How should we monitor women treated for endometrial carcinoma?

Follow-up of ovarian and primary peritoneal carcinoma: The value of physical examination in patients with pretreatment elevated CA125 levels

OBJECTIVE

To assess the value of routine periodic physical examination in the follow-up of ovarian (OvC) and primary peritoneal carcinoma (PPC) patients with pretreatment elevated CA125 levels.

METHODS

Included were patients who had a pretreatment serum CA125 level above normal limits, had completed initial treatment, were in complete clinical remission on completion of the initial treatment and routinely attended the gynecologic oncology outpatient clinic. Recurrence was diagnosed when at least one of the following criteria was abnormal: symptoms, physical examination or elevated serum CA125 levels.

RESULTS

Of 69 patients, a recurrence was diagnosed in 43. Abnormal physical examination for diagnosis of recurrence yielded a sensitivity rate of only 34.9%. The diagnosis of recurrence was based on an abnormal physical examination alone in 2 (4.6%) patients.

CONCLUSION

In OvC and PPC patients with elevated pretreatment CA125 levels, physical examination has a limited impact on the diagnosis of recurrence.

Survival after relapse in patients with endometrial cancer: results from a randomized trial

OBJECTIVE

The aim of this study was to determine the rates of local control and survival after relapse in patients with stage I endometrial cancer treated in the multicenter randomized PORTEC trial.

METHODS

The PORTEC trial included 715 patients with stage 1 endometrial cancer, either grade 1 or 2 with deep (>50%) myometrial invasion or grade 2 or 3 with <50% invasion. In all cases an abdominal hysterectomy was performed, without lymphadenectomy. After surgery, patients were randomized to receive pelvic RT (46 Gy) or no further treatment.

RESULTS

The analysis was done by intention-to-treat. A total of 714 patients were evaluated. At a median follow-up of 73 months, 8-year actuarial locoregional recurrence rates were 4% in the RT group and 15% in the control group (P < 0.0001). The 8-year actuarial overall survival rates were 71 (RT group) and 77% (control group, P = 0.18). Eight-year rates of distant metastases were 10 and 6% (P = 0.20). The majority of the locoregional relapses were located in the vagina, mainly in the vaginal vault. Of the 39 patients with isolated vaginal relapse, 35 (87%) were treated with curative intent, usually with external RT and brachytherapy, and surgery in some. A complete remission (CR) was obtained in 31 of the 35 patients (89%), and 24 patients (77%) were still in CR after further follow-up. Five patients subsequently developed distant metastases, and 2 had a second vaginal recurrence. The 3-year survival after first relapse was 51% for patients in the control group and 19% in the RT group (P = 0.004). The 3-year survival after vaginal relapse was 73%, in contrast to 8 and 14% after pelvic and distant relapse (P < 0.001). At 5 years, the survival after vaginal relapse was 65% in the control group compared to 43% in the RT group.

CONCLUSION

Survival after relapse was significantly better in the patient group without previous RT. Treatment for vaginal relapse was effective, with 89% CR and 65% 5-year survival in the control group, while there was no difference in survival between patients with pelvic relapse and those with distant metastases. As pelvic RT was shown to improve locoregional control significantly, but without a survival benefit, its use should be limited to those patients at sufficiently high risk (15% or over) for recurrence in order to maximize local control and relapse-free survival.

Endometrial adenocarcinoma: a primer for the generalist

Endometrial cancer is the most common gynecologic malignancy in the United States. The mean and median age of women with endometrial adenocarcinoma is 61 years. Most endometrial cancers are type I estrogen-dependent endometrioid adenocarcinomas. Most women with endometrial adenocarcinoma have stage I disease. Patients with stage I disease endometrial adenocarcinoma can be treated with a simple hysterectomy, bilateral salpingo-oophorectomy, peritoneal lavage, and periaortic node dissection in selected cases. The probability of survival according to international statistics is as follows: stage IA, 91%; stage IB, 88%; stage IC, 81%; stage IIA, 77%; stage IIB, 67%; stage IIA, 60%; stage IIIB, 41%; stage IIC, 32%; stage IVA, 20%; stage IVB, 5%.

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.