Pattern of failure and value of follow-up procedures in endometrial and cervical cancer patients

Cervical cancer: a new era

Cervical cancer is a major global health issue, ranking as the fourth most common cancer in women worldwide. Depending on stage, histology, and patient factors, the standard management of cervical cancer is a combination of treatment approaches, including (fertility- or non-fertility-sparing) surgery, radiotherapy, platinum-based chemotherapy, and novel systemic therapies such as bevacizumab, immune checkpoint inhibitors, and antibody-drug conjugates. While ambitious global initiatives seek to eliminate cervical cancer as a public health problem, the management of cervical cancer continues to evolve with major advances in imaging modalities, surgical approaches, identification of histopathological risk factors, radiotherapy techniques, and biomarker-driven personalized therapies. In particular, the introduction of immune checkpoint inhibitors has dramatically altered the treatment of cervical cancer, leading to significant survival benefits in both locally advanced and metastatic/recurrent settings. As the landscape of cervical cancer therapies continues to evolve, the aim of the present review is to provide a comprehensive discussion of the current state and the latest practice-changing updates in cervical cancer.

Management for Cervical Cancer Patients: A Comparison of the Guidelines from the International Scientific Societies (ESGO-NCCN-ASCO-AIOM-FIGO-BGCS-SEOM-ESMO-JSGO)

Cervical cancer continues to have a significant incidence, despite global efforts in HPV vaccination campaigns. Managing this condition involves a diverse team of healthcare professionals. Research in this field is undergoing a period of great revolution in multiple areas, and international guidelines will soon have to adapt to new scientific evidence. This could be true mainly in locally advanced stages, and it could also be true for minimal invasive surgery. This paper aims to summarize and compare the most recent recommendations published by international gynecological oncological societies for patients with cervical cancer. From their comparison, common aspects and disagreements emerged, especially in the diagnostic pathway and follow-up strategies. Several issues that remain to be debated in the literature were addressed and compared, highlighting similarities and differences, from the role of the sentinel lymph node in early stages to that of the adjuvant hysterectomy in locally advanced tumors. On the surgical side, for this last subset of patients, currently, a laparotomic approach is recommended. At the same time, the advent of immunotherapy has just opened up new and promising scenarios in systemic treatment for locally advanced cervical cancer, and international guidelines will soon introduce it into their algorithms.

An evaluation of the utility of computed tomography in high-risk endometrial cancer surveillance

OBJECTIVES

Endometrial cancer is a collection of heterogeneous histologies and molecular subtypes with different risk profiles. High-risk endometrial cancer surveillance regimens vary amongst providers. The National Comprehensive Cancer Network (NCCN) recommends symptom and exam-based surveillance for all endometrial cancers after remission, regardless of cancer stage and histology. Our objective was to identify the first method of detection of recurrence in high-risk endometrial cancers and examine disease recurrence and treatment patterns.

METHODS

A retrospective review of patients diagnosed with high-risk endometrial cancer between November 2013 and February 2020 was conducted at a large academic institution. High-risk endometrial cancers were classified by histology and pathologic stage and were categorized by primary method of detection.

RESULTS

Two hundred and twenty-nine patients were identified with high-risk endometrial cancer, 63 (28 %) of whom had a recurrence. Most recurrences were first detected with routine imaging in 31 patients (49.2 %) and symptom surveillance in 24 patients (38.15 %). Regardless of the detection method, most patients underwent systemic treatment. The average survival after recurrence was 2.0 years in the imaging cohort and 1.6 years in the non-imaging surveillance cohort.

CONCLUSIONS

The most common site of recurrence in our cohort of high-risk endometrial cancer was in the lung, and most recurrences were identified with asymptomatic imaging. Though there was no statistically significant difference between the survival of those who underwent imaging surveillance vs. standard of care, there was a trend toward survival that deems further exploration with a larger cohort.

