Postoperative vaginal brachytherapy alone is the treatment of choice for grade 1-2, stage IC endometrial cancer

Impact of different adjuvant radiotherapy modalities on women with early-stage intermediate- to high-risk endometrial cancer

OBJECTIVE

Vaginal brachytherapy was recommended for patients with intermediate-risk endometrial cancer, however, optimal radiotherapy modalities for intermediate-high- or high-risk patients remains controversial. Previous studies have mainly focused on survival outcomes and have seldom taken cost issues into consideration, especially for high-risk patients. The purpose of this study is to compare the survival outcomes and costs associated with two adjuvant radiotherapy modalities in the management of patients with early-stage, intermediate- to high-risk endometrial cancer.

METHODS

According to ESMO-ESCO-ESTRO criteria, 238 patients with stage I/II, intermediate- to high-risk endometrial cancer who underwent radiotherapy from January 2003 to December 2015 at our institution were reviewed. The vaginal brachytherapy group and external beam radiation therapy combined with the vaginal brachytherapy group were propensity score-matched at a 1:1 ratio. The Kaplan-Meier method and Cox proportional hazards regression model were used.

RESULTS

A total of 361 patients met our inclusion criteria, the median age of the patients was 58 years (range, 28-85). All were diagnosed with stage I-II endometrial cancer (324 with stage I and 37 with stage II; 350 with endometrioid adenocarcinoma; and 10 with mucinous carcinoma). The median follow-up time was 60.5 months (range, 3-177). Among 119 matched pairs, no significant differences were found in overall (10.9% vs 8.4%, P=0.51), locoregional (4.2% vs 1.7%, P=0.45), or distant recurrence rates (6.7% vs 6.7%, P=1.0) between the two groups. There were also no differences in the 5-year overall (94.8% vs 93.9%, P=0.78) or progression-free survival (90.0% vs 84.4%, P=0.23) between the two groups. The rates of acute and late toxicity were significantly higher in the external beam radiation therapy combined with vaginal brachytherapy vs the vaginal brachytherapy group (all P<0.05), except for the acute hematological toxicity rate (17.6% vs 9.2%, P=0.06). External beam radiation therapy combined with vaginal brachytherapy had a higher median cost ($2759 vs $937, P<0.001) and longer median radiotherapy duration (41 days vs 17 days, P<0.001) than vaginal brachytherapy.

CONCLUSION

Vaginal brachytherapy was associated with similar local control and long-term survival outcomes relative to the combination of external beam radiotherapy and vaginal brachytherapy and it also minimizes radiation-related complications, reduces medical costs, and shortens radiotherapy duration. Vaginal brachytherapy may be the optimal radiation modality for patients with early-stage endometrial cancer at intermediate to high risk.

Retrospective Analysis of Intravaginal Brachytherapy in Adjuvant Treatment of Early Endometrial Cancer

The aim of this study was to determine the role of adjuvant endovaginal brachytherapy HDR (High Dose Rate) or observation, as well as identification of risk factors of tumor recurrence. The study included 178 women after radical hysterectomy. All patients belonged to the group of low- and medium-risk stage I FIGO. Analysis consisted of 3-, 5-, and 10-year OS, DFS, and LRFS in both groups. Follow-up was more than 6.5 years. The 5-OS, 5-DFS, and 5-LRFS were 93%, 96%, and 98% in the treated group and 95%, 94%, and 96% in the observed group, respectively. These differences were not statistically significant. There was a statistically significant difference in 5-OS in the treated group, between low- and medium-risk subgroups (100% versus 87.55%, p = 0.018). There was a better prognosis among the patients with FIGO IA compared to FIGO IB (5-DFS, 97 versus 86%, p = 0.047). Among the risk factors, there were only statistically significant differences in the 5-OS, between the ages of ≤ 70 years and >70 years. Use of brachytherapy may affect the reduction in the number of local recurrences at the vaginal stump (6% versus 2%). This is particularly noticeable in the low-risk subgroup (9% versus 0%).

