundamental and translational endometrial cancer research.

Adjuvant Therapy Use and Survival in Stage II Endometrial Cancer

OBJECTIVE

Radiotherapy (RT) is an established adjuvant treatment for stage II endometrioid endometrial carcinoma (EEC). The role of chemotherapy (CT) in stage II EEC is less proven. We used the National Cancer Data Base to identify factors associated with adjuvant CT in stage II EEC and to explore whether receipt of CT was associated with improved overall survival (OS).

METHODS/MATERIALS

Women diagnosed in 2010 to 2013 with International Federation of Obstetrics and Gynecology stage II EEC (grades 1-3) after hysterectomy and bilateral salpingo-oophorectomy were identified in the National Cancer Data Base. Multivariable logistic regression was used to identify covariates associated with receipt of CT. Overall survival among patients receiving RT, CT, or chemoradiotherapy (CRT) after surgery was compared using Kaplan-Meier estimates, the log-rank test, Cox proportional hazards regression, and propensity score matching.

RESULTS

We identified 6102 stage II EEC patients. There were 358 patients (6%) who received adjuvant CT alone and 525 (9%) who received CRT; the remainder received RT alone (n = 1906; 31%) or no adjuvant treatment (n = 3313; 54%). The presence of lymphovascular invasion (odds ratio, 3.58; P < 0.001) and grade 3 disease (odds ratio, 3.40; P < 0.001) was strongly associated with receipt of CT or CRT. The OS at 3 years for the entire cohort was 89%. On multivariable analysis, CT versus RT was associated with worse OS (hazard ratio [HR], 2.12 [95% confidence interval, 1.46-3.06]; P < 0.001), whereas CRT versus RT was not associated with improved OS (HR, 1.07 [95% confidence interval, 0.71-1.62]; P = 0.781). After propensity score matching, there remained no difference in OS between RT and CRT (HR, 1.14; P = 0.614).

CONCLUSIONS

Patients with stage II EEC have an excellent prognosis, and most undergo observation or receive adjuvant RT in the United States. Receipt of CT (alone or with RT) was not associated with an OS advantage compared with RT alone in this observational cohort. Randomized trials will help clarify the role of CT in stage II patients.

Synchronous uterine adenocarcinoma and leiomyosarcoma: A rare case report causing a clinical conundrum

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We present a rare case of concurrent uterine adenocarcinoma and leiomyosarcoma.

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Literature review confirms this is a very rare combination of synchronous tumors.

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We discuss therapeutic challenges in synchronous gynecologic malignancies.

Introduction

Synchronous gynecologic primary cancers are uncommon. When present, the most frequent malignancies consist of endometrial and ovarian carcinomas. Here we report an exceedingly rare case of concurrent uterine adenocarcinoma and leiomyosarcoma.

Case presentation

A 60 year-old female presented with four years of postmenopausal bleeding. An endometrial sampling showed grade 2 endometrioid adenocarcinoma. She proceeded with hysterectomy that contained an anterior endometrial mass and a posterior myometrial mass. The final pathology demonstrated concurrent uterine adenocarcinoma and leiomyosarcoma.

Discussion

To the best of our knowledge, this is the third reported case of simultaneous uterine adenocarcinoma and leiomyosarcoma. As this presentation is infrequent with limited literature, this caused a clinical management conundrum. Unfortunately, the follow-up PET scan suggested possible recurrence or metastasis three months after the surgery.

Conclusion

Simultaneous uterine adenocarcinoma and leiomyosarcoma is an exceptionally rare event. As the experience is limited, a multidisciplinary approach in managing these patients may be the best option currently available.

Lymphovascular space invasion and the treatment of stage I endometrioid endometrial cancer

OBJECTIVES

Treatment of clinical early-stage endometrioid endometrial cancer (EEC) in The Netherlands consists of primary hysterectomy and bilateral salpingo-oophorectomy. Adjuvant radiotherapy is given when 2 or more the following risk factors are present: 60 years or older, grade 3 histology, and 50% or more myometrial invasion. Lymphovascular space invasion (LVSI) is a predictor of poor prognosis and early distant spread. It is unclear whether adjuvant radiotherapy is sufficient in patients with LVSI-positive EEC.