Endometrial Cancer. Guideline of the DGGG, DKG and DKH (S3-Level, AWMF Registry Number 032/034-OL, September 2022) - Part 2 with Recommendations on the Therapy of Precancerous Lesions and Early-stage Endometrial Cancer, Surgical Therapy, Radiotherapy and Drug-based Therapy, Follow-up Care, Recurrence and Metastases, Psycho-oncological Care, Palliative Care, Patient Education, and Rehabilitative and Physiotherapeutic Care

Summary The S3-guideline on endometrial cancer, first published in April 2018, was reviewed in its entirety between April 2020 and January 2022 and updated. The review was carried out at the request of German Cancer Aid as part of the Oncology Guidelines Program and the lead coordinators were the German Society for Gynecology and Obstetrics (DGGG), the Gynecology Oncology Working Group (AGO) of the German Cancer Society (DKG) and the German Cancer Aid (DKH). The guideline update was based on a systematic search and assessment of the literature published between 2016 and 2020. All statements, recommendations and background texts were reviewed and either confirmed or amended. New statements and recommendations were included where necessary. Aim The use of evidence-based risk-adapted therapies to treat low-risk women with endometrial cancer prevents unnecessarily radical surgery and avoids non-beneficial adjuvant radiation therapy and/or chemotherapy. For women with endometrial cancer and a high risk of recurrence, the guideline defines the optimum level of radical surgery and indicates whether chemotherapy and/or adjuvant radiation therapy is necessary. This should improve the survival rates and quality of life of these patients. The S3-guideline on endometrial cancer and the quality indicators based on the guideline aim to provide the basis for the work of certified gynecological cancer centers. Methods The guideline was first compiled in 2018 in accordance with the requirements for S3-level guidelines and was updated in 2022. The update included an adaptation of the source guidelines identified using the German Instrument for Methodological Guideline Appraisal (DELBI). The update also used evidence reviews which were created based on selected literature obtained from systematic searches in selected literature databases using the PICO process. The Clinical Guidelines Service Group was tasked with carrying out a systematic search and assessment of the literature. Their results were used by interdisciplinary working groups as a basis for developing suggestions for recommendations and statements which were then modified during structured online consensus conferences and/or additionally amended online using the DELPHI process to achieve a consensus. Recommendations Part 2 of this short version of the guideline provides recommendations on the treatment of precancerous lesions and early-stage endometrial cancer, surgical treatment, radiotherapy and drug-based therapy, follow-up, recurrence, and metastasis of endometrial cancer as well as the state of psycho-oncological care, palliative care, patient education, rehabilitative and physiotherapeutic care.

The contemporary presentation and diagnosis of endometrial cancer recurrence: When, where, and how?

OBJECTIVE

To examine patients with confirmed endometrial cancer recurrence; evaluate patterns, presentation, and mode of diagnosis.

STUDY DESIGN

A retrospective review of women with endometrial cancer diagnosis between 2014 and 2020. Disease recurrences were evaluated. Medical records were reviewed focusing on presentation at time of recurrence. Relationships were assessed using χ2, Fisher's exact test, t-test, and Wilcoxon test. The Kaplan-Meier product limit was used to estimate survival. Multiple logistic regression analysis was used to assess the impact of covariates.

RESULTS

Endometrial cancer recurrence was identified in 201 (11.7%) patients. Sixty percent (120/201) of patients presented with symptoms. Pain was the most common presenting symptom (23.4%, 47/201) and bleeding was reported in <14% (28/201). Patients with symptomatic presentation were less likely to be able to receive treatment for their recurrent disease (76.7% vs 91.3%, p = 0.005). Asymptomatic pelvic exam diagnosed recurrence in 13.4% (27/201) and was more common in patients initially diagnosed with early-stage disease (66.7% vs 34.5% p = 0.001) of endometrioid histology (66.7% vs 36.8%, p = 0.003) without prior adjuvant therapy (48.2% vs 17.9%, p = 0.001). More than1/3 of diagnoses were made by providers outside of the oncologic care team.