Could S6K1 immunopositivity be used to distinguish early and advanced stages of endometrioid endometrial adenocarcinoma?

OBJECTIVE

To assess whether the immunopositivity of S6K1, a crucial effector of the mTOR signaling pathway, varies between early-stage low-grade and advanced-stage high-grade endometrial endometrioid adenocarcinoma (EEA) as well as to discuss its prognostic significance.

MATERIAL AND METHODS

A total of 22 normal endometrial tissue samples (Control group) and 41 EEA specimens (Study group) were enrolled in the study, and all the samples underwent immunohistochemical staining for S6 kinase alpha (S6K1). The study group was further evaluated in two subgroups; stage 1A, grade 1 (Group 1) and stage ≥1A, grade 2 or 3 (Group 2). Group 2 patients were considered as a poor prognosis for EEA. The samples were examined by two independent pathologists. Statistical analyses were performed using the Student's t-test for continuous variables, the Chi-square test for categorical variables, and one-way analysis of variance for the comparison of multiple variables.

RESULTS

The immunopositivity rate for all the included EEA patients was 56.1%, whereas none of the 22 normal endometrial tissue samples revealed immunoreactivity for S6K1. The immunopositivity rates were significantly different between Groups 1 and 2 [38.1% (8/21) and 75.0% (15/20), respectively, p=0.039]. When S6K1 positivity was used as a criterion of poor prognosis in EEA, the sensitivity, specificity, positive predictive value, and negative predictive value were calculated to be 62%, 75%, 72%, and 65%, respectively (OR: 4.9 and 95% CI: 1.3-18.7).

CONCLUSION

S6K1 was positive in the majority of EEAs and malignancies at an advanced stage. Higher grade disease had a significantly higher rate of S6K1 positivity. S6K1 immunopositivity appears to be a promising method to predict poor prognosis in EEA.

Bladder (ICRU) dose point does not predict urinary acute toxicity in adjuvant isolated vaginal vault high-dose-rate brachytherapy for intermediate-risk endometrial cancer

Purpose

High-dose-rate brachytherapy (HDR-BT) alone is an adjuvant treatment option for stage I intermediaterisk endometrial cancer after complete surgical resection. The aim of this study was to determine the value of the dose reported to ICRU bladder point in predicting acute urinary toxicity. Oncologic results are also presented.

Material and methods

One hundred twenty-six patients were treated with postoperative HDR-BT 24 Gy (4 × 6 Gy) per ICRU guidelines for dose reporting. Cox analysis was used to identify variables that affected local control. The mean bladder point dose was examined for its ability to predict acute urinary toxicity.

Results

Two patients (1.6%) developed grade 1 gastrointestinal toxicity and 12 patients (9.5%) developed grades 1-2 urinary toxicity. No grade 3 or greater toxicity was observed. The mean bladder point dose was 46.9% (11.256 Gy) and 49.8% (11.952 Gy) for the asymptomatic and symptomatic groups, respectively (p = 0.69). After a median follow-up of 36.8 months, the 3-year local failure and 5-year cancer-specific and overall survival rates were 2.1%, 100%, and 94.6%, respectively. No pelvic failure was seen in this cohort. Age over 60 years (p = 0.48), lymphatic invasion (p = 0.77), FIGO histological grade (p = 0.76), isthmus invasion (p = 0.68), and applicator type (cylinder × ovoid) (p = 0.82) did not significantly affect local control.

Conclusions

In this retrospective study, ICRU bladder point did not correlate with urinary toxicity. Four fractions of 6 Gy HDR-BT effected satisfactory local control, with acceptable urinary and gastrointestinal toxicity.

Are outcomes of adjuvant vaginal vault brachytherapy in endometrial cancer related to the way it is delivered?

Aims:Endometrial cancer is the commonest malignancy of the female genital tract. Surgery forms the cornerstone of treatment with adjuvant therapy proven to reduce local recurrence without demonstrating a clear survival benefit. The selection of adjuvant therapy is becoming increasingly more complex. The aim of this study was to investigate current adjuvant practices by reviewing outcomes of patients with endometrial cancer treated with intracavitary vaginal brachytherapy (VB).

