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

Laparoscopic-Assisted Hysteroscopic Surgery for Endometrial Tumors Arising after Pelvic Radiation Therapy

Uterine tumors detected after pelvic radiation therapy are rare. We report a case in which an endometrial tumor developed after pelvic radiation therapy for cervical cancer. The patient was a 70-year-old female with a history of pelvic radiotherapy for locally advanced cervical cancer. After 12 months of radiation therapy, magnetic resonance imaging showed tumors in the uterine cavity, and positron emission tomography-computed tomography showed no tumors, except uterine tumors. Since radiation therapy-induced cervical stenosis was conducted, endometrial examination could not be performed without anesthesia. As these tumors were detected after radiation therapy for uterine cancer, malignancy was considered. A laparoscopic-assisted transcervical hysteroscopic resection was performed for the diagnosis and treatment of uterine tumors after radiation therapy. This operative method was useful and enabled us to perform complete resection, observe the abdominal cavity, prepare for the possibility of secondary hysterectomy, and improve safety.

Clinicopathologic features and treatment in patients with early stage uterine clear cell carcinoma: A 16-year experience

OBJECTIVE

To evaluate clinicopathologic factors and adjuvant treatment effects on recurrence free (RFS) and overall survival (OS) in early stage uterine clear cell carcinoma (UCCC).

METHODS

Our retrospective review included central pathology confirmed stage I or II UCCC treated and/or followed between 2000 and 2016. Cases with pure or mixed histology with >50% UCCC were included. Data were analyzed using Kaplan-Meier method and Cox proportional hazards regressions.

RESULTS

112 women were identified. Median age was 65.5 years (range 34-94). Most patients had mixed UCCC (61%), while 39% had pure UCCC. The majority of patients had stage IA UCCC (66%) versus stage IB (15%) or stage II (18%) disease. Adjuvant treatment included chemotherapy + radiation (26%), brachytherapy (27%), whole pelvic radiation (15%), chemotherapy alone (8%), and observation (24%). Thirty-eight (34%) women had recurrent disease. Median RFS was 4.32 years (95% CI 2.77-5.78). On multivariate analysis, age ≥70 (HR 2.48, 95% 1.28-4.81) and positive LVSI (HR 2.19, 95% CI 1.15-4.18) were associated with shorter RFS. Median OS was 9.8 years (95% CI 7.46-15.93). On multivariate analyses, age ≥70 (HR 3.57, 95% CI 1.64-7.74) and positive LVSI (HR 2.46, 95% CI 1.12-5.37) were associated with shorter OS. In this retrospective descriptive uncontrolled patient series, adjuvant treatment type did not impact RFS or OS.

CONCLUSIONS

OS approaches 10 years for early stage UCCC patients. Women ≥70 years have worse PFS and OS regardless of treatment modality, encouraging consideration of quality of life implications when electing for adjuvant therapy.

Outcomes of Adjuvant Therapy for Stage IA Serous Endometrial Cancer

PURPOSE

Serous adenocarcinoma is a rare, aggressive histologic subtype of endometrial cancer with a high rate of recurrence and a poor prognosis. The optimal adjuvant treatment for early-stage patients is unclear. Our objective was to evaluate the outcomes of stage IA serous endometrial cancers only treated at a single institution and determine whether our current approach of chemotherapy plus vaginal brachytherapy (VBT) is sufficient.

METHODS

A retrospective chart review of our institution's pathology database, including all cases of stage IA serous endometrial carcinoma from 2000-2014 was completed. Kaplan-Meier estimates were calculated for Overall and Recurrence-Free Survival (OS and RFS); hazard ratios were calculated using Cox proportional hazards modeling for independent prognostic factors.

RESULTS

There were 63 patients with stage IA serous endometrial cancer of whom 79.4% were surgically staged. Percent RFS was 76.5% at five years while OS was 84.7% for the whole cohort. One of the 23 patients receiving VBT and chemotherapy recurred at the vagina versus four of 32 patients who were observed. Two patients in the observation group recurred in the pelvis while there were no first pelvic recurrences in the VBT and chemotherapy group (non- significant). Overall survival was 95% in the brachytherapy and chemotherapy group versus 79.6% in the observation group (non-significant). Post-operative management included observation (n=33), combination VBT and chemotherapy (n=21), or chemotherapy with or without external beam radiation therapy (EBRT) (n=9).

DISCUSSION

We report one of the largest cohorts of serous endometrial cancer stage IA patients. Our results emphasize the inferior RFS and OS of stage IA serous versus endometrioid endometrial cancer patients. While some centers continue to use EBRT for these patients, our results demonstrate low pelvic recurrence rates with radiotherapy limited to VBT, as well as the high systemic risk regardless of treatment. We advocate for combination chemotherapy and brachytherapy given the poor outcomes in these patients.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Economic evaluation of hormonal therapies for postmenopausal women with estrogen receptor-positive early breast cancer in Canada

BACKGROUND

Aromatase inhibitor (ai) therapy has been subjected to numerous cost-effectiveness analyses. However, with most ais having reached the end of patent protection and with maturation of the clinical trials data, a re-analysis of ai cost-effectiveness and a consideration of ai use as part of sequential therapy is desirable. Our objective was to assess the cost-effectiveness of the 5-year upfront and sequential tamoxifen (tam) and ai hormonal strategies currently used for treating patients with estrogen receptor (er)-positive early breast cancer.

