Extent of pelvic lymphadenectomy and use of adjuvant vaginal brachytherapy for early-stage endometrial cancer

Utilization Trend and Comparison of Different Radiotherapy Modes for Patients with Early-Stage High-Intermediate-Risk Endometrial Cancer: A Real-World, Multi-Institutional Study

This study aimed to compare the outcomes of RT modalities among patients who met different HIR criteria based on multicentric real-world data over 15 years. The enrolled patients, who were diagnosed with FIGO I-II EC from 13 medical institutes and treated with hysterectomy and RT, were reclassified into HIR groups according to the criteria of GOG-249, PORTEC-2, and ESTRO-ESMO-ESGO, respectively. The trends in RT modes utilization were reviewed using the Man-Kendall test. The rate of VBT alone increased from zero in 2005 to 50% in 2015, which showed a significant upward trend (p < 0.05), while the rate of EBRT + VBT utilization declined from 87.5% to around 25% from 2005 to 2015 (p > 0.05). There were no significant differences in OS, DFS, LRFS, and DMFS between VBT alone and EBRT ± VBT in three HIR cohorts. Subgroup analyses in the GOG-249 HIR cohort showed that EBRT ± VBT had higher 5-year DFS, DMFS, and LRFS than VBT alone for patients without lymph node dissection (p < 0.05). Thus, VBT could be regarded as a standard adjuvant radiation modality for HIR patients. EBRT should be administrated to selected HIR patients who meet the GOG-249 criteria and did not undergo lymph node dissection.

Utilization and Outcomes of Sentinel Lymph Node Biopsy for Early Endometrial Cancer

OBJECTIVE

To examine trends, characteristics, and oncologic outcomes of sentinel lymph node biopsy for early endometrial cancer.

METHODS

This observational study queried the National Cancer Institute's Surveillance, Epidemiology, and End Results Program by examining 83,139 women with endometrial cancer who underwent primary hysterectomy with nodal evaluation for T1 disease from 2003 to 2018. Primary outcome measures were the temporal trends in utilization of sentinel lymph node biopsy and patient characteristics associated with sentinel lymph node biopsy use, assessed by multivariable binary logistic regression models. Secondary outcome measure was endometrial cancer-specific mortality associated with sentinel lymph node biopsy, assessed by propensity score inverse probability of treatment weighting.

RESULTS

The utilization of sentinel lymph node biopsy increased from 0.2 to 29.7% from 2005 to 2018 (P<.001). The uptake was higher for women with endometrioid (0.3-31.6% between 2005 and 2018) compared with nonendometrioid (0.6-21.0% between 2006 and 2018) histologic subtypes (both P<.001). In a multivariable analysis, more recent year surgery, endometrioid histology, well-differentiated tumors, T1a disease, and smaller tumor size were independently associated with sentinel lymph node biopsy use (P<.05). Performance of sentinel lymph node biopsy was not associated with increased endometrial cancer-specific mortality compared with lymphadenectomy for endometrioid tumors (subdistribution hazard ratio [HR] 0.96, 95% CI 0.82-1.13) or nonendometrioid tumors (subdistribution HR 0.85, 95% CI 0.69-1.04). For low-risk endometrial cancer, the increase in sentinel lymph node biopsy resulted in a 15.3 percentage-point (1.4-fold) increase in surgical nodal evaluation by 2018 (expected vs observed rates, 37.8 vs 53.1%).

CONCLUSION

The landscape of surgical nodal evaluation is shifting from lymphadenectomy to sentinel lymph node biopsy for early endometrial cancer in the United States, with no indication of a negative effect on cancer-specific survival.

Systematic Lymphadenectomy and Oncological Outcomes of Women With Apparent Early-Stage Clear Cell Carcinoma of the Endometrium: A Multi-Institutional Cohort Study

Objective

The survival value of systematic lymphadenectomy for endometrial cancer is ambiguous and controversial. The current study aimed to evaluate the long-term survival role of combined pelvic and para-aortic lymphadenectomy in patients with presumed early-stage clear cell carcinoma of the endometrium.

Methods

Patients in three Chinese teaching hospitals who presented between 2012 and 2017 with apparent early-stage clear cell carcinoma of the endometrium and underwent surgical staging were selected. Patients who did and did not undergo systematic lymphadenectomy were identified and clinicopathological characteristics were compared. Disease-free survival and overall survival were evaluated following the generation of the Kaplan-Meier curves and the comparison using the log-rank test. A Cox proportional hazards model was employed to control for confounders.