METHODS/MATERIALS

Eighty-one patients treated from 1999 until 2011 for stage I LVSI-positive EEC in 11 Dutch hospitals were included. The outcomes of patients with 0 to 1 risk factors were compared with those with 2 to 3 risk factors, and both were compared with the known literature.

RESULTS

Eighteen patients presented with recurrent disease, and 12 of those recurrences had a distant component. Overall and distant recurrence rates were 19.2% and 11.5% in patients with 0 to 1 risk factors followed by observation and 25.5% and 17% in patients with 2 to 3 risk factors who received adjuvant radiotherapy. Only 1 patient with grade 1 disease had a recurrence.

CONCLUSIONS

In stage I LVSI-positive EEC with 0 to 1 risk factors, observation might not be adequate. Moreover, despite adjuvant radiotherapy, a high overall and distant recurrence rate was observed in patients with 2 to 3 risk factors. The use of systemic treatment in these patients, with the exception of patients with grade 1 disease, should be investigated.

Retrospective analysis of prognostic variables and clinical outcomes in surgically staged intermediate risk endometrial carcinoma

OBJECTIVE

To identify independent prognostic variables for surgically staged intermediate risk endometrial carcinoma as defined by the Gynecologic Oncology Group 99 (GOG99) criteria.

STUDY DESIGN

Retrospective study of 239 patients with FIGO stage IB-occult IIB endometrioid type endometrial cancer, who were primarily treated with comprehensive staging surgery. Data were collected on clinicopathological variables, extent of primary surgery, postoperative adjuvant treatment, and patterns of recurrences. Kaplan-Meier survival curves were used to estimate disease free survival (DFS) and overall survival (OS), and multivariate Cox regression models were used to identify independent prognostic variables. The median follow-up time was 67 months (range, 12-183 months).

RESULTS

The 5-year DFS and OS were 91.0% and 93.0%, respectively. On univariate Kaplan-Meier analysis, age>60 years, deep myometrial invasion (MI), presence of lymph vascular invasion (LVSI), and negative progesterone receptor (PR) status were significantly associated with diminished 5-year DFS and OS. The univariate analysis on patterns of failures demonstrated that patients with older age or positive LVSI were more inclined to develop locoregional recurrence, while PR status and the depth of MI had a statistically significant impact on distant failure. On multivariate analysis, PR status, age, and the depth of MI were independent prognostic variables for 5-year DFS, and age was the only independent prognostic variable for 5-year OS. LVSI and age were independent prognostic variables for locoregional recurrence, while PR status and depth of MI were independent prognostic variables for distant recurrence.

CONCLUSIONS

Age, depth of MI, PR status and presence of LVSI are of independent prognostic value for intermediate risk endometrial cancer. The presence of these variables warrants consideration when deciding upon treatment strategies.

Adjuvant chemotherapy for endometrial cancer after hysterectomy

BACKGROUND

Endometrial adenocarcinoma (womb cancer) is a malignant growth of the lining (endometrium) of the womb (uterus). It is distinct from sarcomas (tumours of the uterine muscle). Survival depends the risk of microscopic metastases after surgery. Adjuvant (postoperative) chemotherapy improves survival from some other adenocarcinomas, and there is evidence that endometrial cancer is sensitive to cytotoxic therapy. This systematic review examines the effect of chemotherapy on survival after hysterectomy for endometrial cancer.

OBJECTIVES

To assess efficacy of adjuvant (postoperative) chemotherapy for endometrial cancer.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2010, Issue 3), MEDLINE and EMBASE up to August 2010, registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing adjuvant chemotherapy with any other adjuvant treatment or no other treatment.

DATA COLLECTION AND ANALYSIS

We used a random-effects meta-analysis to assess hazard ratios (HR) for overall and progression-free survival and risk ratios (RR) to compare death rates and site of initial relapse.