Materials & Methods:A retrospective analysis was carried out of all women with Stage II endometrial endometroid adenocarcinoma treated at Weston Park Hospital, Sheffield with adjuvant VB from 2003–2006. The data collected and analysed included histology, stage and grade of disease, radiotherapy treatment–related parameters, morbidity, recurrence rates and survival rates. Kaplan-Meier was used to analyse recurrence-free and overall survival rates. Wilson’s score was used to determine statistical significance of outcomes. Attention was focused on the method of treatment delivery, and this was compared with available literature.

Results:In total, 33 patients were identified. All patients were treated with LDR 48 Gy prescribed to the surface of the applicator. Median follow-up was 36 months. Vaginal, pelvic and distant relapse rates were 9%, 15% and 18%, respectively. Recurrence-free and overall survival rates were 78.8% and 84.8%, respectively. Six of the seven patients (86%) who recurred developed distant metastases, not influenced by VB. No severe (Grade 3 or 4 toxicity) was recorded. When vaginal relapse rates were compared to published trials based on technique used, no statistically significant difference was demonstrated.

Conclusion:Rates of vaginal relapses were comparable to the available literature suggesting current VB practice is an effective adjuvant local treatment. The study highlights the importance of surveillance and patient education regarding toxicity and its prevention with particular attention drawn to vaginal stenosis.

Comprehensive staging surgery including complete pelvic and para-aortic lymphadenectomy followed by adjuvant vaginal brachytherapy improves survival rates for intermediate-risk endometrial cancer patients

AIM

To investigate the survival of patients with intermediate-risk endometrial cancer treated with comprehensive staging surgery including complete pelvic and para-aortic lymphadenectomy and adjuvant vaginal brachytherapy (VBT).

METHODS

Between January 2000 and December 2009, we retrospectively reviewed the medical records of 156 patients who underwent comprehensive surgical staging consisting of total hysterectomy, adnexectomy, peritoneal cytology, and complete pelvic/para-aortic lymphadenectomy. There were 122 low-risk and 34 intermediate-risk patients, and intermediate-risk patients received adjuvant VBT.

RESULTS

During the follow-up period, 7 (4.5%) of the 156 patients developed recurrent disease: 3 (2.5%) of the 122 low-risk and 4 (11.8%) of the 34 intermediate-risk patients. Among the 7 patients with recurrent disease, only 1 intermediate-risk patient died of disease and 6 stayed alive for the rest of the follow-up period. Disease-free survival at 5 years was 95.7% in the low-risk patients and 81.6% in the intermediate-risk patients, and this difference was statistically significant (p = 0.009). There was no statistically significant difference in overall survival at 5 years between the two groups (100% in low-risk patients vs. 96.7% in intermediate-risk patients, p = 0.061). Overall, grade 3 toxicities were seen in 1 (2.9%) patient.

CONCLUSION

Comprehensive staging surgery including complete pelvic and para-aortic lymphadenectomy followed by adjuvant VBT improves survival rates for intermediate-risk endometrial cancer patients, which are comparable with those of low-risk patients.

Adjuvant radiotherapy in early stage endometrial cancer

OBJECTIVE

To compare the rates of overall survival (OS), disease-free survival (DFS) and toxicity in different techniques of postoperative radiotherapy for stage IA endometrioid adenocarcionoma of endometrium, histological grades 1and 2.

METHODS

A historical comparison between treatment regimens was performed, and 133 women with a minimum follow-up of 5 years were included. Teletherapy (TELE group), with 22 patients treated from 1988 to 1996, with a 10 MV linear accelerator, average dose 46.2 Gy. Low dose rate brachytherapy (LDRB group) was performed between 1992 and 1995, in 19 women, with an insertion of Cesium 137, at a 60 Gy dose. Fourteen women operated between 1990 and 1996 did not receive radiotherapy (NO RT group). High dose rate brachytherapy was performed in 78 patients (HDRB group), from 1996 to 2004, in five weekly 7 Gy insertions, prescribed at 0.5 cm from the vaginal cylinder.

