Surgery followed by radiotherapy in endometrial cancer: analysis of survival and patterns of failure

Altered expression of lysophosphatidic acid receptors, in association with the synthesis of estrogens and androgens in type 1 endometrial cancer biology

To establish association between two main lysophosphatidic acid (LPA) receptors (LPAR2 and LPAR1) with the synthesis of estrogens and androgens in type-1 endometrial carcinoma (EC), we evaluated correlation of LPARs expression with expression of steroid 5 alpha-reductase 2 - aromatase (SRD5A2), or cytochrome P450 family 19 subfamily A member 1-5α-reductase (CYP19A1) in EC. Moreover, we aimed to investigate SRD5A2 and CYP19A1 expression in type 1 endometrial cancer and normal endometrium with its correlation to selected clinicopathological features. The studied cancerous samples showed higher CYP19A1 and SRD5A2 expression comparing to normal endometria. We also documented positive correlations between LPAR1 and LPAR2 with responsible for proliferation SRD5A2 in EC tissue which suggests that intratumoral estrogen metabolism and synthesis are pivotal in endometrial carcinoma progression, with the involvement of LPA in this process. However, positive correlation between CYP19A1 and LPAR1 accounts for supporting role of LPA acting via LPAR1 in intratumoral DHT concentration and the ethiology of endometrial cancer progression. Also, owing to the highest expression of LPARs, CYP19A1 and SRD5A2 as well as their association with depth of myoinvasion and FIGO stage LPAR2 and LPAR1 seem to be the efficient candidate prognostic markers in the individual, targeted therapies for EC.

The significance of the altered expression of lysophosphatidic acid receptors, autotaxin and phospholipase A2 as the potential biomarkers in type 1 endometrial cancer biology

In order to study lysophosphatidic acid (LPA) signaling associated with type 1 endometrial carcinoma (EC), we evaluated the LPA receptors (LPARs), autotaxin (ATX) and phospholipase A2 (PLA2) expression in EC and normal endometrium with correlation to clinicopathological features. We investigated LPAR1, LPAR2, LPAR3, LPAR4, ATX and PLA2 expression at mRNA and protein levels using quantitative real-time PCR and western blot analyses in 37 ECs and 10 normal endometria. All the examined LPARs (except for LPAR3 protein), ATX and PLA2 were overexpressed in cancerous compared to healthy endometrium. The studied ECs showed the highest LPAR2 and LPAR1 expression. Statistically positive correlations were found between depth of myoinvasion and levels of LPAR1, LPAR2 and PLA2 transcripts and proteins. We also found positive correlations between LPAR1, LPAR2, LPAR4 and PLA2 expression with the International Federation of Gynecology and Obstetrics (FIGO) stage. The expression of LPAR1, LPAR2 and PLA2 was positively associated with the age of patients. Positive correlations were found between the expression of LPAR1 mRNA, LPAR2 mRNA and protein and LPAR3 mRNA and body mass index (BMI) of the examined patients. We found no association between the expression levels of the studied factors and diabetes or hypertension among the examined patients. Owing to the highest LPAR2 and LPAR1 expression in EC and positive correlations of these two receptors with the depth of myoinvasion and the FIGO stage, we believe that LPAR2 and LPAR1 show promise as predictors of the EC progression as well as the main receptors responsible for LPA action in the EC tissue.

Function and regulation of MTA1 and MTA3 in malignancies of the female reproductive system

The family of metastasis-associated (MTA) genes is a small group of transcriptional co-regulators which are involved in various physiological functions, ranging from lymphopoietic cell differentiation to the development and maintenance of epithelial cell adhesions. By recruiting histone-modifying enzymes to specific promoter sequences, MTA proteins can function both as transcriptional repressors and activators of a number of cancer-relevant proteins, including Snail, E-cadherin, signal transducer and activator of transcriptions (STATs), and the estrogen receptor. Their involvement in the epithelial-mesenchymal transition process and regulatory interactions with estrogen receptor activity has made MTA proteins highly interesting research candidates, especially in the field of hormone-sensitive breast cancer and malignancies of the female reproductive tract. This review focuses on the current knowledge about the function and regulation of MTA1 and MTA3 proteins in gynecological cancer, including ovarian, endometrial, and cervical tumors.