METHODS

The cost-effectiveness analysis used a Markov model that took a Canadian health system perspective with a lifetime time horizon. The base case involved 65-year-old women with er-positive early breast cancer. Probabilistic sensitivity analyses were used to incorporate parameter uncertainties. An expected-value-of-perfect-information test was performed to identify future research directions. Outcomes were quality-adjusted life-years (qalys) and costs.

RESULTS

The sequential tam-ai strategy was less costly than the other strategies, but less effective than upfront ai and more effective than upfront tam. Upfront ai was more effective and less costly than upfront tam because of less breast cancer recurrence and differences in adverse events. In an exploratory analysis that included a sequential ai-tam strategy, ai-tam dominated based on small numerical differences unlikely to be clinically significant; that strategy was thus not used in the base-case analysis.

CONCLUSIONS

In postmenopausal women with er-positive early breast cancer, strategies using ais appear to provide more benefit than strategies using tam alone. Among the ai-containing strategies, sequential strategies using tam and an ai appear to provide benefits similar to those provided by upfront ai, but at a lower cost.

High-dose-rate vaginal brachytherapy with chemotherapy for surgically staged localized uterine serous carcinoma

Purpose

To evaluate our institutional experience combining carboplatin-paclitaxel (C/T) chemotherapy with high-dose-rate (HDR) intra-vaginal brachytherapy (IVB) following comprehensive surgical staging in localized uterine serous carcinoma (USC).

Material and methods

Institutional chart review identified 56 patients with FIGO 2009 stage I-II USC treated between 2000-2010. Patients underwent total hysterectomy, bilateral salpingo-oopherectomy, and comprehensive surgical staging including pelvic and para-aortic lymph node dissection, omentectomy, and peritoneal cytology. Chemotherapy was 6 cycles of C/T, and the IVB dose was 14 Gy in 2 fractions, prescribed to 0.5 cm from the cylinder surface. Kaplan-Meier methods were used to estimate recurrence-free survival (RFS) and overall survival (OS).

Results

The median follow-up time was 49 months (range: 9-145). The 5-yr RFS and OS were 85% and 93%, respectively. In all cases of recurrence (n = 8), the first site of failure was extra-pelvic. There were no isolated vaginal recurrences, however, there was one vaginal apex recurrence recorded at 19 months in a patient with simultaneous lung metastases. Thus, the 2-year vaginal RFS was 98%.

Conclusions

Excellent vaginal/pelvic control rates were observed. Further study of HDR brachytherapy dose and fractionation in combination with chemotherapy is worthwhile.

The incidence of pelvic and para-aortic lymph node metastasis in uterine papillary serous and clear cell carcinoma according to the SEER registry

Objective

In this study we utilized the Surveillance, Epidemiology and End-Results (SEER) registry to identify risk factors for lymphatic spread and determine the incidence of pelvic and para-aortic lymph node metastases in patients with uterine papillary serous carcinoma (UPSC) and uterine clear cell carcinoma (UCCC) who underwent complete surgical staging and lymph node dissection.

Methods

Nine hundred seventy-two eligible patients diagnosed between 1998 to 2009 with International Federation of Gynecology and Obstetrics (FIGO) 1988 stage IA-IVA UPSC (n=685) or UCCC (n=287) were identified for analysis. Binomial logistic regression was used to determine risk factors for lymph node metastasis, with the incidence of pelvic and para-aortic lymph node metastases reported for each FIGO primary tumor stage. The Cox proportional hazards regression model was used to determine factors associated with overall survival.

Results

FIGO primary tumor stage was the only independent risk factor for lymph node metastasis (p<0.01). The incidence of pelvis-only and para-aortic lymph node involvement according to the FIGO primary tumor stage were as follows: IA (2.3%/3.8%), IB (7.5%/5.2%), IC (22.5%/16.9%), IIA (20.8%/13.2%), IIB (25.7%/14.9%), and III/IV (25.7%/24.3%). Prognostic factors for overall survival included lymph node involvement (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.09 to 1.85; p<0.01), patient age >60 years (HR, 1.70; 95% CI, 1.21 to 2.41; p<0.01), and advanced FIGO primary tumor stage (p<0.01). Tumor grade, histologic subtype, and patient race did not predict for either lymph node metastasis or overall survival.

Conclusion

There is a high incidence of both pelvic and para-aortic lymph node metastases for FIGO stages IC and above uterine papillary serous and clear cell carcinomas, suggesting a potential role for lymph node-directed therapy for these patients.

A prospective phase II study of chemoradiation followed by adjuvant chemotherapy for FIGO stage I-IIIA (1988) uterine papillary serous carcinoma of the endometrium

OBJECTIVE

To prospectively evaluate tumor control, survival, and toxic effects in patients with International Federation of Gynecology and Obstetrics (1988) stage I-IIIA papillary serous carcinoma of the endometrium treated with concurrent chemoradiation and adjuvant chemotherapy.

METHODS

Thirty-two patients were enrolled from October 2001 through July 2009. Patients underwent full surgical disease staging and postoperative concurrent weekly paclitaxel (50 mg/m2) and pelvic RT to 45 Gy plus a vaginal cuff boost followed by 4 cycles of adjuvant paclitaxel (135 mg/m2).