Results

A total of 244 patients underwent systematic lymphadenectomy and 89 did not receive lymph node dissection. The demographic and baseline data were comparable between the two groups. The rate of disease-free survival at 5 years was 64.10% in patients who underwent systematic lymphadenectomy and 45.05% in patients who did not undergo lymphadenectomy. Patients who underwent systematic lymphadenectomy had better disease-free survival than those who did not receive lymphadenectomy (HR, 0.54. 95% CI, 0.38-0.76. P=0.000). The rate of 5-year overall survival was 68.87% in the lymphadenectomy group and 53.33% in patients who did not undergo systematic lymphadenectomy. Systematic lymphadenectomy was also associated with improved 5-year overall survival for women with presumed early-stage clear cell carcinoma of the endometrium (HR, 0.58. 95% CI, 0.39-0.85. P=0.005). After adjusting for confounders, systematic lymphadenectomy was still independently associated with improved disease-free survival and overall survival.

Conclusion

Patients with apparent early-stage clear cell carcinoma of the endometrium who underwent systematic lymphadenectomy had better long-term survival than those who did not undergo systematic lymphadenectomy.

Lenvatinib plus pembrolizumab in patients with advanced or recurrent uterine carcinosarcoma

OBJECTIVES

To investigate the efficacy of pembrolizumab plus lenvatinib as a second-line or later-line therapy in women with advanced or recurrent uterine carcinosarcoma (UCS).

METHODS

A single-institution pharmacy database was queried for women with advanced or recurrent UCS who were prescribed concurrent pembrolizumab and lenvatinib. Patient demographic, oncologic, and immunotherapy outcomes data were recorded. Univariate analysis summarized progression-free survival (PFS) and overall survival (OS).

RESULTS

Seven patients with advanced or recurrent UCS were treated with combination pembrolizumab and lenvatinib, with a median age of 63.0 years. The majority had stage III or IV disease (n = 6, 85.7%) and had failed two or more lines of therapy (n = 7, 100.0%), and a minority were MMR deficient (n = 1, 14.3%) or PD-L1+ (n = 1, 14.3%). No partial or complete responses were observed. The median PFS was 2.6 months (95% CI, 0.9-11.2 months), and the median OS was 2.8 months (95% CI, 2.4-NE).

CONCLUSIONS

In this small, retrospective series, we demonstrate that pembrolizumab and lenvatinib combination therapy may not be highly active in UCS and may be associated with similar PFS and OS as traditional cytotoxic regimens. Further study is warranted to assess the efficacy of this regimen in more targeted cohorts of women with advanced or recurrent UCS.

Preliminary clinical outcomes of patients treated with vaginal brachytherapy alone using multi-channel vaginal brachytherapy applicator in operated early-stage endometrial cancer

Background

Recommendations for adjuvant treatment for postoperative, early-stage endometrial cancer varies from observation through vaginal brachytherapy alone to pelvic radiation. While observation alone can lead to recurrence, external radiotherapy has increased morbidity. The aim of this study is to show our results with vaginal brachytherapy alone using a multichannel applicator for treatment of early-stage endometrial cancer.

Materials and methods

Consecutive patients undergoing vaginal brachytherapy alone following surgery for early-stage endometrial cancer were examined. A Miami multichannel vaginal brachytherapy applicator was used to deliver HDR brachytherapy in 62 patients from May 2013 to June 2018. CT scan-based images guided planning. A dose of 5.5-6.5 Gy × 4 fractions was prescribed 5 mm from the surface of the applicator.

Results

At a median follow up of 19 months (6-48 months), 93% of patients treated were alive with no recurrence. Two patients had only local recurrence, and 1 was salvaged with external radiotherapy and chemotherapy. There was only one nodal failure and 2 distant failures. There was no grade 2 or higher vaginal, gastrointestinal or genitourinary toxicity.

Conclusion

Vaginal brachytherapy alone using a multichannel applicator can be considered for early-stage endometrial cancers without compromising outcomes.