MAIN RESULTS

Five RCTs compared no additional treatment with additional chemotherapy after hysterectomy and radiotherapy. Four trials compared platinum based combination chemotherapy directly with radiotherapy. Indiscriminate pooling of survival data from 2197 women shows a significant overall survival advantage from adjuvant chemotherapy (RR (95% CI) = 0.88 (0.79 to 0.99)). Sensitivity analysis focused on trials of modern platinum based chemotherapy regimens and found the relative risk of death to be 0.85 ((0.76 to 0.96); number needed to treat for an additional beneficial outcome (NNT) = 25; absolute risk reduction = 4% (1% to 8%)). The HR for overall survival is 0.74 (0.64 to 0.89), significantly favouring the addition of postoperative platinum based chemotherapy. The HR for progression-free survival is 0.75 (0.64 to 0.89). This means that chemotherapy reduces the risk of being dead at any censorship by a quarter. Chemotherapy reduces the risk of developing the first recurrence outside the pelvis (RR = 0.79 (0.68 to 0.92), 5% absolute risk reduction; NNT = 20). The analysis of pelvic recurrence rates is underpowered but the trend suggests that chemotherapy may be less effective than radiotherapy in a direct comparison (RR = 1.28 (0.97 to 1.68)) but it may have added value when used with radiotherapy (RR = 0.48 (0.20 to 1.18)).

AUTHORS' CONCLUSIONS

Postoperative platinum based chemotherapy is associated with a small benefit in progression-free survival and overall survival irrespective of radiotherapy treatment. It reduces the risk of developing a metastasis, could be an alternative to radiotherapy and has added value when used with radiotherapy.

Long-term survival of endometrioid endometrial cancer patients

INTRODUCTION

To establish risk factors for onset and progression of endometrioid endometrial cancer still remains the aim of scientists. The aim of the study was to determine disease-free survival (DFS) and overall survival (OS) in women with endometrioid endometrial cancer.

MATERIAL AND METHODS

A retrospective review of 142 patients with endometrioid endometrial cancer after surgery treated with adjuvant radiotherapy and/or chemotherapy in the Regional Cancer Centre in Lodz between 2002 and 2004 was performed. Clinical and pathological data were correlated with clinical outcome and survival.

RESULTS

In 3 patients (2.1%) clinical progression was diagnosed during the treatment. In 23 patients (16.7%) after primary remission, relapse was diagnosed 2-56 months after treatment. DFS and OS were 81.7% and 83.1% respectively. Better DFS significantly correlated with larger number of pregnancies (> 1), stage I of the disease and optimal surgery. Lower stage of disease, pelvic lymph node dissection, optimal surgery and depth of myometrial infiltration ≤ 50% were independent prognostic factors for better OS.

CONCLUSIONS

The results of our study provided significant evidence that early detection of endometrioid endometrial cancer enables optimal surgery. It reduces the indications for adjuvant therapy in stage I of the disease, and makes the prognosis significantly better. Other clinical and pathological factors such as numerous pregnancies, pelvic lymphadenectomy, and depth of myometrial infiltration, although important, are of less significance. Further prospective, randomized studies are necessary to prove the role of these factors.

Survival and disease relapse in surgical stage I endometrioid adenocarcinoma of the uterus after adjuvant vaginal vault brachytherapy

INTRODUCTION

Advanced age, deep myoinvasion, whole cavity or lower uterine segment tumors, poor differentiation, and lymphovascular space invasion are known to increase recurrence risk and adversely affect survival in stage I endometrioid adenocarcinoma of the uterus.

OBJECTIVES

To ascertain survival rates, failure patterns, and salvageability and to correlate adverse histopathologic effects to recurrences in these patients.

METHODS

Data of 162 patients with surgical stage I endometrioid adenocarcinoma of the uterus with an increased risk of recurrence were reviewed from the year 1997 to 2008 at KK Gynaecological Cancer Centre, Singapore. Each patient underwent surgical staging and histopathologic evaluation and received high-dose rate vaginal vault brachytherapy. The data of all patients were discussed in a multidisciplinary meeting.