CONCLUSION

The majority of women with recurrent endometrial cancer were symptomatic and pain is a common complaint associated with disease recurrence. Patients with symptomatic presentation of disease recurrence were less likely to receive treatment for recurrent disease but this did not result in an overall survival (OS) difference. Given the rising mortality rate of endometrial cancer further work is needed to develop multidisciplinary surveillance strategies that will enable meaningful treatment of disease recurrence.

The long game: Telemedicine patient satisfaction metrics and methods of recurrence detection for gynecologic cancer patients throughout the initial year of the COVID-19 pandemic

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Survey results of demonstrated persistence in high satisfaction with telemedicine over one year into the COVID-19 pandemic.

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Gynecologic oncology patients welcome ongoing use of telemedicine for delivery of cancer care.

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The most common method of gynecologic cancer recurrence detection is patient reported symptoms.

Objective

The primary aim of this study was to evaluate gynecologic cancer patients’ satisfaction with telemedicine visits over a one-year period during the COVID-19 pandemic. The secondary aim was to characterize how gynecologic cancer recurrence was detected with high telemedicine utilization.

Methods

A survey study and a retrospective cohort study of patients participating in telemedicine visits between April 20, 2020 and March 30, 2021 in a gynecologic oncology clinic were undertaken. To assess patient satisfaction with telemedicine visits, the Telemedicine Satisfaction Survey (TeSS) was administered to patients by phone. Retrospective chart review was conducted to gather clinical data regarding diagnosis, treatment, and recurrence.

Results

Three hundred and sixteen patients completed the TeSS for a response rate of 80.2%. Patients rated the following aspects of the telemedicine encounter as good or excellent: quality of technology (97.8%), personal comfort (90.8%), length-of-visit (95.2%), treatment explanation (93.7%), overall experience (92.7%). Moreover, 87.0% of patients would use telemedicine again. Retrospective data was collected for 394 patients, 312 of which had invasive cancer (79.2%). Twenty-nine (7.4%) patients experienced a recurrence during the study period. The most common method of detection was patient-reported symptoms (n = 17, 58.6%). The remaining recurrences were diagnosed by scheduled biomarkers (n = 7, 24.1%), scheduled imaging (n = 4, 13.8%) and asymptomatic exam (n = 1, 3.4%).

Conclusions

After one year of the COVID-19 pandemic and the implementation of routine telehealth visits, gynecologic cancer patients were overwhelmingly satisfied with the use of telemedicine. During this period, recurrences were most often diagnosed by patient-reported symptoms.

Patterns of Recurrent Disease in Cervical Cancer

Uterine cervical cancer is one of the most common causes of cancer-related deaths among women worldwide. Patients with cervical cancer are at a high risk of pelvic recurrence or distant metastases within the first few years after primary treatment. However, no definitive agreement exists on the best post-treatment surveillance in these patients. Imaging may represent an accurate method of detecting relapse early, right when salvage treatment could be effective. In patients with recurrent cervical cancer, the correct interpretation of imaging may support the surgeon in the proper selection of patients prior to surgery to assess the feasibility of radical surgical procedure, or may help the clinician plan the most adaptive curative therapy. MRI can accurately define the extension of local recurrence and adjacent organ invasion; CT and 18F-FDG PET/CT may depict extra-pelvic distant metastases. This review illustrates different patterns of recurrent cervical cancer and how imaging, especially MRI, accurately contributes towards the diagnosis of local recurrence and the assessment of the extent of disease in patients with previous cervical cancer. Normal post-therapy pelvic appearance and possible pitfalls related to tissue changes for prior treatments will be also illustrated.