Altered expression of ERs, aromatase, and COX2 connected to estrogen action in type 1 endometrial cancer biology

In order to study estrogen-driven microenvironment associated with type 1 endometrial carcinoma, we evaluated estrogen receptors (ERs), aromatase, and cyclooxygenase II (COX2) molecular and immunohistochemical profiles with correlation to clinicopathological features. We investigated aromatase, ERα, ERβ, and COX2 expression at the mRNA and protein levels using quantitative real-time PCR and immunohistochemical method in 51 endometrial carcinomas and 16 normal endometria. All the studied tumors, as well as normal endometria, expressed ERα, ERβ, and COX2 mRNAs. Five endometrial carcinoma tissues and one normal endometrium showed no aromatase mRNA expression. The majority of tumors expressed ERα (82%), aromatase (80%), and COX2 (88%) proteins. Forty-one percent of the studied tumors were ERβ-negative. ERα and ERβ showed significantly decreased mRNA and protein expression levels in endometrial carcinoma as compared to normal endometrium. An opposite trend was shown for COX2 and aromatase proteins. ERα expression correlated positively with COX2 expression at both mRNA and protein levels (P < 0.005, r = 0.398; P < 0.0005, r = 0.510, respectively). There was also a positive correlation between COX2 and aromatase expression in cancer tissue (P < 0.002, r = 0.433 for transcriptional level; P < 0.0005, r = 0.614 for protein level). We observed positive correlations between ERβ and ERα, as well as between ERβ and COX2 at the transcriptional level only (P < 0.0005, r = 0.644; P < 0.002, r = 0.444, respectively). Negative correlations were found between pT category of primary tumor and levels of ERα and ERβ transcripts (P < 0.02, r = -0.332; P < 0.02, r = -0.348, respectively). A negative association between ERβ and the International Federation of Gynecology and Obstetrics (FIGO) staging was also found. The growth of EC1 with the presence of ERα and overexpression of aromatase and COX2 is dependent on estrogens. We believe that ERβ may be considered as a potential marker in the progression of disease in endometrial cancer patients.

Incidence of radiation toxicity in cervical cancer and endometrial cancer patients treated with radiotherapy alone versus adjuvant radiotherapy

AIM

The study was made to evaluate early and late toxicity in a diversified group of patients receiving definitive or adjuvant radiotherapy in terms of clinical diagnosis and treatment methods.

BACKGROUND

Radiotherapy is a standard way of treatment in cervical and endometrial cancer patients, both as definitive and adjuvant therapy. But every radiation treatment may be involved with toxicity.

MATERIALS AND METHODS

A detailed analysis was performed of 263 patients with gynaecological cancer treated with definitive (90 patients with cervical cancer received radiochemotherapy or radiotherapy exclusively) and adjuvant radiotherapy (38 with cervical and 135 with endometrial cancer).

RESULTS

Acute reactions were found in 51.3% and late reactions were found in 14.8% of patients. It was stated that early (p < 0.007) and late (p < 0.003) post radiation reaction appear more frequently in women treated with definitive than adjuvant radiotherapy. The analysis of the whole group revealed higher rate of toxicity, both early and late, in the gastrointestinal tract than in the urinary system (p < 0.004). Comparing the subgroups, it was found that intestinal reactions occurred more frequently in the definitive radiotherapy group than in the adjuvant one. The occurrence of side effects was associated with the prolongation of total irradiation time due to necessary interruptions of radiotherapy. The comparison of the subgroups showed that interruptions occurred more frequently in patients receiving definitive rather than adjuvant radiotherapy (17.7-2.9%).

CONCLUSIONS

Definitive radiotherapy compared with adjuvant treatment may by associated with higher percentage of side effects caused by dose of therapy and correlation with chemotherapy.

Endoplasmic reticulum stress is activated in endometrial adenocarcinoma

OBJECTIVES

Endometrial cancer is the most common malignancy of the female genital tract. However, in spite of a huge advance in our understanding of endometrial cancer biology, therapeutic modalities haven't significantly changed over the past 40 years. The activation of the Unfolded Protein Response (UPR) and GRP78 increase following Endoplasmic Reticulum (ER) stress have been recently identified as mechanisms favoring growth, invasion and resistance to therapy of different types of cancer. However, a possible role of ER stress and GRP78 in endometrial cancer has never been investigated.