RESULTS

Thirty patients (94%) were evaluable (3 with stage IA disease, 11 IB, 3 IC, 1 IIB, and 12 IIIA). Eighteen patients (60%) received all 5 planned courses of concurrent chemotherapy, 10 (33%) received 4 courses, and 2 (7%) received 3 courses. All 30 patients received RT; 27 (90%) received the full dose, 2 received 43.2 Gy, and 1 received 39.6 Gy owing to toxic effects. Twenty-three patients (77%) completed all 4 cycles of adjuvant paclitaxel, 3 (10%) completed 3 cycles, 2 (7%) completed 2 cycles, and 2 received no adjuvant therapy. Overall survival (OS), progression-free survival (PFS), and local control rates for all patients were 93%, 87%, and 87%, respectively, at 2 years and 85%, 83%, and 87%, respectively, at 5years. Six patients developed (20%) grade 3/4 toxicities from the treatment. Four patients (13%) had grade 3 or more severe bowel complications and two patients developed symptomatic pelvic fractures.

CONCLUSIONS

Treatment with concurrent paclitaxel and pelvic RT followed by 4 courses of systemic paclitaxel produced favorable results in patients with surgically staged I-III UPSC.

Uterine papillary serous cancer: a review of the literature

OBJECTIVE

Uterine papillary serous carcinoma (UPSC) represents a distinct subtype of endometrial cancer. UPSC is less common than endometrioid carcinoma (ECC) but accounts for a disproportionate number of uterine cancer related deaths. This article critically reviews the literature pertinent to the pathology, pathogenesis, diagnosis, management, and outcome of patients with UPSC.

METHODS

MEDLINE was searched for all research articles published in English between January 1, 1967-January 1, 2012 which reported on patients diagnosed with UPSC. Given the rarity of this tumor, studies were not limited by design or number of reported patients.

RESULTS

UPSC represents a histologically aggressive subtype of endometrial cancer. It commonly presents with extra uterine disease involvement which can be identified by comprehensive surgical staging. Optimal cytoreduction and systemic platinum/taxane-based adjuvant therapy appear to confer a survival advantage.

CONCLUSIONS

UPSC is a biologically distinct entity, different from ECC. Future studies should explore the role of targeted therapies in the management of UPSC.

Prognostic determinants in patients with stage I uterine papillary serous carcinoma: a 15-year multi-institutional review

OBJECTIVE

The aim of this retrospective, multi-institutional study was to evaluate the importance of surgical staging for stage I uterine papillary serous carcinomas (UPSCs) to determine optimal management of this rare tumor.

METHODS

With institutional review board approval from both participating institutions, all patients with 2009 International Federation of Gynecology and Obstetrics stage I mixed serous and UPSC diagnosed between January 1, 1992, and December 31, 2007, were identified at the 2 institutions. Clinical factors were correlated using Spearman correlation coefficients, Kaplan-Meier survival estimates and a Cox proportional hazards model.

RESULTS

Of the 204 UPSC patients treated during this period, 84 were classified as stage I, with substages as follows: stage IA, n = 71; stage IB, n = 13. Thirty-seven patients (44%) had a history of a second cancer (22 breast tumors, 9 synchronous müllerian cancers). Surgical staging with at least hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and bilateral pelvic lymph node dissection was performed in 60 (71%) of 84 patients. The median survival for all patients was 10 years. Univariate analysis revealed surgical staging (P < 0.001), normal preoperative CA-125 (P < 0.001), and absence of additional cancers (P < 0.01) to be associated with improved survival. Age-adjusted multivariate analysis incorporating these factors revealed that advancing substage (hazard ratio, 4.59; P < 0.05), a second malignancy (hazard ratio, 2.75; P < 0.04), and surgical staging (hazard ratio, 0.18; P < 0.001) were independent factors associated with overall survival. In a subset analysis excluding patients with a second malignancy, substage (hazard ratio, 3.52; P < 0.05), and surgical staging (hazard ratio, 0.16; P < 0.001) were independent factors affecting overall survival.

CONCLUSIONS

Independent of adjuvant chemotherapy or radiation, stage of disease, comprehensive surgical staging, and the presence of a second malignancy were predictors of overall survival.

Evaluation of adjuvant therapy in women with uterine papillary serous cancer

BACKGROUND AND OBJECTIVE

Uterine papillary serous cancer (UPSC) represents only 10% of all uterine cancers and is associated with a significantly worse prognosis compared with other histological types of endometrial cancers. It closely resembles the behavior of ovarian carcinoma.

DESIGN AND SETTING

Retrospective study in a referral center covering period from February 1989 to January 2009.

PATIENTS AND METHODS

Eighteen patients who underwent definitive surgery followed by adjuvant therapy-platinum-based chemotherapy, radiotherapy, or both-were reviewed. Median age was 62 years (range, 52-76 years). All patients underwent total abdominal hysterectomy and salpingo-oophorectomy. Positive lymph nodes were found in 4 of 7 patients who underwent lymph node sampling/dissection. Seven patients had stage I/II disease, whereas 11 patients had stage III disease. Six patients received chemotherapy, 5 patients received radiation therapy, while 7 patients received both chemotherapy and radiation therapy.

RESULT

Median follow-up was 27 months. The median survival and relapse-free survival were 33 and 23 months, respectively. Eight patients were alive and free of disease, of whom 5 patients were stage I/II and 4 patients were stage III. Distant metastasis was the most common site of relapse. Early stage (I/II) was associated with significant improvement in relapse-free survival (RFS) and overall survival (OS) (P=.004 and P=.05, respectively). The combined-modality treatment including chemotherapy-radiotherapy showed statistically significant improvement in RFS (P=.012), while the improvement in OS did not reach statistical significance (P=.12).