Treatment Strategies and Prognostic Factors of 2018 FIGO Stage IIIC Cervical Cancer: A Review

Cervical cancer is the fourth most common malignant tumor globally in terms of morbidity and mortality. The presence of lymph node metastasis (LNM) is an independent prognostic factor for progression-free survival (PFS) and overall survival (OS) in cervical cancer patients. The International Federation of Gynecology and Obstetrics (FIGO) staging system was revised in 2018. An important revision designates patients with regional LNM as stage IIIC, pelvic LNM only as stage IIIC1, and para-aortic LNM as stage IIIC2. However, the current staging system is only based on the anatomical location of metastatic lymph nodes (LNs). It does not consider other LN status parameters, which may limit its prognostic significance to a certain extent and needs further exploration and confirmation in the future. The purpose of this review is to summarize the choice of treatment for stage IIIC cervical cancer and the effect of different LN status parameters on prognosis.

Cancer of the corpus uteri: 2021 update

Endometrial cancer is the most common gynecological malignancy in high‐ and middle‐income countries. Although the overall prognosis is relatively good, high‐grade endometrial cancers have a tendency to recur. Recurrence needs to be prevented since the prognosis for recurrent endometrial cancer is dismal. Treatment tailored to tumor biology is the optimal strategy to balance treatment efficacy against toxicity. Since The Cancer Genome Atlas defined four molecular subgroups of endometrial cancers, the molecular factors are increasingly used to define prognosis and treatment. Standard treatment consists of hysterectomy and bilateral salpingo‐oophorectomy. Lymphadenectomy (and increasingly sentinel node biopsy) enables identification of lymph node‐positive patients who need adjuvant treatment, including radiotherapy and chemotherapy. Adjuvant therapy is used for Stage I–II patients with high‐risk factors and Stage III patients; chemotherapy is especially used in non‐endometrioid cancers and those in the copy‐number high molecular group characterized by TP53 mutation. In advanced disease, a combination of surgery to no residual disease and chemotherapy with or without radiotherapy results in the best outcome. Surgery for recurrent disease is only advocated in patients with a good performance status with a relatively long disease‐free interval.

The latest state‐of‐the‐art treatment for endometrial cancer is described, incorporating the most recent new data that influence its clinical management.

The annual recurrence risk model for tailored surveillance strategy in patients with cervical cancer

PURPOSE

Current guidelines for surveillance strategy in cervical cancer are rigid, recommending the same strategy for all survivors. The aim of this study was to develop a robust model allowing for individualised surveillance based on a patient's risk profile.

METHODS

Data of 4343 early-stage patients with cervical cancer treated between 2007 and 2016 were obtained from the international SCCAN (Surveillance in Cervical Cancer) consortium. The Cox proportional hazards model predicting disease-free survival (DFS) was developed and internally validated. The risk score, derived from regression coefficients of the model, stratified the cohort into significantly distinctive risk groups. On its basis, the annual recurrence risk model (ARRM) was calculated.

RESULTS

Five variables were included in the prognostic model: maximal pathologic tumour diameter; tumour histotype; grade; number of positive pelvic lymph nodes; and lymphovascular space invasion. Five risk groups significantly differing in prognosis were identified with a five-year DFS of 97.5%, 94.7%, 85.2% and 63.3% in increasing risk groups, whereas a two-year DFS in the highest risk group equalled 15.4%. Based on the ARRM, the annual recurrence risk in the lowest risk group was below 1% since the beginning of follow-up and declined below 1% at years three, four and >5 in the medium-risk groups. In the whole cohort, 26% of recurrences appeared at the first year of the follow-up, 48% by year two and 78% by year five.

CONCLUSION

The ARRM represents a potent tool for tailoring the surveillance strategy in early-stage patients with cervical cancer based on the patient's risk status and respective annual recurrence risk. It can easily be used in routine clinical settings internationally.

Innovative Follow-up Strategies for Endometrial Cancer

Increasing recognition of the heterogeneous nature of endometrial cancer, the excellent prognosis of low-risk cases and improvements in risk stratification offer opportunities for innovative, personalised follow-up strategies. This review article outlines the evidence base for alternative follow-up strategies in the different risk categories of endometrial cancer, cancer survivorship programmes and considers future directions in endometrial cancer follow-up, including emerging new techniques, such as the liquid biopsy, and opportunities for combining molecular and clinicopathological features to personalise endometrial cancer follow-up.