METHODS

Tissue specimens from normal and neoplastic endometrium were analyzed for the expression of the ER stress markers GRP78, ATF6 and CHOP by Real-Time RT-PCR. In addition, GRP78 protein expression and localization were evaluated by Western blot and immunohistochemistry, respectively. The effect of GRP78 knock down on cell growth of Ishikawa cells was analyzed by proliferation curve analysis.

RESULTS

In this analysis, the expression levels of GRP78, ATF6 and CHOP mRNAs were significantly increased in specimens of endometrioid endometrial carcinomas. GRP78 and ATF6 protein expression levels were also increased in specimens of endometrial adenocarcinomas. GRP78 knock down caused a decrease of Ishikawa cells' growth.

CONCLUSIONS

The increased expression of ER stress markers in endometrioid endometrial carcinomas suggests a role for ER stress, the UPR and, possibly, GRP78 in endometrial cancer. Whether these mechanisms have a substantial function in the pathogenesis of malignant transformation of human endometrium is still under investigation in our laboratory.

Exercise training prevents endometrial hyperplasia and biomarkers for endometrial cancer in rat model of type 1 diabetes

Background

Endometrial cancer is one of the most common types of gynecologic cancers. The ability of exercise to reduce the risk of endometrial cancer in women with type 2 diabetes has been established, but no studies have examined this link in type 1 diabetes.A randomized, controlled animal study was designed using a standard rat model of type 1 diabetes. The goal of this study was to investigate the ability of exercise to prevent increased levels of endometrial cancer biomarkers, estrogen receptor (ERα) and p16, and endometrial hyperplasia associated with diabetes.

Methods

Forty female rats were randomized into four groups: sedentary control, exercise control, sedentary or exercised diabetic. Diabetes was induced by alloxan injection. A 4-week treadmill training program was initiated with the development of diabetes. Endometrial tissues were evaluated for hyperplasia and ERα and p16 levels and subcellular localization using microscopy.

Results

Severe diabetes lead to hyperplasia in the endometrial tissue in 70% of sedentary diabetic rats. Exercise-trained diabetic rats and the non-diabetic rats displayed no hyperplasia. The expression of ERα increased significantly (p < 0.02) while the expression level of p16 decreased significantly (p < 0.04) in the diabetic sedentary group compared to the non-diabetic groups. Exercise training led to a reversal in the percentage of p16 and ERα positive cells in diabetic rats.

Conclusions

Severe diabetes leads to hyperplasia of the endometrial tissue and increased ERα levels and decreased p16 levels in rats, which can be prevented with aerobic exercise.

Keywords

Diabetes; Estrogen receptor alpha; P16; Endometrial hyperplasia; Endometrial cancer; Exercise

Inhibin-alpha, -betaA and -betaB subunits in uterine non-endometrioid carcinomas: prognostic significance and clinical implications

Inhibins, dimeric peptide hormones composed of an alpha-subunit and one of two possible beta-subunits (betaA or betaB), exhibit substantial roles in human reproduction and in endocrine-responsive tumours. However, the prognostic significance and clinical implications of the inhibin-alpha, -betaA and -betaB subunits in uterine non-endometrioid cancers are still quite unclear. A series of 41 uterine non-endometrioid carcinomas were immunohistochemically analysed with monoclonal antibodies against inhibin-subunits. The staining reactions were correlated with several clinicopathological characteristics and clinical outcome. The inhibin-alpha subunit showed a significant association with age although the loss of this subunit did not affect the survival of patients with non-endometrioid carcinomas and did not constitute an independent prognostic parameter. The inhibin-betaA expression was not associated with any of the analysed clinicopathological parameters and did not affect patients' survival. In contrast, a low betaB-subunit demonstrated a significant better cause-specific survival. Moreover, inhibin-betaB did constitute an independent prognostic parameter in uterine non-endometrioid cancer patients. In contrast to inhibin-alpha and -betaA subunits, the inhibin-betaB subunit seems to have a substantial role in the carcinogenesis and pathology of uterine non-endometrioid carcinomas and might be used as a marker to identify high-risk patients and may aid in the selection of patients for a more aggressive adjuvant therapy.