RESULTS

The mean patient age was 58.9 years. Most patients (54.3%) had surgical stage IC endometrioid adenocarcinoma, whereas the rest had stage IB. Grade 2 tumors were seen in 53.7% of the patients and grade 3 in 21.61%. The mean follow-up duration was 52.9 months, with a maximum of 11.5 years. Five- and 10-year survival rates were 94% and 89%, respectively. There were 9 recurrences (5.56%). Stage IC had 77.78% recurrences, whereas stage IB had 22.22%, the median time being 19 months. The initial 3 years had 77.78% relapses. There was no recurrence in grade 3 tumors, with a 100% 5-year survival rate for stage IC grade 3. Age, lymphovascular space invasion, and tumor volume and location were not significant parameters in surgical stage I endometrioid adenocarcinoma patients who failed. One patient had isolated pelvic failure, whereas 5 had a pure distant relapse. Three patients failed at both locoregional and distant sites. Vault recurrence coupled with distant metastasis occurred in 1 patient. Three patients (33.33%) with recurrences, all with limited relapse sites, were salvaged, with a mean survival of 71.33 months. The median survival for recurrent endometrial cancer was 5 years.

CONCLUSIONS

This treatment has excellent survival rates with acceptable morbidity, and recurrence is mostly distant.

Endometrial cancer: what is new in adjuvant and molecularly targeted therapy?

Endometrial cancer is the most common gynaecological cancer in western countries. Radiotherapy remains the mainstay of postoperative management, but accumulating data show that adjuvant chemotherapy may display promising results after staging surgery. The prognosis of patients with metastatic disease remains disappointing with only one-year survival. Progestins represent an effective option, especially for those patients with low-grade estrogen and/or progesterone receptor positive disease. Chemotherapy using the combination of paclitaxel, doxorubicin, and cisplatin is beneficial for patients with advanced or metastatic disease after staging surgery and potentially for patients with early-stage disease and high-risk factors. Toxicity is a point in question; however, the combination of paclitaxel with carboplatin may diminish these concerns. In women with multiple medical comorbidities, single-agent chemotherapy may be better tolerated with acceptable results. Our increased knowledge of the molecular aspects of endometrial cancer biology has paved the way for clinical research to develop novel targeted antineoplastic agents (everolimus, temsirolimus, gefitinib, erlotinib, cetuximab, trastuzumab, bevacizumab, sorafenib) as more effective and less toxic options. Continued investigation into the molecular pathways of endometrial cancer development and progression will increase our knowledge of this disease leading to the discovery of novel, superior agents.

Endometrioid endometrial adenocarcinoma in a premenopausal woman with multiple organ metastases

Endometrial adenocarcinoma is the third common malignancy of the female genital tract occurring most often in the postmenopausal age group. High tumor grade, advanced surgical stage, and lymphovascular space invasion are implicated as poor prognostic factors for dissemination of disease. We present an unusual case of endometrial adenocarcinoma in a premenopausal woman with simultaneous metastases in brain, liver, skin and skeletal system, within one month of completion of treatment. The role of adjuvant/concurrent chemotherapy in addition to radiotherapy in high risk cases is discussed along with the review of literature.

Heparanase expression in endometrial cancer: analysis of immunohistochemistry

The human enzyme heparanase has been shown to function in tumour progression, metastatic spread and tumour angiogenesis. The aim of the present study was to assess heparanase expression assessed by immunohistochemical staining (IHC) in endometrial cancer in correlation with clinicopathological factors. A total of 52 endometrial cancers were obtained from previously untreated patients (median age, 56 years, range, 35-80 years). The expression of heparanase was evaluated by using IHC with anti-heparanase polyclonal antibody. This antibody was raised by immunising a rabbit with a peptide containing the amino acid residues from 238 to 250 of the heparanase. The IHC data were used to determine the relationship between heparanase expression, and clinicopathological parameters. IHC showed that the heparanase was expressed in 23 of 52 (44.2%) endometrial cancers. Heparanase was abundantly and equally expressed in both the cytoplasm and the cell membrane of the cells in endometrial cancer. Strong heparanase-positive staining was also seen at the invasive front of the tumour into myometrium. The expression was significantly related to lymph-vascular space involvement (p = 0.0028), depth of myometrial invasion (p = 0.0026), and histological tumour grade (p = 0.0135). In six tumours with positive lymph nodes, the heparanase expression was observed as being higher compared with tumours with negative lymph nodes, which was not significant (p = 0.2349). In terms of peritoneal cytology, ovarian metastasis, and cervical invasion, we observed no significant difference in the heparanase expression assessed by IHC. These results suggest that the expression of heparanase may promote tumour invasion into myometrium and lymph vascular space in endometrial cancer.

