Clinical stage I and II endometrial carcinoma treated with surgery and/or radiation therapy: analysis of prognostic and treatment-related factors

Role of SUVmax and GLUT-1 Expression in Determining Tumor Aggressiveness in Patients With Clinical Stage I Endometrioid Endometrial Cancer

OBJECTIVE

The aim of this study was to determine the role of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography in estimating tumor aggressiveness in patients with clinical stage I endometrial cancer and the correlation between aggressiveness and expression of glucose transporter 1 (GLUT-1).

METHODS

F-fluorodeoxyglucose positron emission tomography/computed tomography was performed on 43 patients with clinical stage I endometrioid endometrial cancer. (18)F-fluorodeoxyglucose uptake was quantified by calculating the maximum standardized uptake value (SUV(max)) and GLUT-1 expression status based on immunohistochemistry.

RESULTS

The mean (SD) SUV(max) of the primary tumor was 8.55 (5.04). The mean SUV(max) and GLUT-1 expression in stage IB and stage IC were significantly higher than that in stage IA (P = 0.001; P = 0.003). The mean (SD) SUV(max) was 6.81 (4.55) in grade 1, 10.92 (4.61) in grade 2, and 15.35 (1.34) in grade 3 (grade 1 vs grade 2 and 3; P = 0.005). The mean (SD) GLUT-1 expression was 1.17 (0.94) in grade 1, 2.00 (0.94) in grade 2, and 3.00 (0.00) in grade 3 (grade 1 vs grade 2 and 3; P = 0.017).

CONCLUSIONS

Tumor aggressiveness, such as myometrial invasion or tumor grade, had a positive correlation with the SUV(max) and GLUT-1 expression in patients with clinical stage I endometrioid endometrial cancer.

Lymph node metastasis in endometrioid adenocarcinomas of the uterine corpus with occult cervical involvement

OBJECTIVE

Surgical-pathologic studies have defined the risk of lymphatic metastasis in clinical stage I endometrial cancers. However, data on the risk of lymph node metastasis in endometrial cancers involving the uterine cervix are less robust. The aim of this study was to determine the risk of lymphatic metastasis in patients with endometrial cancers with occult tumor extension to the uterine cervix.

METHODS

Our institutional tumor registry identified all patients with endometrioid endometrial cancers who underwent comprehensive surgical staging. Patients with gross involvement of the cervix and patients with extra-uterine disease were excluded. The risk of lymphatic metastasis associated with cervical involvement was analyzed in the context of known uterine risk factors for lymphatic metastasis such as age, depth of invasion, grade, and lymphovascular space invasion (LVSI).

RESULTS

We identified 169 patients who met inclusion and exclusion criteria. Univariate analyses revealed that LVSI (p<0.01), tumor grade (p<0.01), depth of myometrial invasion (p<0.01), tumor free distance (p<0.01), tumor size (p=0.02), and cervical involvement (p<0.01) were associated with lymphatic metastasis while age at diagnosis (p=0.85) was not. Multivariate analyses revealed that only LVSI (p<0.01), tumor grade (p=0.02), and depth of myometrial invasion (p=0.03) were independently associated with lymphatic metastasis.

CONCLUSION

Cervical involvement is not an independent predictor of lymphatic metastasis in endometrial cancer. In an unstaged patient, decisions regarding adjuvant treatment or additional diagnostic procedures such as lymphadenectomy should be based on uterine factors.

Vaginal treatment of endometrial cancer: role in the elderly

Background

To compare abdominal hysterectomy, the most currently used for treating cancer of the endometrium, to the vaginal hysterectomy in term of survival, morbidity and failure rates.

Methods

We retrospectively analyzed 68 cases divided into two sub-groups. A study group of 31 cases received vaginal surgery; a control group of 37 cases was treated with a laparotomy. Mean operative time, median hospital stay, intra- and post-operative complications, DFS and OS time as well as occurrence of local or distant recurrences have been evaluated and reported. Cases included patients with a higher rate of medical morbidities (p = 0.01) than controls.