FGFR2 as a molecular target in endometrial cancer

Although molecularly targeted therapies have been effective in some cancer types, no targeted therapy is approved for use in endometrial cancer. The recent identification of activating mutations in fibroblast growth factor receptor 2 (FGFR2) in endometrial tumors has generated a new avenue for the development of targeted therapeutic agents. The majority of the mutations identified are identical to germline mutations in FGFR2 and FGFR3 that cause craniosynostosis and hypochondroplasia syndromes and result in both ligand-independent and ligand-dependent receptor activation. Mutations that predominantly occur in the endometrioid subtype of endometrial cancer, are mutually exclusive with KRAS mutation, but occur in the presence of PTEN abrogation. In vitro studies have shown that endometrial cancer cell lines with activating FGFR2 mutations are selectively sensitive to a pan-FGFR inhibitor, PD173074. Several agents with activity against FGFRs are currently in clinical trials. Investigation of these agents in endometrial cancer patients with activating FGFR2 mutations is warranted.

Immunohistochemical labelling of steroid receptors in normal and malignant human endometrium

For several years it was generally believed that only a single estrogen receptor (ER) and progesterone receptor (PR) existed. However, the discovery of a new ER (ERbeta) with specificity for estrogens has induced new insights in the estrogen signalling system. Moreover, PR is expressed as two major isoforms, PR-A and PR-B that arise from alternative transcriptional starting sites within the same gene. Although PR-A and PR-B were thought to occur in similar amounts, it is now clear that they are differentially expressed and thus have distinct functions in several human tissues, including human endometrium. The ER and PR expression and distribution pattern might play an important role in normal endometrial function and pathogenesis and the expression and relationship of the two distinct ER's and PR's could be of essential clinical implications. Moreover, the imbalance in ERalpha/ERbeta expression and the PR-A/PR-B ratio might play an important role in endometrial transition and subsequently influence endometrial pathogenesis. The knowledge of the pattern of steroid receptors in human endometrial tissue is of extreme importance, since it might start a new field in hormone therapy of endometrial cancer.

Application of DNA methylation biomarkers for endometrial cancer management

It has become clear that aberrant gene expression, via alterations in promoter methylation or histone acetylation, is a contributing factor for carcinogenesis, perhaps as important as genetic mutation. This is particularly evident in endometrial cancer, in which multiple genes are silenced through hypermethylation. In this review, we discuss the field of epigenetics and relevant techniques to characterize methylation and acetylation alterations. The CpG island methylator phenotype, epimutations and the effects of aging on methylation are also discussed. In endometrial cancer there is evidence that hypermethylation of relevant genes can be reversed using epigenetic inhibitors, resulting in re-expression of silenced genes. Preliminary data also suggest that a panel of methylation biomarkers could be useful for diagnosis and even screening in selected populations at high risk. This disease is particularly well suited for such a strategy given that the endometrium is readily accessible for testing and endometrial cancer precursors are well defined.

Prognostic significance of oestrogen receptor alpha (ERα) and beta (ERβ), progesterone receptor A (PR-A) and B (PR-B) in endometrial carcinomas

The expression of the classic steroid receptors ERalpha and PR-A has been correlated with stage, histological grade and survival in endometrial cancer. Endometrial cancer samples (293) were immunohistochemically analysed with monoclonal antibodies against the four steroid receptors. The loss of ERalpha, PR-A and PR-B resulted in a poorer survival in endometrial cancer patients, while ERbeta expression did not demonstrate any correlations with several analysed clinicopathological characteristics and did not affect survival. Additionally, multivariate survival analysis demonstrated that PR-B was a significant independent prognostic factor for cause-specific survival. In contrast, although ERalpha and PR-A showed a significant association between different endometrial histological subtypes and grading, both receptors were not independent factors with survival in endometrial carcinoma patients. Therefore, the PR-B immunostaining might be used as an easy, simple and highly efficient marker to identify high-risk patients and may aid in the selection of patients for a more aggressive adjuvant therapy.

Inhibin/activin subunits beta-A (-betaA) and beta-B (-betaB) are differentially localised in normal, hyperplastic and malignant human endometrial tissue