Uterine carcinosarcoma: Contemporary clinical summary, molecular updates, and future research opportunity

Uterine carcinosarcoma (UCS) is a biphasic aggressive high-grade endometrial cancer in which the sarcoma element has de-differentiated from the carcinoma element. UCS is considered a rare tumor, but its incidence has gradually increased in recent years (annual percent change from 2000 to 2016 1.7%, 95% confidence interval 1.2-2.2) as has the proportion of UCS among endometrial cancer, exceeding 5% in recent years. UCS typically affects the elderly, but in recent decades patients became younger. Notably, a stage-shift has occurred in recent years with increasing nodal metastasis and decreasing distant metastasis. The concept of sarcoma dominance may be new in UCS, and a sarcomatous element >50% of the uterine tumor is associated with decreased survival. Multimodal treatment is the mainstay of UCS. Lymphadenectomy, chemotherapy, and brachytherapy have increased in the past few decades, but survival outcomes remain dismal: the median survival is less than two years, and the 5-year overall survival rate has not changed in decades (31.9% in 1975 to 33.8% in 2012). Carboplatin/paclitaxel adjuvant chemotherapy improves progression-free survival compared with ifosfamide/paclitaxel, particularly in stages III-IV disease (GOG-261 trial). Twenty-six clinical trials previously examined therapeutic effectiveness in recurrent/metastatic UCS. The median response rate and progression-free survival were 37.5% and 5.9 months, respectively, after first-line therapy, but after later therapies, the outcomes were far worse (5.5% and 1.8 months, respectively). One significant discovery was that epithelial-mesenchymal transition (EMT) plays a pivotal role in the pathogenesis of sarcomatous dedifferentiation in UCS and that heterologous sarcoma is associated with a higher EMT signature compared with homologous sarcoma. Furthermore, next-generation sequencing has revealed that UCS tumors are serous-like and that common somatic mutations include those in TP53, PIK3CA, FBXW7, PTEN, and ARID1A. This contemporary review highlights recent clinical and molecular updates in UCS. A possible therapeutic target of EMT in UCS is also discussed.

Recurrence, death, and secondary malignancy after ovarian conservation for young women with early-stage low-grade endometrial cancer

OBJECTIVE

To examine the association between ovarian conservation and oncologic outcome in surgically-treated young women with early-stage, low-grade endometrial cancer.

METHODS

This multicenter retrospective study examined women aged <50 with stage I grade 1-2 endometrioid endometrial cancer who underwent primary surgery with hysterectomy from 2000 to 2014 (US cohort n = 1196, and Japan cohort n = 495). Recurrence patterns, survival, and the presence of a metachronous secondary malignancy were assessed based on ovarian conservation versus oophorectomy.

RESULTS

During the study period, the ovarian conservation rate significantly increased in the US cohort from 5.4% to 16.4% (P = 0.020) whereas the rate was unchanged in the Japan cohort (6.3-8.7%, P = 0.787). In the US cohort, ovarian conservation was not associated with disease-free survival (hazard ratio [HR] 0.829, 95% confidence interval [CI] 0.188-3.663, P = 0.805), overall survival (HR not estimated, P = 0.981), or metachronous secondary malignancy (HR 1.787, 95% CI 0.603-5.295, P = 0.295). In the Japan cohort, ovarian conservation was associated with decreased disease-free survival (HR 5.214, 95% CI 1.557-17.464, P = 0.007) and an increased risk of a metachronous secondary malignancy, particularly ovarian cancer (HR 7.119, 95% CI 1.349-37.554, P = 0.021), but was not associated with overall survival (HR not estimated, P = 0.987). Ovarian recurrence or metachronous secondary ovarian cancer occurred after a median time of 5.9 years, and all cases were salvaged.

CONCLUSION

Our study suggests that adoption of ovarian conservation in young women with early-stage low-grade endometrial cancer varies by population. Ovarian conservation for young women with early-stage, low-grade endometrial cancer may be potentially associated with increased risks of ovarian recurrence or metachronous secondary ovarian cancer in certain populations; nevertheless, ovarian conservation did not negatively impact overall survival.