Adjuvant therapy in high-risk early endometrial carcinoma: a retrospective analysis of 46 cases

OBJECTIVE

We assessed the prognostic factors and the efficacy of adjuvant therapy and reviewed randomized studies carried out on patients receiving adjuvant therapy with early endometrial carcinoma.

METHODS

One hundred and five patients that received primary surgical treatment for stage IB, IC and II endometrial cancer were enrolled in this study. The clinical outcomes were compared among the patients with variable prognostic factors and adjuvant treatments.

RESULTS

One hundred and five patients fulfilled the eligibility criteria and 46 patients (43.8%) underwent adjuvant therapy. Disease recurrence occurred in nine patients within a median time of 24 months. Cervical involvement was an independent prognostic factor for the disease-free survival rates. Eight of 16 patients with FIGO stage II disease received adjuvant chemotherapy consisting of cisplatin and etoposide (or cyclophosphamide) or combined chemoradiation. The 5-year disease-free survival rate for these patients was 87.5%, a value significantly higher than for patients that received radiation therapy alone (30%).

CONCLUSION

Adjuvant chemotherapy or combination chemo-radiotherapy might be superior to radiation therapy alone in high-risk early endometrial cancer patients.

[Chemotherapy of advanced endometrial carcinoma]

<zakljucak> Pri donosenju odluke o lecenju bolesnice sa karcinomom endometrijuma znacajno je: 1) da li je bolest u odmaklom stadijumu ili je prisutan recidiv tumora, 2) da li je prethodno sprovedena terapija i ako jeste, koji vid terapije (zracenje ili hemioterapija), 3) da li je tumor merljiv ili nemerljiv i 4) o kom se histoloskom tipu tumora radi. Kod pojave recidiva znacajno je da li se on javio u prethodno zracenom polju ili van njega. Treba imati u vidu da je prezivljavanje bolesnica sa odmaklim i recidivirajucim karcinomom endometrijuma oko jedne godine i da su dosadasnji protokoli pokazali manje ili vise izrazenu toksicnost. S tog aspekta, vazno je i da primenjena terapija ne izazove znacajno oboljenje i narusavanje kvaliteta zivota bolesnice. Terapija uznapredovalog, metastatskog i recidivirajuceg karcinoma endometrijuma zahteva individualni pristup u zavisnosti od zivotne dobi i opsteg stanja bolesnice, mesta recidiva i prethodno sprovedene terapije. Pored hemioterapije, terapijske mogucnosti koje su na raspolaganju za sada su palijativna hirurgija i radioterapija, kao i hormonska terapija. .

Chemotherapy for high-risk early-stage endometrial cancer

PURPOSE OF REVIEW

To discuss the usefulness of chemotherapy in high-risk early-stage endometrial cancer and the best chemotherapy regimen.

RECENT FINDINGS

External radiation therapy has been successfully used to prevent local recurrence; however, it does not improve the overall survival and it increases the incidence of late toxicity. A recent randomized study revealed that adjuvant platinum-based combination chemotherapy might be a suitable alternative to radiotherapy for high-risk early-stage endometrial cancer. The optimal regimen is still in question because combinations of doxorubicin-cisplatin and paclitaxel-doxorubicin-cisplatin cause significant toxicity. The combination of paclitaxel-carboplatin may be better than doxorubicin-cisplatin with regard to toxicities.

SUMMARY

Radiation treatment following surgery has been the standard adjuvant therapy for endometrial cancer for a long time. Radiotherapy decreases the local recurrence rates; however, a significant impact on the overall survival has not been demonstrated. The usefulness of adjuvant chemotherapy has been demonstrated by only a little evidence. Nonetheless, we are encouraged by a recent randomized study. In light of the excellent outcomes associated with early-stage endometrial cancer, it is important to conduct another large randomized trial based on standardization of high-risk criteria to evaluate the efficacy of adjuvant chemotherapy.

Adjuvant chemotherapy vs radiotherapy in high-risk endometrial carcinoma: results of a randomised trial

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.