Inhibins (INHs) are dimeric glycoproteins composed of an alpha (-alpha) subunit and one of two possible beta (beta-) subunits (betaA or betaB). The aims of this study were to determine the frequency and distribution of INH beta (betaA and betaB) subunits in normal, hyperplastic and malignant human endometrium. Endometrial tissue was obtained from normal, hyperplastic (simple, complex and atypical) and endometrioid adenocarcinoma (EC) and INH-alpha, -betaA and -betaB were labelled using immunohistochemistry and immunofluorescence. INH-betaA and -betaB labelling was increased significantly between the proliferative and secretory phase (p<0.05). The lowest labelling was demonstrated in EC, being significantly lower than in secretory phase (p<0.01) and in simple, complex and atypical hyperplastic tissue (p<0.05). For inhibin-betaB, the most intense labelling was noted in atypical hyperplasia compared to EC (p<0.05). A strong colocalisation of inhibin-alpha and -betaA could be demonstrated in malignant endometrial tissue, suggesting the production of inhibin A within the tumour. Additionally, only limited colocalisation of inhibin-betaB with -alpha subunit could be observed, suggesting the synthesis of activin B rather than inhibin B in malignant endometrium. In conclusion, INH-betaA and -betaB were labelled in normal, hyperplastic and malignant endometrium. Hyperplastic tissue labelled more intensely than EC for the presence of INH-betaA and -betaB, suggesting a substantial function in endometrial pathogenesis and an important role in endometrial carcinogenesis.

Time without symptoms and toxicity (TWIST) analysis of adjuvant radiation therapy for endometrial cancer

BACKGROUND AND PURPOSE

Postoperative radiotherapy in endometrial cancer reduces the risk of local relapse but is also associated with substantial acute and late reactions. The aim of our study was to evaluate time without tumor symptoms and toxicity (TWIST) in a consecutive series of 317 endometrial cancer patients administered postoperative irradiation.

PATIENTS AND METHODS

Both low-dose rate brachytherapy (BRT) and external beam irradiation (EBRT) were applied in 247 patients (78%), only BRT--in 49 (15%) and only EBRT--in 21 patients (7%). Median follow-up was 7.3 years (range, 4-21 years). TWIST analysis based on actuarial freedom from recurrent disease and from late radiotherapy effects was performed with the use of Kaplan-Meier method. The impact of patient- and treatment-related factors on TWIST was assessed with uni- and multivariate tests.

RESULTS

Five-year overall survival was 78%, and five-year disease free survival--75%. Recurrence occurred in 70 patients (22%), of whom in 11 (3.5%)--exclusively in the pelvis. Acute and late reactions of any grade occurred in 268 (85%) and 158 patients (51%), respectively. Late bowel effects of any grade were observed in 41% of patients. Severe late effects occurred in 35 patients (11%). Actuarial probability of two- and five-year survival free of disease and severe (grades 3 or 4) late effects (TWIST) was 84% and 71%, respectively (median TWIST, 16.2 years). When all-grade late effects were considered, two- and five-year TWIST probability was 50 and 30%, respectively, and median TWIST was only 2.0 years. When both acute and late reactions were taken into account, median TWIST was 22 months. In unifactorial test, higher age ( P = 0.013) FIGO stage ( P < 0.001) total radiotherapy dose ( P < 0.001) normalized total dose based on linear-quadratic model ( P = 0.001) EBRT fraction dose ( P < 0.001) and use of cesium BRT ( P = 0.042) were correlated with shorter TWIST. In multifactorial analysis, higher age ( P = 0.001) FIGO stage ( P = 0.001) and total radiotherapy dose ( P < 0.001) were independent factors correlated with shorter TWIST.

CONCLUSIONS

Endometrial cancer patients treated with postoperative irradiation have a long time interval without relapse and severe late toxicity. However, when any late normal tissue injury is considered, the median time without relapse and late toxicity is significantly shorter. The impact of mild late radiotherapy complications on the quality of life should be further investigated. TWIST calculation should be attempted in future prospective studies evaluating the role of postoperative radiotherapy.

Molecular assessment of depth of myometrial invasion in stage I endometrial cancer: a model based on K-ras mutation analysis

INTRODUCTION

Overall nearly 20% of endometrial cancer (EC) patients die of the disease and over half of these had initially presented with clinical stage I disease. There is a strong correlation between disease mortality and depth of myometrial invasion. Current assessment of depth of invasion relies on light microscopy. Tumor cells can evade detection by light microscopy if they are vastly outnumbered by myometrial cells. Molecular techniques have a great potential in the detection of such isolated cells.

OBJECTIVE

The objective was to develop a model for the application of molecular techniques to advance the assessment of risk status in patients with clinical stage I EC.