Decreasing Trends of Secondary Primary Colorectal Cancer among Women with Uterine Cancer: A Population-Based Analysis

The current study examined trends, characteristics, and outcomes of women with uterine cancer who had secondary colorectal cancer. This is a retrospective study utilizing the Surveillance, Epidemiology, and End Results Program between 1973-2013. Among uterine cancer (n = 246,272) and colorectal cancer (n = 421,312) cohorts, women with both diagnoses were identified, and clinico-pathological factors and survival were extracted and analyzed. There were 6862 women with both cancer diagnoses, representing 2.8% of the uterine cancer cohort and 1.6% of the colorectal cancer cohort. Among 123,940 women with uterine cancer survivors, the number with postcedent colorectal cancer decreased from 5.3% to 0.7% between 1981-2008 (relative risk reduction 87.0% p < 0.001). Similarly, of 141,801 women with colorectal cancer survivors, the number with postcedent uterine cancer decreased from 1.7% to 0.5% between 1973-2008 (relative risk reduction 71.6%, p < 0.001). In the uterine cancer cohort, women with antecedent/synchronous colorectal cancer had more high-grade tumors and advanced-stage disease resulting in poorer survival, whereas those who had postcedent colorectal cancer had more low-grade tumors and early-stage disease resulting in superior survival compared to those without secondary colorectal cancer (all, p < 0.05). In conclusion, the development of postcedent colorectal cancer following uterine cancer has decreased in recent years in the United States.

Trends of uterine carcinosarcoma in the United States

Objective

Uterine carcinosarcoma (UCS) is a rare type of high-grade endometrial cancer (EC) that has been understudied with population-based statistics due to its rarity. This study examined temporal trends in the proportion of UCS among women with EC.

Methods

This is a retrospective observational study examining The Surveillance, Epidemiology, and End Results program between 1973–2013. Primary EC cases were eligible for analysis, and a time-specific proportion of UCS was examined during the study period.

Results

UCS was seen in 11,000 (4.7%) women among 235,849 primary EC cases. Mean age at UCS diagnosis increased from 65.9 to 71.7 years between 1973–1989 and then decreased from 71.7 to 67.0 years between 1989–2013 (both, p<0.001). Proportion of Black women significantly increased during the study period (11.9%–20.0%, p<0.001), whereas the proportion of White women decreased from 86.0% to 60.5% between 1987–2013 (p<0.001). There was a significant increase in the proportion of UCS among primary EC from 1.7% to 5.6% between 1973–2013 (p<0.001). Among type II ECs (n=76,118), the proportion of UCS also increased significantly from 6.0% to 17.5% between 1973–2013 (p<0.001). An increasing proportion of UCS was seen in both young and older women but the magnitude of interval increase was larger in the older age group between 1973–2013 (<60 years, from 1.3% to 3.3%. p<0.001; and ≥60 years, from 2.6% to 7.0%, p<0.001).

Conclusion

Our study demonstrated that the proportion of UCS has significantly increased among EC, accounting for more than 5% in recent years.

Patient compliance for postoperative radiotherapy and survival outcome of women with stage I endometrioid endometrial cancer

BACKGROUND AND OBJECTIVES

To examine characteristics and survival outcome of women with endometrial cancer who declined postoperative radiotherapy.

METHODS

A retrospective study was conducted to examine surgically-treated grade 1-2 stage IB and grade 3 stage IA-IB endometrioid endometrial cancer in the Surveillance, Epidemiology, and End Results Program between 1983 and 2013 (n = 10 613). Associations of patient declination for guideline-based postoperative radiotherapy and clinico-pathological demographics or survival outcome were examined on multivariable analysis.

RESULTS

There were 323 (3.0%) women who declined adjuvant radiotherapy. Women who declined postoperative radiotherapy were more likely to be older, White, Western U.S. residents, and register in recent years (all, adjusted-P < 0.05). On multivariable analysis, patient declination for guideline-based postoperative radiotherapy remained an independent prognostic factor for decreased endometrial cancer-specific survival in unstaged grade 1-2 stage IB or staged/unstated grade 3 stage IA-IB diseases (adjusted-hazard ratio 1.84, 95% confidence interval 1.34-2.51, P = 0.001). Association of patient declination for guideline-based postoperative radiotherapy and decreased overall survival remained independent in the entire cohort on multivariable analysis (adjuvant-hazard ratio 1.71, 95% confidence interval 1.44-2.02, P < 0.001).

CONCLUSIONS

Our study suggested that patient compliance to guideline-based postoperative radiotherapy is a prognostic factor for women with stage I endometrioid endometrial cancer.