Preoperative radiotherapy and surgery for endometrial carcinoma: prognostic significance of the sterilization of the specimen

Neoadjuvant radiotherapy and brachytherapy in endometrial cancer with gross cervical involvement: a CHIRENDO research group study

BACKGROUND

Historically, radical hysterectomy followed by adjuvant radiotherapy has been offered to patients with endometrial cancer who have gross cervical involvement; however, this approach is known to carry considerable morbidity. Neoadjuvant radiotherapy followed by extra-fascial hysterectomy has been proposed as an alternative treatment but has been poorly studied to date.

OBJECTIVE

To evaluate the locoregional control rate associated with neoadjuvant radiotherapy followed by extra-fascial hysterectomy.

METHODS

A retrospective cohort study of 30 patients with endometrial cancer with gross cervical involvement treated between May 2006 and January 2016 was performed. Eligible patients were those aged >18 years with non-metastatic endometrial adenocarcinoma and gross cervical disease treated with curative intent at the Centre hospitalier de l'Université de Montréal. Treatment protocol consisted of pelvic neoadjuvant radiotherapy and high-dose rate brachytherapy followed by extra-fascial hysterectomy. Kaplan-Meier curves were used for survival analysis.

RESULTS

The median age was 60 (range 37-82) and median body mass index was 32 kg/m² (range 16-55). Twenty-four (80%) patients were diagnosed with a positive cervical/endocervical biopsy. Clinical staging confirmed 36.7% (n=11) as stage II, 20% (n=6) stage IIIB, 30% (n=9) stage IIIC1, and 13.3% (n=4) stage IIIC2. Seventy-seven per cent (n=23) of patients had an endometrioid histology. Locally advanced disease was identified by imaging alone in six patients. Rates of parametrial, adnexal, vaginal, and nodal invasion were 10% (n=3), 6.7% (n=2), 13.3% (n=4), and 43.3% (n=13) at diagnosis, respectively. All patients completed pelvic radiotherapy (13.3% extended field) and 90% received brachytherapy. Twenty per cent (n=6) of surgeries were performed using minimal invasive technique. On surgical specimen, 63.3% (n=19) had complete cervical response, 90% (n=27) had negative margins, and 10% (n=3) had residual nodal involvement. Median follow-up time was 62 months (range 1-120). Six recurrences were identified; all except one involved distant failure, and two with locoregional failure. Five-year locoregional control rate, disease-free, overall, and disease-specific survival were 90.5%, 78.5%, 92.6%, and 96.2%, respectively. Two patients (6.7%) had grade 3+ acute radiation-related complications (all grade 3). Grade 3+ post-operative morbidity was noted in 2 (6.7%) patients.

CONCLUSIONS

Neoadjuvant radiotherapy followed by extra-fascial hysterectomy offers good locoregional control with low treatment-related morbidity in patients with endometrial cancer with overt cervical involvement.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Preoperative brachytherapy for clinical stage I and II endometrial carcinoma: results from a series of 780 patients with a 10-year follow-up]

AIMS OF THE STUDY

Retrospective analysis of patients treated by preoperative brachytherapy for endometrial carcinoma.

PATIENTS AND METHODS

From 1973 to 1994, 780 consecutive patients with a clinical stage I-II endometrial carcinoma were treated with brachytherapy followed by surgery and pelvic irradiation if necessary. Tumour was staged according to 1979 UICC classification. There were 462 T1a, 257 T1b, and 61 T2, 62% were well differentiated. Brachytherapy consisted in one low dose rate endocavitary application. Sixty grays were delivered on the reference isodose. Surgery consisted in a TAH/BSO (Piver II) and was performed 6 weeks later. Nodal pelvic irradiation was indicated in case of unfavourable pathological prognostic factors.

RESULTS

Median follow up was 122 months. Five year survival rates were: 84% for overall survival, 86% for survival without recurrence, 92.8% for local control, and 3.8% for late complications. Pronostic factors were age, stage, differentiation, grade and postoperative extension. Multivariate analysis showed only age, differentiation and postoperative extension to be independent prognostic factors.

CONCLUSION

If for stage 1, initial surgery has now replaced preoperative brachytherapy in most cases because it allows to identify initial prognostic factors, preoperative brachytherapy remains the most interesting option for stage 2 endometrial carcinomas.