METHODS

The study sample included 21 stage I ECs with a documented K-ras mutation from two series of 96 and 106 ECs from the United Kingdom and Norway, respectively. K-ras was documented using heteroduplex mobility analysis and amplified created restriction site, followed by sequencing to identify the specific base substitution at codon 12 and 13 of K-ras oncogene. For each case with a K-ras mutation, a modified mutant allele-specific amplification technique was carried out on a series of tissue strips microdissected at increasing depths from the myometrium underlying tumor. The microdissected myometrium had been previously examined histologically for absence of infiltrating tumor cells on light microscopy. Presence of K-ras mutations was used to identify the tumor cells within the histologically normal myometrium. Correlations between submicroscopic myometrial tumor cell infiltration and clinicopathological factors were studied.

RESULTS

Of 21 cases with K-ras mutation, 6 cases (28%) showed molecular evidence of tumor cell infiltration beyond the histological boundary. The depth of submicroscopic myometrial infiltration was found to be variable. The staging of the tumors would have changed in 3 cases (14%) if tumor cells been detected histologically. A borderline significant correlation between presence of submicroscopic myometrial invasion and depth of myometrial invasion was noted (P = 0.053). The recurrence rate and survival of patients without submicroscopic invasion were better than those with, although it did not reach statistical significance (recurrence rate P = 0.13, recurrence free survival P = 0.14, cause-specific survival P = 0.12, and total survival P = 0.2).

CONCLUSIONS

Molecular assessment of depth of myometrial invasion using K-ras mutation is feasible and may add information to conventional light microscopy. Further prospective studies are required to define the clinical significance of this technology.

Factors determining acute normal tissue reactions during postoperative radiotherapy in endometrial cancer: analysis of 317 consecutive cases

BACKGROUND AND PURPOSE

Acute radiotherapy reactions are commonly underestimated and under-reported in the literature. Our aim was to evaluate the incidence and risk factors for acute reactions during postoperative radiotherapy in endometrial cancer patients.

MATERIAL AND METHODS

Performed was detailed retrospective analysis of 317 endometrial cancer patients given postoperative radiotherapy. Two hundred forty seven patients (78%) received both intracavitary (BRT) and external beam irradiation (EBRT), 49 patients (15%) received only BRT and 21 patients (7%) - only EBRT. BRT included radium (Ra) or cesium (Cs). The mean total dose at 0.5 cm for Ra and Cs was 50.5+/-10.3 Gy and 48.4+/-15.0 Gy, respectively, and the mean dose rate - 0.47+/-0.06 Gy/h and 1.42+/-0.41 Gy/h, respectively. Mean EBRT dose in the ICRU reference point was 49.0+/-3.7 Gy given in fractions of 1.54-2.49 Gy (mean 2.0+/-0.17 Gy). Radiotherapy and Oncology Group classification system was employed to score acute reactions. The impact of patient- and treatment-related factors on the risk of acute bowel and urinary bladder reactions was assessed with uni- and multivariate tests.

RESULTS

Acute radiotherapy reactions of any grade occurred in 265 patients (84%) including bowel complications in 66% and urinary bladder complications in 36%. There were 21 severe (grade 3 or 4) reactions, all but one seen in the patients treated with combined EBRT and BRT. Higher total dose (P=0.024), higher EBRT dose (P=0.022) and higher age (P=0.026) were correlated with increased acute bowel toxicity in univariate analysis. Multivariate analysis showed that higher EBRT dose (P=0.015) and older age (P=0.016) were independently correlated with the risk of acute bowel events. Higher total dose (P=0.009), BRT dose (P=0.029), BRT dose rate (P=0.004), EBRT fraction size (P=0.007), the use of Cs BRT (P=0.001) and lower parity (P=0.041) were correlated with increased risk of acute bladder toxicity in univariate test. Multivariate analysis demonstrated that the independent risk factors for acute bladder events were BRT dose rate (P=0.002) and low parity (P=0.042) and there was a trend for EBRT dose (P=0.076). In multivariate analysis there was no impact of other clinical factors (FIGO stage, diabetes mellitus, hypertension, prior abdominal surgery) on the risk of acute bowel and/or bladder reactions nor was the impact of surgery-to-radiotherapy interval, overall radiotherapy time and overall treatment time.

CONCLUSIONS

The risk of acute reactions depends both on treatment-related (BRT dose rate, EBRT dose) and patient-related factors (age, parity). Precise treatment prescription, planning and verification are of paramount concern. Further studies are warranted to evaluate the impact of extrinsic and intrinsic factors associated with acute normal tissue injury.