Long-term outcomes of cervical cancer patients with complete metabolic response after definitive chemoradiotherapy

OBJECTIVE

We investigated the importance of metabolic parameters measured with ¹⁸F-fluorodeoxyglucose positron-emission tomography integrated with computed tomography (FDG-PET/CT) for predicting progression-free survival (PFS) and overall survival (OS) in cervical cancer with complete metabolic response (CMR) after chemoradiotherapy (ChRT).

METHODS

The clinical data and PET parameters including standardized uptake value (SUV), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of 122 patients having CMR in post-treatment ¹⁸F-FDG-PET/CT delivered a median of 3.9 months after ChRT completion were analyzed.

RESULTS

With a median follow-up of 8.4 years, 55 patients (45%) presented with disease a median of 19.7 months after ChRT. For SUVp, MTVp, TLGp, SUVln, MTVln, and TLGp, the cut-off values for OS determined by receiver operating curve analysis were 15.8, 48.7 cm³, 552.3, 8.7, 7.0 cm³, respectively. All metabolic PET parameters were significant prognostic factors for OS and PFS in univariate analysis. International Federation of Gynecology and Obstetrics (FIGO) stage was predictive of both OS and PFS, while pelvic and/or para-aortic lymph node metastasis were predictive of OS only. In multivariate analysis, FIGO stage ≥IIB, MTVp ≥49.8 cm³, and TLGp ≥597.4 were predictive of worse OS. Advanced stage, presence of lymph node metastasis, higher TLGp, and larger MTVln were significant factors for poor PFS rates.

CONCLUSION

We found that advanced stage and higher TLGp values were significant predictors for poor survival and higher progression rates. Volumetric PET parameters could be used to predict treatment outcomes in patients with CMR after definitive ChRT.

Diagnostic Strategies for Recurrent Cervical Cancer: A Cohort Study

Objective

The effectiveness of various strategies for the post-treatment monitoring of cervical cancer is unclear. This pilot study was conducted to explore recurrence patterns in and diagnostic strategies for patients with uterine cervical cancer who were meticulously followed using a customized monitoring plan.

Methods

The epidemiological and clinical data of patients with recurrent cervical cancer treated from March 2012 to April 2018 at a tertiary teaching hospital were retrospectively collected. The diagnostic methods and their reliability were compared across patients with various clinicopathological characteristics and were associated with survival outcomes.

Results

Two hundred sixty-four patients with recurrent cervical cancer were included in the study, among which recurrence occurred in the first three years after the last primary treatment in 214 patients (81.06%). Half of the recurrence events (50.76%) occurred only within the pelvic cavity, and most lesions (78.41%) were multiple in nature. Among all recurrent cases, approximately half were diagnosed based on clinical manifestations (n=117, 44.32%), followed by imaging examinations (n=76, 28.79%), serum tumor markers (n=34, 12.88%), physical examinations (n=33, 12.50%) and cervical cytology with or without high-risk human papillomavirus (hrHPV) testing (n=4, 1.52%). The reliability of the diagnostic methods was affected by the stage (p<0.001), primary treatment regimen (p=0.001), disease-free survival (p=0.022), recurrence site (p=0.002) and number of recurrence sites (p=0.001). Primary imaging methods (sonography and chest X-ray) were not inferior to secondary imaging methods (computed tomography, magnetic resonance imaging and positron emission tomography-computed tomography) in the detection of recurrence. The chest X-ray examination only detected three cases (1.14%) of recurrence. Patients assessed with various diagnostic strategies had similar progression-free and overall survival outcomes.

Conclusions

A meticulous evaluation of clinical manifestations might allow recurrence to be discovered in a timely manner in most patients with cervical cancer. Specific diagnostic methods for revealing recurrence were not associated with the survival outcomes.

Use of bevacizumab before or after radiotherapy increases the risk of fistula formation in patients with cervical cancer

OBJECTIVE

Several reports have documented the risk of fistula formation after bevacizumab in patients previously treated with radiation therapy. The aim of this study was to investigate the risk of fistula formation with bevacizumab and radiotherapy compared with radiotherapy alone.