Results

Mean age was 76.2 and 70.4 years in the vaginal (V) group and abdominal (A) group respectively. Mean operative time was longer for the group A. Group V patients had a lower mean post-operative hospital stay (p < 0.05). Differences in the two groups regarding intra- and post-operative complications, occurrence of local or distant recurrences and DFS time were not statistically significant. Disease specific survival time at 5 years scored 97% for group V, and 97% for group A.

Conclusions

Results show how vaginal approach had a similar outcome in selected patients. Vaginal surgery could therefore be the proper choice in patients with early stages and lower surgical risk, in addition to elderly patients exposed to a higher surgical risk.

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.

VEGF, flt-1, and KDR/flk-1 as prognostic indicators in endometrial carcinoma

OBJECTIVE

Tumor angiogenesis is a highly regulated process under the influence of the host microenvironment and mediators. Studies of breast cancer and, more recently, ovarian and cervical cancer, demonstrate that neovascularization correlates with the likelihood of metastasis and recurrence. Vascular endothelial growth factor (VEGF), an important regulator of tumor angiogenesis in the endometrium, flt-1, and KDR/flk-1 are good markers of vascular proliferation. Being that angiogenesis is a precursor to the development of progressive disease, we hypothesize that quantifying VEGF, flt-1, and KDR/flk-1 expression in uterine malignancies is a superior predictor of metastatic potential and survival than is FIGO grade of tumor, depth of invasion, and histology.

METHODS

The histologic slides of 47 patients with uterine malignancies (35 adenocarcinomas, 6 papillary serous, and 6 carcinosarcomas) were reviewed. The paraffin blocks from the primary tumor were obtained. Immunohistochemistry staining was performed for VEGF, flt-1, and KDR/flk-1. Microvessel density, used to analyze VEGF and receptor concentrations, was determined by two independent investigators, who were blinded to the patients clinical status. The impact of VEGF, flt-1, and KDR/flk-1 as well as stage, grade, depth of invasion, and nodal status on the incidence of metastases, recurrence, and survival was determined using logistic regression analysis and product limit life system survival analysis, respectively.

RESULTS

Results indicated that when evaluating all three histologic types, only stage and grade of tumor were found to impact upon the incidence of recurrence and survival. When patients with carcinosarcoma and papillary serous adenocarcinoma were excluded from the analysis, once again only stage and grade of tumor were significant prognostic indicators of recurrence and survival. Only grade of tumor and depth of uterine invasion were significant predictors of a tumor's metastatic potential. VEGF, flt-1, and KDR/flk-1 proved to be of little significance in predicting metastases, recurrence, and survival. Patients with advanced disease in all three histologic subtypes often had low VEGF and receptor positivity.

CONCLUSIONS

In this study, VEGF, flt-1, and KDR/flk-1 receptor concentrations did not correlate with the incidence of metastases, recurrence, and survival.

SEER data, corpus uteri cancer: treatment trends versus survival for FIGO stage II, 1988-1994

OBJECTIVE

1998 Surveillance, Epidemiology, and End Results (SEER) data estimate an 83.1% 5-year survival rate for corpus uteri adenocarcinoma FIGO stage II. The SEER data were evaluated to determine whether primary treatment differences using simple hysterectomy or radical hysterectomy, with or without radiation, altered disease survival.

MATERIALS AND METHODS

SEER incidence data for FIGO II uterine corpus cancer of adenocarcinoma histology from 1988 to 1994 were stratified by hysterectomy type (simple versus radical) and whether radiation was given. Survival rates were calculated using a relative survival method and are expressed as percentages. Statistical analysis was done using a Z test.

RESULTS

The 5-year cumulative survival rate for patients with stage II uterine corpus adenocarcinoma who received surgery alone as primary therapy was 84.36% with simple hysterectomy and 92.96% with radical hysterectomy (P<0.05). Survival for patients who received combination radiation and surgery as primary therapy was 82.77% with simple hysterectomy and 88.02% with radical hysterectomy (P<0.05). Pelvic and para-aortic nodes were negative. There was no significant survival difference for radiation versus no radiation in either surgical group.