Outcome after salvage radiotherapy (brachytherapy +/- external) in patients with a vaginal recurrence from endometrial carcinomas

BACKGROUND AND PURPOSE

The vagina is the site most commonly affected by loco-regional failure in endometrial carcinoma (EC). The aim of this study was to evaluate the efficacy of vaginal brachytherapy (BT) combined or not with whole pelvic external radiotherapy (RT) for the treatment of patients with vaginal recurrences from endometrial cancer.

PATIENTS AND METHODS

Between 1986 and 1999 25 women were treated at the Institut Gustave Roussy (IGR) for a vaginal relapse (VR) from EC. Patient characteristics were as follows: median age 65 years (range 43-84), histologic type: adenocarcinoma (21 patients); endometrioid carcinoma (three patients); adenoacanthoma (one patient); FIGO staging for initial disease: Ia, three; Ib, eight; Ic, four; II, seven; IIIa, two; IVa, one. The initial tumor was treated by surgery alone in 18 patients, or surgery combined with RT and/or BT in seven patients. A VR occurred in a median interval of 21 months (range 2-89); 10/25 (40%) occurred within the first year following initial treatment. The recurrence was exclusively in the vagina in 18 patients and was associated with parametrial and or nodal involvement in seven patients; it was localized in the upper 1/3 of the vagina in nine patients, in the upper 2/3 or the entire vagina in 11 patients or in the lower 1/3 in five patients. The largest tumor diameter ranged from 10 to 70 mm (median: 25 mm). The treatment of the VR included low-dose rate endocavitary BT in all cases: three patients received endocavitary BT alone, or it was associated with external RT in 22 patients or delivered after surgical removal of the lesion in nine patients. Seven patients were submitted to further irradiation combining endocavitary and interstitial BT.

RESULTS

Local control was achieved in 23 patients (92%). With a follow-up ranging from 4 to 154 months, 13 patients have died (ten due to metastasis, two of intercurrent disease and two due to local tumor progression) and ten patients are alive and disease free. The 3-year actuarial survival was 48%. Late radiation-related sequelae were observed in nine patients (mucous necrosis in one patient, moderate sclerosis in six patients) in an interval varying between 8 and 45 months. The majority of recurrences occurred in patients who had not previously received irradiation, which emphasizes the role of systematic prophylactic post-operative vaginal BT. Extra-vaginal extension (P < 0.001), the tumor size (P < 0.03) and the stage of initial disease (P < 0.01) appeared to have a significant impact on the prognosis.

CONCLUSION

BT combined with external RT is an efficient treatment for VR from EC even in previously irradiated patients. Poor survival remains related to metastatic dissemination.

Relationship between acute and late normal tissue injury after postoperative radiotherapy in endometrial cancer

PURPOSE

To evaluate the relationship between acute and late normal tissue reactions in 317 consecutive endometrial cancer patients treated with surgery and adjuvant radiotherapy (RT).

METHODS

The data of 317 patients (staging according to the International Federation of Gynecology and Obstetrics) treated with postoperative RT were analyzed. Both low-dose-rate brachytherapy and external beam RT were applied in 247 patients (78%); brachytherapy only in 49 (15%) and external beam irradiation only in 21 (7%). The median follow-up was 7.3 years (range 4-21). The European Organization for Research and Treatment of Cancer, Radiation Therapy Oncology Group system with elements of the late effects of normal tissue, subjective, objective, management, analytic (LENT/SOMA) scale was used to score the RT reactions. The correlation between the occurrence and severity of acute and late bowel and bladder toxicity, as well as the relationship between the severity of acute effects and time to occurrence of late reactions, were assessed using linear and logistic regression analyses.

RESULTS

Of the 317 patients, 268 (85%) experienced acute RT reactions of any grade. Severe acute bowel reactions were observed in 15 patients (5%), urinary bladder complications in 1 patient (0.5%), cutaneous in 1 patient (0.5%), and vaginal in 1 patient (0.5%). Severe acute hematologic toxicity was seen in 3 patients (1%). A total of 158 patients (51%) experienced late RT reactions of any grade. Severe late bowel reactions were observed in 19 patients (6%), urinary bladder in 5 (2%), vaginal in 3 (1%), and bone in 10 (4%). When all toxic events were considered, there was a highly significant correlation between the acute and late bowel reactions (p <0.001), but the acute and late urinary bladder reactions did not correlate (p = 0.64). The grade of acute toxicity was found to predict the grade of late toxicity for the bowel but not for the bladder (p <0.001 and p = 0.47, respectively). The severity of acute bowel and bladder toxicity did not correlate with the time to occurrence of late toxicity in these locations (p = 0.34 and p = 0.47, respectively).