CONCLUSION

This study indicates that postoperative combined treatment with chemotherapy and radiation therapy plays a role in the management of UPSC by improving RFS. Distant metastasis remains the major site of relapse. Future studies using combined-modality therapy are needed to improve the outcome in patients with UPSC.

The importance of chemotherapy and radiation in uterine papillary serous carcinoma

PURPOSE

To identify prognostic and predictive factors of overall survival (OS), relapse-free survival (RFS) and toxicity for patients with uterine papillary serous carcinoma (UPSC).

MATERIALS AND METHODS

Patient, tumor, treatment and relapse characteristics of 135 women with Stages I-IVA UPSC treated between 1980 and 2006 at Dana-Farber/Brigham and Women's Cancer Center (DF/BWCC) were analyzed using Cox regression models to determine prognostic and predictive factors for OS, RFS and toxicity.

RESULTS

Mean follow-up was 5.5 years (range, 0.01-25.2). Median 5-year OS was 52%, and RFS was 42% for all patients. On Cox regression analysis, increasing age, stage, and myometrial invasion were prognostic factors associated with shorter OS and RFS. A paclitaxel-platinum chemotherapy regimen was significantly associated with longer OS (hazard ratio [HR]=0.34, 95% confidence interval [CI] 0.15-0.74, p=0.007) and RFS (HR=0.45, 95% CI 0.22-0.92, p=0.03). RFS was improved for patients treated with RT (HR=0.44, 95% CI 0.25-0.77, p=0.004). The 5-year grade 3+ toxicity rate was 3.5% for those who received RT and was 2.9% for those who did not (p=NS).

CONCLUSION

Uterine papillary serous cancer can be an aggressive tumor type with a poor prognosis. RFS was improved by radiation and chemotherapy with few grade 3 or higher complications. Using radiation and paclitaxel-platinum chemotherapy should be attempted whenever feasible for patients with UPSC who do not have distant metastases at diagnosis.

Clinical tolerance in large field radiotherapy--the knowledge gained over the last ten years

Malignant disorders are still far from being successfully managed in spite of the apparent progress achieved by surgical treatment, high energy radiotherapy (RT) and chemotherapy (CHT). They keep being the second most frequent cause of lethal outcomes both in Bulgaria and in most countries of the world. One of the promising approaches to increasing the efficaciousness of treatment is development and use of methods that are in full accord with the modern requirements of a complex therapy. Over the last fifty years, large field radiation techniques, applied as systemic therapy in oncology, have been investigated and established. These techniques show the transition in oncology to using actively various variants of large field radiotherapy (LFR), the "heavy artillery" of oncoradiologic practice, as an alternative or adjunct therapy to chemotherapy (CHT). In the present paper we review the current knowledge in the field and present the clinical experience accumulated over the last ten years with respect to clinical tolerance in the major large-field radiotherapy techniques--total body irradiation, half body irradiation, whole abdominal irradiation, total and partial lymphoid irradiation. Described in detail are the contemporary knowledge about clinical and hematologic tolerance in total body irradiation as part of the myelo- and nonmyeloablative conditioning regimens as well as in half body irradiation as a systemic therapy in oncology. We also present the amassed experience in clinical tolerance in partial body irradiation in the form of whole abdominal and total or partial lymphoid irradiation. Another point worth noting based again on the experience gained over the last ten years is that for LFR we need to develop a radiotherapy technique that is designed carefully to achieve an optimal therapeutic effect that should include the disease control, good clinical tolerance and reduction of post-radiotherapy sequelae.

Clinical applications of volumetric modulated arc therapy

PURPOSE

To present treatment planning case studies for several treatment sites for which volumetric modulated arc therapy (VMAT) could have a positive impact; and to share an initial clinical experience with VMAT for stereotactic body radiotherapy (SBRT).

METHODS AND MATERIALS

Four case studies are presented to show the potential benefit of VMAT compared with conformal and intensity-modulated radiotherapy (IMRT) techniques in pediatric cancer, bone marrow-sparing whole-abdominopelvic irradiation (WAPI), and SBRT of the lung and spine. Details of clinical implementation of VMAT for SBRT are presented. The VMAT plans are compared with conventional techniques in terms of dosimetric quality and delivery efficiency.

RESULTS

Volumetric modulated arc therapy reduced the treatment time of spine SBRT by 37% and improved isodose conformality. Conformal and VMAT techniques for lung SBRT had similar dosimetric quality, but VMAT had improved target coverage and took 59% less time to deliver, although monitor units were increased by 5%. In a complex pediatric pelvic example, VMAT reduced treatment time by 78% and monitor units by 25% compared with IMRT. A double-isocenter VMAT technique for WAPI can spare bone marrow while maintaining good delivery efficiency.

CONCLUSIONS

Volumetric modulated arc therapy is a new technology that may benefit different patient populations, including pediatric cancer patients and those undergoing concurrent chemotherapy and WAPI. Volumetric modulated arc therapy has been used and shown to be beneficial for significantly improving delivery efficiency of lung and spine SBRT.

Adjuvant Whole Pelvic Radiotherapy in 43 Patients with Uterine Serous Cancer: Outcome and Patterns of Failure

Aims and background

Uterine serous cancer is associated with a poor outcome and poses a therapeutic challenge. We retrospectively evaluated the experience of the Radiotherapy Department of the University of Florence.