CONCLUSION

Radical hysterectomy is associated with better survival when compared to simple hysterectomy for FIGO II corpus uteri adenocarcinoma.

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

We performed a retrospective evaluation of survival and patterns of failure in 317 consecutive endometrial cancer patients treated between 1974 and 1991 with surgery and adjuvant radiotherapy. Two hundred and forty seven patients (78%) had FIGO stage I disease, 30 (9%) - stage II, 35 (11%) - stage III and 5 (2%) - stage IV. Both low dose rate brachytherapy (BRT) and external beam radiation (EBRT) were applied in 247 patients (78%), only BRT in 49 (15%), and only EBRT in 21 (7%). Median follow-up was 7.3 years. Five-year overall survival was 75%, and five-year disease free survival was 81%. Both overall and disease free survival rates were correlated with stage (P = 0.001 and P = 0.000, respectively). Recurrence occurred in 70 patients (22%): 11 (3.5%) in the pelvis, 51 (16%) outside the pelvis and 6 (2%) both in- and outside the pelvis. Independent risk factors for local recurrence included older age (P = 0.03) and variant histologic subtypes (P = 0.039), whereas independent risk factors for distant spread were stage (P = 0.000) and older age (P = 0.011). Normalized Total Dose (the sum of EBRT and BRT doses, based on linear-quadratic equation), type of radiotherapy regimen, overall radiotherapy time and surgery-to-radiotherapy interval did not correlate with the risk of relapse. Severe early and late radiotherapy complications were observed in 21 (7%) and 35 patients (11%), respectively. In view of the relatively low risk of exclusive pelvic recurrences and the high rate of severe late radiotherapy complications, indications for postoperative radiotherapy and its scheme should be verified. A relatively high rate of extrapelvic recurrences calls for effective systemic adjuvants to surgery. Further definition of high risk patients is warranted in order to tailor postoperative therapy to the prognostic factors and to increase the therapeutic index of management of endometrial cancer.

Stage I corpus cancer: is teletherapy necessary?

OBJECTIVE

Our aim was to evaluate the perioperative morbidity after hysterectomy and lymphadenectomy as primary treatment of endometrial cancer and to analyze the recurrence and survival of patients classified as having surgical stage I disease who did not receive adjunctive teletherapy.

STUDY DESIGN

Over a 10-year interval 444 patients underwent extensive surgical staging for corpus cancer. Perioperative events were recorded prospectively. Outcome events were updated after the last year of study.

RESULTS

After patients with high-risk histologic types of cancer were excluded, 396 patients were evaluable. The risk of extrauterine disease, detected in 21.8% of patients, increased with increasing lack of tumor differentiation. The associated surgical morbidity, including blood loss (mean 336 ml), surgical site infection (3.5%), thromboembolic events (1.5%), and urinary injury (0.6%), and deaths (0.6%) did not differ from those in reports of women undergoing lesser operative procedures. Late complications, including lymphocyst (1.2%), leg edema (1.8%), and hernia (2.9%), were infrequent. Recurrence and survival analysis indicated a calculated 5-year survival of 97% of all patients with surgical stage I disease. There was a significant survival difference related to grade and stage for women in whom disease was confined to the uterus. Overall survival in patients with stage IA (100%) was significantly different (p < 0.0001) from that of patients with stage IB (97%) and stage IC (93%). All recurrences included a distal component.

CONCLUSION

Extensive surgical staging including lymphadenectomy can be performed safely. Our results suggest that the risk of pelvic recurrence is not increased and the risk of survival is not compromised in those women not receiving adjunctive teletherapy.