[Basic anatomopathological features of tumors and their extensions. Prognostic and therapeutic implications]

Surgical pathology analysis of biopsies or surgical specimens directly determines the diagnosis of the disease. It gives also the different characteristics that are useful for the establishment of the prognosis and for the treatment of each tumor. We report here a synthesis of the different characteristics of neoplastic lesions, necessary or useful for the establishment of the care program of the patients. These macroscopic and microscopic analyses should result in the most precise possible diagnosis and should take into account a list of other factors that allow the development of an optimal strategy for therapy, and the establishment of prognosis of the tumor. These characteristics include properties of the tumor like the size, shape, exact location, and the grade of the lesion, etc. They also concern the relationship of the tumor with certain structures like the basal membranes, the extracapsular extensions, the stroma reaction, the lymphatic vessels, the nerves, etc. The description of local and loco-regional spreading, as well as the analysis of the surgical margins gives also essential information. Sometimes, the description of modifications induced by neoadjuvant therapy, as chemo or radiotherapy, allows the evaluation of the efficiency of these treatments.

[Gross tumor volume and clinical target volume in radiotherapy: generalities. Definitions and generalities in anatomic pathology]

In the field of oncology, surgical pathology analysis of biopsies or surgical specimens directly determines the care program of each patient. Without going into too much detail, we report here the description of different characteristics of neoplastic lesions, necessary or useful for the establishment of the care program of the patients. These macroscopic and microscopic analyses should result in the most precise possible diagnosis and should take into account a list of other factors which allow the development of an optimal strategy for therapy, and the establishment of prognosis of the tumor. These characteristics include properties of the tumor such as the size, shape, exact location, and the grade of the lesion, etc. They also concern the relationship of the tumor to certain structures like the basal membranes, the stroma reaction, the lymphatic vessels, the nerves, and so forth. The description of local and locoregional spreading, as well as the analysis of the surgical margins gives essential information as well. Finally, in certain cases, the description of modifications induced by neoadjuvant therapy allows the evaluation of the treatment's efficacy.

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

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSION

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

Postoperative irradiation in endometrial cancer: still a matter of controversy

Although endometrial cancer is the most common female malignancy, evidence-based uniform guidelines for postoperative therapy have not been established. The most logical management is adjuvant irradiation tailored to the extent of surgery, the tumour grade, depth of myometrial invasion, degree of lymph node involvement and age of the patient. Currently, the only widely accepted treatment recommendations are no further therapy in low-risk patients who underwent extensive surgical staging, and external beam radiotherapy (EBRT) in high-risk patients. Most authors recommend postoperative application of only one radiotherapy modality: either brachytherapy (BRT) or EBRT, as their routine combination does not clearly improve the outcome but does increase the risk of late complications. A combination of BRT and EBRT should however be considered in patients with stage II disease, for infiltration of the lower uterine segment, vaginal involvement, positive or close surgical margins, capillary space involvement or unfavourable histology. Two recent randomized studies including mostly intermediate-risk patients managed with either extensive surgical staging or total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH&BSO) with or without postoperative EBRT, showed better local control but no survival benefit from adjuvant irradiation. Two ongoing Gynecologic Oncology Group (GOG) studies compare adjuvant chemotherapy with pelvic or abdominal irradiation in patients with high risk of local relapse. The role of adjuvant radiotherapy (EBRT with or without BRT) in high-risk patients as well as the value of lymphadenectomy in patients fit for such surgery is being addressed in a trial co-ordinated by the Medical Research Council. Future studies are warranted to define whether any irradiation should be employed in intermediate-risk patients and which radiotherapy modality should be used in high-risk node-negative patients with stage I tumours (stage Ib grade 3 and all stage Ic). Other issues which should be addressed in future studies include the extent of surgery, the role of systemic therapies, the relevance of novel biologic prognostic factors, salvage therapies after recurrence, cost-benefit analysis and quality of life.

The role of preoperative brachytherapy as an adjunct to surgery and postoperative radiotherapy in the treatment of stage I endometrial carcinoma

PURPOSE

Between 1978 and 1993, 817 cases of endometrial carcinoma were treated with simple hysterectomy with bilateral salpingo-oophorectomy. Five hundred and twenty-six cases had preoperative brachytherapy (Preo), and 291 cases underwent surgery without preoperative radiotherapy (Nopre). The aim of the study was to compare disease-free survival of the two groups.

METHODS AND MATERIALS

Survival comparison of the two groups was controlled for postoperative treatment type, according to stage, histological type, degree of differentiation, depth of myometrial invasion and age. The life-table method was used for survival analysis. Cumulative disease-free survival probabilities were calculated as a function of the proportion of normal remaining life elapsed from the time of diagnosis.

RESULTS

Five-year disease-free survival of patients with and without preoperative brachytherapy in stage IA, IB and IC was 93 and 93.6%, 93 and 94%, and 80 and 65%, respectively. In well differentiated tumors and poorly differentiated tumors, there was no difference in disease-free survival between patients with and without preoperative brachytherapy. Patients with moderately differentiated tumor treated with preoperative brachytherapy had significantly better disease-free survival than those without preoperative radiotherapy, however, this was confounded by uneven distribution of invasion depth.

CONCLUSION

Preoperative brachytherapy plays a limited role in the treatment of early stage endometrial carcinoma.