Methods

Forty-three patients with stage I-III uterine serous cancer underwent surgery with (18 patients, group 1) or without complete surgical staging (25 patients, group 2) followed by adjuvant whole pelvic radiotherapy alone or combined with vaginal brachytherapy (in 35 and 8 cases, respectively). The median dose delivered with whole pelvic radiotherapy was 50Gy (range, 45–56) and for brachytherapy was 20 Gy (range, 20–30).

Results

Actuarial overall survival and disease-free survival rates at 5 years were 62.5% and 61%, respectively. Local failure was observed in 17 patients (39.5%) and distant metastasis in 10 (23.2%). Nine patients had both local failure and distant metastasis, which had developed concurrently in 7 cases. Isolated abdominal failure occurred in 4 cases (9.3%). Local relapse was noted in 22.2% of patients in group 1 compared to 52% in group 2. A trend towards a better 5-year overall survival (67.2% vs 58%), disease-free survival (63% vs 59%) and local control (70% vs 59%) was observed in group 1 than group 2, although the difference between the two groups failed to reach statistical significance.

Conclusions

Given the patterns of failure of patients with uterine serous cancer, adjuvant whole pelvic radiotherapy may be a reasonable approach, although novel integrated strategies are needed because the results achieved remain disappointing. Adjuvant whole pelvic radiotherapy might improve overall survival, disease-free survival and local control in complete surgically staged patients, but further investigations are required.

Endometrial cancer state of the science meeting

There is a pressing need to improve our understanding of endometrial cancer (EC) and uterine carcinosarcoma and to develop new treatment strategies to improve outcomes. In recognition of this, a State of the Science meeting on EC was held last November 28 and 29, 2006, in Manchester, United Kingdom. The meeting was cosponsored by the National Cancer Research Institute (UK), the National Cancer Institute (US), and the Gynecological Cancer Intergroup. The objectives of the meeting were as follows: 1. To review current knowledge and understanding of EC and its treatments. 2. To identify key issues for translational research and clinical trials. 3. To identify the most important trials for women with endometrial carcinoma and uterine carcinosarcoma, both those already underway or to be done, for which the Gynecological Cancer Intergroup might facilitate international cooperation.

Concurrent carboplatin/paclitaxel and intravaginal radiation in surgical stage I-II serous endometrial cancer

OBJECTIVE

To report a single institution experience in surgical stage I-II serous endometrial cancer using combined carboplatin/paclitaxel and intravaginal radiation (IVRT).

METHODS

Between 10/00 and 12/06, 25 stage I-II patients with serous endometrial cancer were treated at our institution with surgery, postoperative IVRT, and concurrent chemotherapy (CT).

RESULTS

The mean age was 67 years old (range, 53-80 years). Surgery consisted of hysterectomy (TAH/BSO, 64%, LAVH/BSO, 36%), peritoneal washing, omental biopsy, and pelvic lymph-node dissection (median 14 nodes). Para-aortic node sampling was done in 88% (median, 6). IVRT median dose was 21 Gy (range, 18-21 Gy, in 3 fractions) and concurrent CT consisted of carboplatin to AUC=5 and taxol to 175 mg/m(2) given every 3 weeks for 6 cycles. CT was well tolerated with 22/25 (88%) receiving 6 cycles. Three patients received <or=5 cycles; 2 owing to physician preference (3 and 4 cycles) and 1 owing to toxicity (5 cycles). Only 1 patient (4%) had grade 3 toxicity (abscess). Grade 2 neurotoxicity was seen in 5 patients (20%). All patients finished their IVRT as scheduled, and there was no grade 3 toxicity. With a median follow-up of 30 months, the 5-year progression-free and overall survival rate was 88%. None of the patients developed vaginal recurrence.

CONCLUSIONS

Based on this study, surgical staging followed by IVRT and carboplatin/paclitaxel is well tolerated and effective in stage I-II serous endometrial cancer. Confirmation of these results on a larger number of patients with longer follow-up is still needed.

Is adjuvant therapy necessary for Stage IA and IB uterine papillary serous carcinoma and clear cell carcinoma after surgical staging?

Adjuvant therapy of early-stage uterine papillary serous carcinoma (UPSC) and clear cell carcinoma (CCC) is controversial. We conducted a prospective cohort study to evaluate outcomes of patients with early-stage UPSC or CCC who were followed without adjuvant therapy after complete surgical staging. From 2000 to 2006, we evaluated all consecutive patients with stage IA/IB UPSC or CCC who had surgical staging by a gynecological oncologist at the London Health Sciences Centre, Canada. Follow-up consisted of history and physical examination every 3 months for 2 years, then every 6 months for the next 3 years. Primary outcome measure was 2-year disease-free survival. There were 22 evaluable patients. Mean patient age was 63.4 years. Median number of pelvic and para-aortic lymph nodes resected was 15 (range 2-39) and 4 (range 0-12), respectively. Thirteen had UPSC, seven had CCC, and two had both UPSC and CCC. Nine had stage IA and 13 had stage IB disease. Median follow-up was 25 months (range 6-72). Only one patient has recurred (stage IB UPSC, isolated vault recurrence 10 months after surgery), but she is well 9 months after receiving pelvic radiotherapy and vault brachytherapy. Two-year disease-free survival was 95%. These results suggest that adjuvant therapy may not be necessary for stage IA and IB UPSC and CCC after surgical staging. Further prospective evaluation of different adjuvant therapy practices is required for early-stage UPSC and CCC, which may be useful in the design of future clinical trials.