Clinicopathologic correlation of DNA flow cytometric content analysis (DFCA), surgical staging, and estrogen/progesterone receptor status in endometrial adenocarcinoma

DNA flow cytometric content analysis (DFCA) and estrogen (ER) and progesterone (PR) receptor levels are reported to be prognostic with regard to the malignant potential of endometrial adenocarcinoma. We retrospectively reviewed the records of 50 patients presenting with endometrial adenocarcinoma between July 1990 and December 1992, to determine the extent of any pathologic features reported at the time of hysterectomy. Patients whose tumors were nondiploid (aneuploid) by flow cytometry generally presented with a higher pathologic stage, higher grade, and more frequent lymph node involvement. In addition, the majority of clear cell and uterine papillary serous (UPS) adenocarcinoma were also nondiploid. Fourteen of 21 ER-positive tumors aneuploid, as were 18 of 37 PR-positive tumors. We also found DNA-A (DNA content aneuploid) patterns frequently associated with tumor characteristics implicated by other authors as related to aggressiveness. Further studies comparing the molecular biology of tumors to their clinicopathologic features and behavior are needed to fully understand the ultimate malignant potential.

Uterine prolapse complicated by endometrial cancer

OBJECTIVE

An infrequent clinical dilemma arises when a patient with uterine prolapse that is best treated vaginally is discovered to have coexisting endometrial cancer. Often the underlying cancer is only discovered intraoperatively or postoperatively. We have reviewed our experience in this situation in an effort to evaluate efficacy of treatment, strategies to avoid late postoperative discovery of cancer, and general guidelines for optimal treatment.

STUDY DESIGN

At the Mayo Clinic from 1950 to 1993, 54 patients with coexisting endometrial carcinoma underwent vaginal hysterectomy with repairs for uterine prolapse.

RESULTS

We have retrospectively reviewed these cases for relevant data and survival analysis. Complete follow-up is available for 53 patients, and there were four recurrences. In 19 patients bilateral oophorectomy was not performed for multiple reasons, and one of these patients had a recurrence. Twenty-five percent of all patients had disease confined to the endometrium, and 80% overall had low-grade lesions with superficial or no myometrial invasion. Of the four recurrences, three would have been considered low risk of extrauterine spread, and it is doubtful that an abdominal approach would have yielded additional useful information. No patient required reoperation for recurrent pelvic relaxation.

CONCLUSION

We believe that for certain selected patients vaginal surgery for uterine prolapse is adequate treatment in the presence of endometrial cancer. We discuss the selection strategies, exclusion criteria, and general guidelines to optimize care for these challenging patients.

Stereological estimate of nuclear volume in endometrial adenocarcinoma of endometrioid type: reproducibility and intra-tumour variation

Stereological volume weighted mean nuclear volume estimate (Vv) is reported to be highly reproducible and to provide excellent prognostic information for some tumours. The aim of the present study was to investigate the reproducibility and the intra-tumour variation of nuclear Vv and compare it with a morphometric nuclear estimate, i.e. the mean shortest nuclear axis, and with conventional histopathological parameters used in the grading of endometrial adenocarcinomas. Sixty-three endometrioid adenocarcinomas were included in the study. Both Vv and mean shortest nuclear axis showed an acceptable reproducibility and the correlation between them was moderate (Spearman test; rs = 0.8). One-third of the tumours showed a marked intra-tumour variation. A considerable discrepancy between Vv and/or mean shortest nuclear axis and nuclear and architectural grade was found.

Clinical stage I adenocarcinoma of the endometrium--analysis of recurrences and the potential benefit of staging lymphadenectomy