Effectiveness of postoperative chemotherapy for para-aortic lymph node metastasis of endometrial cancer

OBJECTIVE

To examine the effectiveness of postoperative chemotherapy for para-aortic lymph node (PAN) metastasis in patients with endometrial cancer.

METHODS

Among 350 clinical stage I-II endometrial cancer patients who underwent systemic pelvic and para-aortic lymphadenectomy during the period 1995 through 2002, 26 patients were identified with PAN metastasis. Of these patients, nine had only one positive PAN and 17 had two or more positive PANs (mean 4.9, range 1-22). All patients were treated postoperatively with a single chemotherapy regimen consisting of ifosfamide, epiadriamycin, and cisplatin scheduled for 5 cycles. Median (range) follow-up for surviving patients was 85 (38-119) months. Treatment outcome, including disease-free survival relative to the number of positive PANs, was investigated.

RESULTS

Among the 26 patients with PAN involvement, four developed recurrence. Three of the four patients had 10 or more positive PANs. Estimated 5-year disease-free survival rates were 89% for patients with one positive PAN, 82% for those with two or more positive PANs, and 85% for all patients. No significant difference was identified between the first two groups (P = 0.6543).

CONCLUSIONS

Postoperative chemotherapy can yield a favorable outcome in endometrial cancer patients with PAN metastasis, even those with multiple positive nodes.

[Role of Laparoscopy in the Treatment of Endometrial Carcinoma]

In the treatment of endometrial carcinoma of stages I and II, laparoscopic or laparoscopically assisted vaginal hysterectomy with bilateral adnexectomy is oncologically equivalent to abdominal hysterectomy. As the pelvic and para-aortal laparoscopic lymph node dissection can now be safely carried out, it is possible to decide definitely for or against adjuvant percutaneous irradiation. The removal of metastatic lymph nodes seems to improve survival significantly.

Efficacy and prognostic implications of administering adjuvant chemotherapy to patients with endometrial cancer that is confined to the uterus

OBJECTIVE

The purpose of this study was to determine the value of prognostic factors and to assess the efficacy of adjuvant chemotherapy in patients with endometrial cancer confined to the uterus.

STUDY DESIGN

Patients surgically stage IB, IC and II endometrial cancer according to the International Federation of Gynecology and Obstetrics were enrolled in this study. Stage IIIA tumors with positive peritoneal cytology, in the absence of other evidence of extra uterine disease, were also included.

RESULTS

One hundred and sixty-seven patients fulfilled the eligibility criteria and 58 patients (34.7%) underwent combination chemotherapy. Disease recurrence occurred in 10 patients within a median time of 17 months. Histologic grade 3 was an independent prognostic factor for both disease-free and overall survival rates. Fourteen of 23 patients with histologic grade 3 tumors received adjuvant chemotherapy consisting of cyclophosphamide (or etoposide), epirubicin and cisplatin (in 1989-1999) or paclitaxel, pirarubicin and carboplatin (in 2000-2002). The 5-year disease-free and overall survival rates for these individuals was 92.3%, a value significantly higher than those in patients who had not undergone chemotherapy (50.0%).

CONCLUSIONS

Histologic grade of 3 is an independent prognostic marker in patients with endometrial cancer confined to the uterus and adjuvant chemotherapy might improve the survival rates in these patients.

What??s new in systemic therapy for endometrial cancer

PURPOSE OF REVIEW

Endometrial cancer is one of the most common gynecologic cancers. Most women present with early disease that is curable. In women with poor prognostic factors or advanced disease, survival is greatly diminished. Recently there have been several trials of adjuvant treatment and treatment for advanced and recurrent endometrial cancer. These trials of systemic therapy will be reviewed.

RECENT FINDINGS

Several areas have been the focus of recent literature on systemic therapy for endometrial cancer. These include large phase III trials of multi-agent chemotherapy regimens for advanced and recurrent endometrial cancer, combined chemotherapy and radiotherapy treatments, and novel targeted agents.

SUMMARY

New approaches to combining the traditional adjuvant modalities for high-risk endometrial cancer as well as combining new novel agents with traditional chemotherapeutics will improve patient outcomes.