CONCLUSION

Patients with increased acute bowel toxicity during postoperative RT for endometrial cancer have an increased risk of late bowel injury. A higher grade of acute bowel complications correlated with more severe late events, but was not predictive for its latency time. These findings suggest the possibility of an early indication of patients with an increased risk of late toxicity in whom preventive measures might be attempted.

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.

Recurrent endometrial cancer after surgery alone: results of salvage radiotherapy

PURPOSE

Postoperative irradiation of endometrial cancer patients decreases the risk of local recurrence but is associated with a number of long-term sequelae. In a proportion of patients, no immediate postoperative radiotherapy is applied and this treatment is introduced only at relapse. The aim of our study was to assess the long-term results of salvage radiotherapy in previously nonirradiated endometrial cancer patients who developed local recurrence, and to evaluate the impact of patient- and treatment-related factors on treatment efficacy.

METHODS AND MATERIALS

We performed a detailed retrospective analysis of 73 endometrial cancer patients given radiotherapy for local recurrence after the initial surgery only. The mean age at diagnosis of the recurrence was 63 years (range, 39-78 years). Median time to recurrence was 11 months (range, 1-19 months). All recurrences were staged with the use of Perez modification of the International Federation of Gynecology and Obstetrics (FIGO) staging system for primary vaginal carcinoma. There were five (7%) Stage I patients, 43 (59%) Stage II patients, and 25 (34%) Stage III patients. Forty-four patients (60%) received both external beam irradiation (EBRT) and endovaginal brachytherapy (BRT), 17 (23%) received only BRT, and 12 (17%) received only EBRT. The mean total physical radiation dose was 75.9 Gy (range, 8-130 Gy), and the mean normalized total dose (NTD) calculated on the base of the linear-quadratic model was 86.6 Gy (range, 8.5-171.9 Gy). Median follow-up for alive patients was 8.8 years (range, 3-21 years). The impact of patient-, tumor-, and therapy-related factors on the treatment outcome was evaluated with the use of uni- and multivariate analyses.

RESULTS

Three- and 5-year overall survival rates were 33% and 25%, respectively. In the univariate analysis, lower stage of recurrent disease (p < 0.0005), combined EBRT and BRT (p = 0.027), higher total radiation dose (p = 0.031), and higher NTD (p = 0.006) were significantly correlated with better survival. In the multivariate analysis, only stage of recurrent disease (p < 0.005) and high total dose (p = 0.047) were independently correlated with better survival. Lower FIGO stage of recurrence (p = 0.023) and higher total dose (p = 0.005) were also independently correlated with longer time to progression, whereas higher radiotherapy dose was the only factor correlated with better local control (p = 0.029).

CONCLUSIONS

The efficacy of salvage radiotherapy in endometrial cancer patients with local failure after previous surgery is limited. Factors determining treatment outcome include advancement of the tumor at relapse and radiotherapy dose.

Identification and partial characterization of differentially expressed mRNAs in normal human endometria and endometrial carcinomas by differential display RT-PCR

Differential display methodology was employed to examine and compare the mRNA species derived from normal endometrial tissue and endometrial carcinoma (grade 3, stage III) tissue biopsies. Two cDNA sequences, one expressed in the tumour group only (T19) and the other expressed only in the normal group (N22), were selected for verification of differential expression by semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR). The expression of N22 was restricted to the normal group, suggesting a possible tumour suppressing function. Sequence analysis of this fragment revealed a high degree of similarity to a human cDNA sequence of unknown function. The expression of T19 mRNA was observed in both normal and neoplastic tissues, however the relative abundance was significantly higher in endometrial carcinomas. Expression of T19 mRNA was further examined in a larger clinical sample set and was significantly increased in the tumours (n = 16), with a three-fold increase when compared with the normal endometria, n = 5 (Kruskal-Wallis analysis of variance, P<0.05). Subsequent sequence analysis of T19 revealed a high degree of similarity to the 3' untranslated region of a rat growth factor responsive gene, SM-20. Further characterization of these mRNA transcripts may lead to the identification of novel genes involved in endometrial tumourogenesis.