RESULTS

The 5-year disease-free survival was 94.6% for the HDRB group, 94.1% for the LDRB group, 100% for the TELE group and NO RT groups (p = 0.681). The 5-year overall survival was 86.6% for the HDRB group, 89.5% for the LDRB group and 90% for the TELE group and NO RT groups (p = 0.962). Grades 3-5 late toxicity was 5.3% in LDRB group and 27.3% for the TELE group (p < 0.001).

CONCLUSION

Patients submitted to adjuvant teletherapy showed very high toxicity, which contraindicates that treatment for those patients. There may be a role for adjuvant HDRB, but randomized controlled trials are still needed to evaluate its benefit.

Vaginal high dose rate brachytherapy alone in patients with intermediate- to high-risk stage I endometrial carcinoma after radical surgery

The objective of this study was to analyze the efficacy and morbidity of vaginal cuff brachytherapy alone in intermediate- to high-risk stage I endometrial cancer patients after complete surgical staging. Between October 1994 and November 2005, 128 patients with intermediate- to high-risk stage I endometrial adenocarcinoma were treated with high dose rate (HDR) brachytherapy alone after complete surgical staging. The intermediate- to high-risk group was defined as any stage I with grade 3 histology or stage IB grade 2 or any stage IC disease. The comprehensive surgery was in the form of total abdominal hysterectomy, bilateral salpingo-oophorectomy in addition to infracolic omentectomy, and routine pelvic and para-aortic lymphadenectomy. The median number of the lymph nodes dissected was 33. The median age at the time of diagnosis was 60 years. Forty patients were staged as IB (grade 2: 25 and grade 3: 15), and 88 patients were staged as IC (grade 1: 31, grade 2: 41, and grade 3: 16). A total dose of 27.5 Gy with HDR brachytherapy, prescribed at 0.5 cm, was delivered in five fractions in 5 consecutive days. Median follow-up was 48 months. Six (4.7%) patients developed either local recurrence (n= 2) or distant metastases (n= 4). Five-year overall survival and disease-free survival (DFS) rates are 96% and 93%, respectively. Only age was found to be significant prognostic factor for DFS. Patients younger than 60 years have significantly higher DFS (P= 0.006). None of the patients experienced grade 3/4 complications due to the vaginal HDR brachytherapy. Vaginal cuff brachytherapy alone is an adequate treatment modality in stage I endometrial adenocarcinoma patients with intermediate- to high-risk features after complete surgical staging with low complication rates.

Prospective clinical trial of bladder filling and three-dimensional dosimetry in high-dose-rate vaginal cuff brachytherapy

PURPOSE

To investigate the effect of bladder filling on dosimetry and to determine the best bladder dosimetric parameter for vaginal cuff brachytherapy.

METHODS AND MATERIALS

In this prospective clinical trial, a total of 20 women underwent vaginal cylinder high-dose-rate brachytherapy. The bladder was full for Fraction 2 and empty for Fraction 3. Dose-volume histogram and dose-surface histogram values were generated for the bladder, rectum, and urethra. The midline maximal bladder point (MBP) and the midline maximal rectal point were recorded. Paired t tests, Pearson correlations, and regression analyses were performed.

RESULTS

The volume and surface area of the irradiated bladder were significantly smaller when the bladder was empty than when full. Of the several dose-volume histogram and dose-surface histogram parameters evaluated, the bladder maximal dose received by 2 cm(3) of tissue, volume of bladder receiving >/=50% of the dose, volume of bladder receiving >/=70% of the dose, and surface area of bladder receiving >/=50% of the dose significantly predicted for the difference between the empty vs. full filling state. The volume of bladder receiving >/=70% of the dose and the maximal dose received by 2 cm(3) of tissue correlated significantly with the MBP. Bladder filling did not alter the volume or surface area of the rectum irradiated. However, an empty bladder did result in the nearest point of bowel being significantly closer to the vaginal cylinder than when the bladder was full.