Clinical aspects of uterine papillary serous carcinoma

PURPOSE OF REVIEW

We review the demographic and clinicopathologic characteristics, and prognosis of women diagnosed with uterine papillary serous carcinoma, with a focus on clinical management.

RECENT FINDINGS

Pathologic evaluation of postmenopausal bleeding is preferred for patients who fit the profile of a high-risk endometrial cancer such as uterine papillary serous carcinoma. Women diagnosed with endometrial cancer who fit this profile and all women with uterine papillary serous carcinoma should undergo comprehensive surgical staging and aggressive cytoreduction of extrauterine disease. Adjuvant therapy remains controversial. Several recent investigations reported on the potential benefit of adjuvant chemotherapy, with many recommending additional loco-regional radiation.

SUMMARY

Despite the lack of randomized trials on uterine papillary serous carcinoma, several recent reports have provided insight into the diagnosis, surgical management, and adjuvant treatment of this high-risk endometrial cancer.

Stage III endometrial cancer: preoperative predictability, prognostic factors, and treatment outcome

OBJECTIVE

The survival rate for the most common gynecologic cancer, endometrial cancer, has fallen significantly in the last 25 years. Stage III (International Federation of Gynecology and Obstetrics) disease accounts for most of the deaths. We evaluated prognostic factors, treatment-related survival, and routinely used assessments for identifying stage III disease before the operation.

STUDY DESIGN

The data for patients with endometrial cancer stage III (n = 101) who had been treated at the McGill University Health Center between 1989 and 2003 were analyzed.

RESULTS

Stage IIIA, IIIB, and IIIC tumors accounted for 63%, 4%, and 33% of the data, respectively. The cause-specific survival at 2, 3, and 5 years was 82%, 77%, and 67%, respectively. In multivariate analysis with an adjustment for the standard prognostic variables, the final tumor grade, adnexal involvement, and lymph node dissection were significant predictors of cause-specific survival (P = .001, .028, and .017, respectively). Of the preoperative investigations, an elevated CA-125 level was a significant predictor of cause-specific survival in multivariate analysis (P = .029).

CONCLUSION

An elevated CA-125 level, adnexal involvement, the final tumor grade, and lymph node dissection were independent predictors for cause-specific survival.

Whole-abdomen radiotherapy for non-Hodgkin's lymphoma using twice-daily fractionation

PURPOSE

To report the tolerability and efficacy of twice-daily whole-abdomen irradiation (WAI) for non-Hodgkin's lymphoma (NHL).

METHODS AND MATERIALS

Of 123 patients treated for NHL with WAI, 37% received previous chemotherapy, 28% received WAI as part of comprehensive lymphatic irradiation (CLI), and 32% received WAI for palliation. The median dose to the whole abdomen was 25.0 Gy, followed by a median tumor boost of 9.8 Gy in 58 patients. Fractionation was 1.0 Gy once daily (54%) or 0.8 Gy twice daily (46%). Blood counts were measured weekly.

RESULTS

At a median follow-up of 4.3 years, local control was 72% and overall survival was 55% at 5 years. Median time of WAI was 42 days for once-daily treatment and 32 days for twice-daily treatment. Patients receiving twice-daily WAI did not have a significantly higher rate of acute side effects (e.g., nausea, diarrhea, platelet or red blood cell toxicity). Overall, acute thrombocytopenia was the most frequent side effect of treatment; 24 of 96 patients (25%) with available hematologic data had Grade 3+ toxicity. There was no acute Grade 3 gastrointestinal toxicity and no late small bowel obstruction. Multiple regression indicated that patients with four or less involved sites and disease size < or =6 cm had improved local control and overall survival.

CONCLUSIONS

Twice-daily WAI using 0.8 Gy/fraction does not appear to have any greater toxicity compared with once-daily treatment using 1 Gy/fraction. Small doses per fraction (0.8-1 Gy/fx) are effective, tolerated well in the acute setting, and associated with a low rate of late toxicity.

Paclitaxel and carboplatin in the adjuvant treatment of patients with high-risk stage III and IV endometrial cancer: A retrospective study

PURPOSE

To determine overall survival and progression-free survival among patients with high-risk, stage III and IV endometrial cancer who receive paclitaxel and carboplatin (TC) after complete tumor resection.

PATIENTS AND METHODS

Patients with stage III/IV endometrial cancer with less than 2 cm of disease after surgical resection who received TC in the adjuvant setting were retrospectively identified and are the subject of this analysis. Data were extracted from electronic medical records. Disease recurrence was documented by radiologic progression or pathologic tissue review. We obtained Institutional Review Board approval before initiating this study.

RESULTS

Forty-eight patients were eligible for analysis--24 (50%) with stage IV disease, 29 (60%) with serous or clear cell tumor histology and 43 (90%) with FIGO grade 3 tumors. All patients underwent surgical resection; 10 (21%) of the 48 patients received adjuvant radiation therapy in addition to chemotherapy. Forty-three patients (90%) received 6 cycles of paclitaxel (175 mg/m(2)) and carboplatin (area under the curve of 5-6) every 3 or 4 weeks, and 44 (92%) completed all planned cycles of treatment. With a median follow-up of 20 months (range, 6-92), 29 patients (60%) recurred, with a 3-year overall survival rate of 56%. The median time to progression for all patients was 13 months (95% CI 10, 18) with a median OS of 47 months (95% CI, 30--upper limit not achieved).