Two hundred forty-eight consecutive patients with clinical Stage I adenocarcinoma of the endometrium were seen between 8/77 and 8/88. Twenty-one were medically not operable and eleven others had papillary serous tumors. The remaining 216 were managed by a consistent operative protocol except that routine preoperative cesium was discontinued after 12/83. Patients received postoperative pelvic radiation on the basis of the depth of invasion, extrauterine pelvic disease, and/or cervix involvement. No patient underwent a pelvic lymphadenectomy. Only palpably suspicious nodes were removed. Twenty-one of these two hundred sixteen patients developed a recurrence. These 21 cases are analyzed for the probability of a staging lymphadenectomy having prevented their recurrence. Median follow-up of all 216 patients is 61 months with a mean time to recurrence of 26.5 months. No patient was lost to follow-up. Patients who recurred are analyzed by grade, depth of invasion, surgical stage, time to recurrence, site of recurrence, survival, protocol breaks, and frozen section discrepancies. No patient recurred on the pelvic side-wall. All patients found to have positive para-aortic nodes have died. No patient who received vaginal and/or pelvic radiation recurred in the pelvis. We conclude that staging lymphadenectomy would not have improved the outcome for these patients.

Evaluation of the reproducibility of the revised 1988 International Federation of Gynecology and Obstetrics grading system of endometrial cancers with special emphasis on nuclear grading

An intraobserver and interobserver analysis of the reproducibility of the revised 1988 International Federation of Gynecology and Obstetrics (FIGO) grading system of endometrial cancers was performed in 47 endometrial cancers (94 biopsy specimens). In the revised FIGO grading system the growth pattern still serves as the basic parameter, but nuclear atypia inappropriate for the architectural grade, raises the grade by 1. Ninety-four slides were graded twice by two pathologists. Analysis by the kappa statistics (corrected for agreement by chance) showed an acceptable result for interobserver reproducibility: kappa value 0.65 (95% confidence interval, 0.480 to 0.818). Further study showed this to be a reflection of the reproducibility of the architectural grade: kappa 0.70 (95% confidence interval, 0.565 to 0.850), whereas the reproducibility of the nuclear grade was poor: kappa value 0.55 (95% confidence interval, 0.383 to 0.713). Review of the literature showed great variability in the definition of nuclear grading, indicating that the revised 1988 FIGO grading system is not applicable as standard of reference for studies of endometrial cancers, before agreeing to the definition of inappropriate nuclear atypia.

A new treatment for endometrial cancer with gonadotrophin releasing-hormone analogue

OBJECTIVE

To test the antitumour effect of gonadotrophin releasing-hormone (GnRH) analogues in women with recurrent endometrial cancer.

DESIGN

An open phase II observational trial of GnRH analogues. Serial measurements of gonadotrophins, sex hormones and tumour dimensions were made together with repeat biopsy when possible to assess the response to treatment.

SETTING

The outpatient clinics of the Department of Medical Oncology at The Royal London, Royal Marsden and St Bartholomew's hospitals.

SUBJECTS

17 patients with endometrial cancer which had recurred after surgery, radiotherapy and progesterone treatment and was symptomatic, progressive and assessable for response.

INTERVENTION

Monthly subcutaneous injection of GnRH analogue.

MAIN OUTCOME MEASURES

Reduction in serum gonadotrophins and reduction in tumour dimensions.

RESULTS

Six out of 17 patients (35%, 95% CI 12.6-58%) achieved a complete or partial remission which continues for a median of 20 months with no adverse effects.

CONCLUSION

GnRH analogues have a significant antitumour effect in recurrent endometrial cancer which warrants further examination in comparison with progestogens.

Use of vaginal hysterectomy for the management of stage I endometrial cancer in the medically compromised patient

Vaginal hysterectomy was performed on 31 patients with stage I endometrial cancer because of medical problems which placed them at high risk for morbidity and mortality from abdominal surgery. These risk factors included morbid obesity (87%), hypertension (58%), diabetes mellitus (35%), and cardiovascular diseases (26%). The perioperative morbidity was minimal, with only four patients (13%) experiencing complications requiring extended hospital stays and no deaths. Adjuvant radiotherapy was administered in 35% of patients with either deep myometrial invasion or unfavorable histology. The 3- and 5-year disease-free survival rates were 100 and 93%, respectively. The only cancer-related death occurred 4.5 years following surgery. Although the authors are not advocating vaginal hysterectomy as standard treatment of endometrial cancer, this approach provides an acceptable alternative to abdominal surgery in the medically compromised patient.