CONCLUSIONS

Patients undergoing vaginal cuff brachytherapy treated with an empty bladder have a lower bladder dose than those treated with a full bladder. The MBP correlated well with the volumetric assessments of bladder dose and provided a noninvasive method for reporting the MBP dose using three-dimensional imaging. The MBP can therefore be used as a surrogate for complex dosimetry in the clinic.

Ten-year data on 138 patients with endometrial carcinoma and postoperative vaginal brachytherapy alone: No need for external-beam radiotherapy in low and intermediate risk patients

OBJECTIVE

To evaluate long-term outcome, risk factors, and causes of death in stage I-IIIA endometrial carcinoma (EC) patients treated only with adjuvant vaginal brachytherapy (VB) and to clarify for which subgroups of patients it is safe to omit external-beam radiotherapy (EBRT).

METHODS

Out of 224 EC patients receiving postoperative radiotherapy between 1990 and 2002, 138 had VB alone in curative intent (FIGO [2002]: 85%I, 12%II, 3%IIIA; 18 low risk [IA G1-2, IB G1], 103 intermediate risk [IB G2-3, IC G1-2, IIA-B G1-2], 17 high risk [IC G3, IIIA]). After surgery+/-lymphadenectomy, HDR-brachytherapy prescription (in 95.7% of patients) was 3x10 Gy to the surface or 3x5 Gy at 5 mm tissue depths.

RESULTS

Median follow-up was 107 months (range 3-185). Three intermediate and 7 high risk-patients relapsed. The 10-year vaginal control was 99.2%, locoregional control was 95.2% (low/intermediate/high risk: 100%/98.9%/68.8%), and disease-free survival (DFS) was 91.7% (100%/96.8%/55.2%). Risk factors for poor DFS were lymphovascular space invasion, > or = 50% myometrial invasion (univariate, p<0.05), pathological FIGO-stage, and grade 3 (uni-/multivariate, p<0.05). Leading causes of deaths (n=41) were cardiovascular disease (29%) and other malignancies (24%) ahead of EC (19.5%). The 10-year overall survival was 68.5% and the disease-specific survival was 92.4%. Thirty-five secondary tumors in 31 patients led to a higher actuarial death rate (10-year 9.9%, 15-year 17.7%) than EC (7.6%).

CONCLUSIONS

Restricting adjuvant therapy to VB alone seems to be safe in low and intermediate risk EC and can be recommended. As death rarely relates to early-stage EC, value of adjuvant therapy is probably better reflected by DFS rather than by overall survival.

External radiotherapy versus vaginal brachytherapy for patients with intermediate risk endometrial cancer

PURPOSE

To determine if brachytherapy alone is adequate adjuvant local therapy in patients classified as intermediate risk after complete surgical staging for endometrioid adenocarcinoma.

METHODS

Between 1991 and 2004, 78 patients with FIGO stage IA-II (occult) disease meeting the eligibility criteria of GOG 99 received adjuvant radiotherapy following complete surgical staging (total abdominal hysterectomy and bilateral salpingo-oophorectomy, peritoneal cytology, and pelvic+/-para-aortic lymphadenectomy) for endometrioid adenocarcinoma at Washington University in St. Louis. Forty-two patients received postoperative vaginal brachytherapy alone and 36 received postoperative pelvis external radiotherapy (XRT) and vaginal brachytherapy. Fifty-two patients were classified as having high intermediate risk disease and 26 patients had low intermediate risk disease as defined by GOG 99. Median follow-up for all patients was 55 months.

RESULTS

The 5-year overall and disease-free survivals for all patients were 86% and 89%, respectively. There was no difference in 5-year disease-free survivals among patients classified as high intermediate risk vs. low intermediate risk (p=0.26) or in terms of radiation treatment received (p=0.95). There were two patients that had >grade 2 gastrointestinal complications, both were treated with external radiotherapy and vaginal brachytherapy.

CONCLUSIONS

Vaginal brachytherapy alone results in minimal morbidity and is adequate local therapy for intermediate risk patients with endometrioid adenocarcinoma after complete surgical staging.