CONCLUSION

TC is a well tolerated, active regimen in the treatment of resected, high-risk stage III and IV endometrial cancer that warrants further investigation.

Paclitaxel and concomitant radiotherapy in high-risk endometrial cancer patients: preliminary findings

Background

There is still much debate about the best adjuvant therapy after surgery for endometrial cancer (EC) and there are no current guidelines. Radiotherapy (RT) alone does not seem to improve overall survival. We investigated whether concomitant Paclitaxel (P) and RT gave better clinical results.

Methods

Twenty-three patients with high-risk EC (stage IIB, IIIA, IIIC or IC G3 without lymphadenectomy or with aneuploid tumor) underwent primary surgery and were then referred for adjuvant therapy. P was given at a dose of 60 mg/m2 once weekly for five weeks during RT, which consisted of a total radiation dose of 50.4 Gy. Three further weekly cycles of P at a dose of 80 mg/m2 were given at the end of RT. Overall survival and disease-free survival were calculated from the time of surgery. Patterns of failure were recorded by the sites of failure.

Results

A total of 157 cycles of P were administered both during radiotherapy and consolidation chemotherapy.

Relapses occurred in five patients (21.7%). Median time to recurrence was 18.6 months (range 3–28). Survival rate for all the patients was 78.2%. Overall survival for the patients who completed chemo-radiation was of 81%. In this group median time to recurrence was 19.2 months (range 3–28). All recurrences were outside the radiation field. Mortality rate was 14.2%.

Conclusion

This small series demonstrates pelvic radiotherapy in combination with weakly P followed by three consolidation chemotherapy cycles as an effective combined approach in high risk endometrial carcinoma patients.

The effect of adjuvant chemotherapy versus whole abdominopelvic radiation on the survival of patients with advanced stage uterine papillary serous carcinoma

OBJECTIVES

To compare the outcomes of stage III and IV uterine papillary serous carcinoma (UPSC) patients treated with platinum-based chemotherapy (PC) versus whole abdominopelvic irradiation (WAPI) after optimal cytoreductive surgery.

METHODS

Surgically staged patients with advanced stage UPSC diagnosed between 1981 and 2002 were identified from tumor registry databases at four hospitals. Survival analyses and predictors of outcome were analyzed using Kaplan-Meier methods.

RESULTS

Of the 40 patients with advanced UPSC (median age: 64.5), 84% were Caucasian, 8% were African American, and 8% were Asian. The majority of patients (85%) presented with vaginal bleeding. Twenty-seven had stage III and 13 had stage IV disease. All patients were optimally debulked; 21 patients received adjuvant PC while 19 underwent WAPI. The median follow-up was 27 months (range: 5-209). The 3-year overall survival (OS) and progression-free survival (PFS) for the patients with stage III disease were 49% and 37% compared to 37% and 31% in those with stage IV disease (P = 0.23 for OS; P = 0.41 for PFS). Women who received PC had a 3-year OS and PFS of 43% and 31% compared to 45% and 41% in those receiving WAPI, respectively (P = 0.40 for OS; P = 0.84 for PFS).

CONCLUSION

Platinum-based chemotherapy or whole abdominopelvic irradiation resulted in similar survival in this series of women with optimally cytoreduced UPSC. Given the overall poor prognosis of these patients, new treatment modalities are warranted.

Treatment of uterine papillary serous carcinoma with platinum-based chemotherapy and paclitaxel

Uterine papillary serous carcinoma (UPSC) is more aggressive than endometrioid endometrial cancer, as it often presents with advanced disease and follows a pattern of spread that resembles the serous carcinoma of the ovary. There exists little data on evaluating the combination of carboplatin and paclitaxel in UPSC. Institutional Review Board permission was obtained for a retrospective review. Tumor registry search was used to identify all patients with UPSC from 1990 to 2003. Charts were retrospectively evaluated from patients who had received at least three cycles of carboplatin and paclitaxel as first-line chemotherapy. Only patients with histologically confirmed UPSC who were treated first line with carboplatin/paclitaxel chemotherapy were included. Nineteen patients with UPSC were identified, who were treated with carboplatin and paclitaxel in the first-line adjuvant setting after initial surgical cytoreduction. All patients received at least three cycles, with 12 of the 19 patients receiving six cycles. Five patients were treated with consolidation radiotherapy following first-line chemotherapy. Mean age was 69 years (range 55-88). The majority of patients had stage III disease (n= 11). Mean follow-up for the group was 29.5 months (7-76 months). A median progression-free interval of 12 months was seen across the entire cohort. Fourteen patients achieved a complete response following chemotherapy. The results of Gynecologic Oncology Group protocol 122 suggest that patients with advanced endometrial cancer have an improved progression-free survival when treated primarily with chemotherapy rather than radiation therapy. The results of our study show a high response rate to paclitaxel/carboplatin outpatient chemotherapy in a group of patients historically believed to have chemoresistant disease. Further prospective study of this regimen is planned.

Impact of adjuvant therapy on survival of patients with early-stage uterine papillary serous carcinoma

PURPOSE

To determine the efficacy of adjuvant therapy in patients with early-stage uterine papillary serous carcinoma.

METHODS AND MATERIALS

Data were collected on all surgically staged Stage I-II uterine papillary serous carcinoma patients. Statistical analyses were performed using the Kaplan-Meier and Cox proportional hazards regression methods.

RESULTS

Of 68 patients, 50 had Stage I and 18 had Stage II disease; 35 underwent adjuvant treatment, including radiotherapy in 26, chemotherapy in 7, and combined RT and chemotherapy in 2. The remaining 33 were treated expectantly. The median follow-up was 56 months (range 1-173). The 5-year overall survival rate was 69%. Of 19 patients with disease limited to the endometrium, 10 received no additional therapy, 3 of whom developed recurrence. However, all 9 women who underwent adjuvant treatment remained free of disease. Patients receiving adjuvant therapy with chemotherapy or radiotherapy had a prolonged 5-year overall and disease-free survival compared with those who were treated expectantly (85% vs. 54%, p = 0.002 for overall survival and 85% vs. 49%, p = 0.01 for disease-free survival). In multivariate analysis, adjuvant therapy (p = 0.035) and the absence of lymphovascular space invasion (p = 0.001) remained as independent prognostic factors for improved survival.

CONCLUSION

Adjuvant therapy with chemotherapy or radiotherapy improves the survival of women with early-stage uterine papillary serous carcinoma.

Association of p53 mutations and a codon 72 single nucleotide polymorphism with lower overall survival and responsiveness to adjuvant radiotherapy in endometrioid endometrial carcinomas

p53 Genetic alterations are associated with advanced stage and aggressive tumors in a variety of human malignancies. The aim of this study was to examine p53 for genetic alterations and to evaluate the association of these alterations with clinical outcome and response to adjuvant radiotherapy in endometrioid endometrial carcinomas. p53 mutations in exons 2-11 were assessed in 59 endometrioid carcinomas by polymerase chain reaction-single-strand conformational polymorphism and sequence analysis. Twelve mutations (20.3%) and nine polymorphisms were identified. Seven of the nine polymorphisms were codon 72 single nucleotide polymorphisms (SNP) with an Arg/Pro allelotype. Women harboring either a mutation or an Arg/Pro allelotype at codon 72 had a lower overall survival rate than women whose tumors lacked alterations in the p53 gene (P= 0.0029). Women were stratified based on p53 genetic alterations (p53 mutation or p53 codon 72 SNP) and whether or not they received adjuvant radiation therapy. Women with p53 genetic alterations who did not receive adjuvant radiotherapy had the lowest survival rate (P= 0.0005). Treated women with p53 genetic alterations and untreated women with no p53 alteration had similar rates of survival. Among women with p53 alterations, adjuvant radiotherapy substantially increased survival (P= 0.035). In multivariate analyses, the group of women with p53 genetic alterations who did not receive adjuvant radiation therapy had a 5.9-fold increased risk of death (95% confidence interval: 1.5-22.7) compared to women whose tumors lacked p53 alterations and did not receive adjuvant radiation therapy.

Adjuvant Radiotherapy in Endometrial Carcinoma

Endometrial cancer is a common female malignancy, affecting approximately 40,000 women per year. Despite the publication of several prospective randomized trials, there continues to be controversy regarding the use of adjuvant radiation therapy in endometrial cancer management. It is clear that most women with early-stage, low-risk disease will do well without adjuvant therapy. Intermediate-risk patients are at risk for local-regional relapse, and radiotherapy has been shown to effectively reduce this risk without significantly impacting overall survival. The absence of a clear impact on survival has resulted in a lack of consensus regarding the use of radiotherapy in intermediate-risk patients. At the same time, the patterns of failure in intermediate-risk patients have resulted in differing recommendations regarding appropriate radiotherapy targets. High-risk patients are at risk for both local and distant failure, and chemotherapy has been shown to improve outcome in these patients. High-risk patients are also at risk for local failure, and targeted radiotherapy may be appropriate. In this article, we discuss the controversies surrounding the use of adjuvant radiotherapy in endometrial cancer using an evidence-based approach.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS AND MATERIAL

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

RESULTS

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

CONCLUSIONS

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

Limitations of adjuvant radiotherapy for uterine sarcomas spread beyond the uterus

OBJECTIVE

The present review analyzes patients with advanced uterine sarcomas with the goal of identifying patients likely to benefit from larger volumes and higher dosages of radiotherapy.

METHODS

A retrospective review was performed of medical records of all patients receiving adjuvant radiotherapy for advanced uterine sarcomas from 1978 to 1997 at the University of Minnesota.

RESULTS

Nineteen women with advanced uterine sarcomas received adjuvant radiotherapy. Seven also received adjuvant chemotherapy. Three patients had FIGO stage IIIA, 1 stage IIIB, 5 stage IIIC, and 12 stage IVB. Patients with mixed mullerian tumors had overall and disease-free survivals of 31% at 1 year and 23% at 5 years. For leiomyosarcomas, overall survival was 67% at 1 year and 33% at 5 years, but relapse-free survival was 33% at 1 and 5 years. First sites of failure were three pelvic and abdominal, one abdominal only, one abdominal and distant, two pelvic and distant, one pelvic, abdominal, and distant, five distant only, and one unknown. No Grade 3 or 4 toxicity occurred.

CONCLUSION

Ongoing technical advancements in radiotherapy offer more precise radiation delivery, particularly to the peritoneal cavity. Although abdominal failures are common in women with mixed mullerian tumors, translation of higher radiation dosage to cure is unproven, and the majority of failures have a distant component. Until effective systemic therapy is developed, the prognosis of uterine sarcomas with any spread beyond the uterus will remain poor.