METHODS

We retrospectively analyzed patients with stage I-IV cervical cancer between January 2013 and December 2018. Patients who had a history of pelvic radiotherapy, who were treated with intracavitary brachytherapy alone, received radiotherapy at another hospital, received concurrent bevacizumab and radiotherapy, or had missing follow-up data or a short follow-up period (<6 months) were excluded. The fistula rates were compared between the groups using the Cox proportional hazards model and propensity score analyses.

RESULTS

A total of 302 patients were included in the study: 249 patients were treated with definitive or adjuvant radiotherapy, and 53 patients were treated with radiotherapy before or after bevacizumab. With a median follow-up of 35.9 (IQR 22.8-53.5) months, the 3 year cumulative fistula incidence rate was significantly higher in the radiotherapy + bevacizumab group than in the radiotherapy group (27.0% vs 3.0%, p<0.001). Bevacizumab administration was significantly associated with fistula formation in the multivariable adjusted model (HR 4.76, 95% CI 1.71 to 13.23) and three propensity score adjusted model (all p<0.05). Biologically equivalent dose in 2 Gy fractions for 2 cc of the rectum more than 76 Gy was also associated with fistula formation (HR 4.30, 95% CI 1.52 to 12.18). Additionally, a 10 month interval between radiotherapy and bevacizumab reduced the incidence of fistula formation in the radiotherapy + bevacizumab group (p=0.032).

CONCLUSIONS

In patients with cervical cancer treated with pelvic radiotherapy, the addition of bevacizumab substantially increased the risk of fistula formation. Physicians should perform pelvic radiotherapy in combination with bevacizumab with caution; moreover, close monitoring for fistula formation is warranted in these patients.

ACR Appropriateness Criteria® Pretreatment Evaluation and Follow-Up of Endometrial Cancer

To date, there is little consensus on the role of pelvic imaging in assessing local disease extent during initial staging in patients with endometrial carcinoma, with practices differing widely across centers. However, when pretreatment assessment of local tumor extent is indicated, MRI is the preferred imaging modality. Preoperative imaging of endometrial carcinoma can define the extent of disease and indicate the need for subspecialist referral in the presence of deep myometrial invasion, cervical extension, or suspected lymphadenopathy. If distant metastatic disease is clinically suspected, preoperative assessment with cross-sectional imaging or PET/CT may be performed. However, most patients with low-grade disease are at low risk of lymph node and distant metastases. Thus, this group may not require a routine pretreatment evaluation for distant metastases. Recurrence rates in patients with endometrial carcinoma are infrequent. Therefore, radiologic evaluation is typically used only to investigate suspicion of recurrent disease due to symptoms or physical examination and not for routine surveillance after treatment. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Gynecologic cancer surveillance in the era of SARS-CoV-2 (COVID-19)

The SARS-CoV-2 (COVID-19) pandemic has significantly impacted the management of patients with gynecologic cancers. Many centers have reduced access to routine visits to avoid crowded waiting areas and specially to reduce the infection risk for oncologic patients. The goal of this review is to propose a surveillance algorithm for patients with gynecologic cancers during the COVID-19 pandemic based on existing evidence and established guidelines. It is time to consider strategies based on telemedicine and to adapt protocols in this new era. We hereby propose a strategy for routine surveillance both during and beyond the pandemic.

Prognostic Value and Risk Factors of Peritoneal Carcinomatosis Recurrence for Patients with Endometrial Cancer: A Multicenter Study from the FRANCOGYN Group

BACKGROUND

The prognosis for patients with endometrial cancer (EC) peritoneal carcinomatosis (PC) recurrence has received little study. This study aimed to determine specific risk factors and prognosis of EC with PC recurrence (PCR) versus no PC recurrence (NPCR).

METHODS

Data of all patients with EC who received primary surgical treatment between January 2000 and February 2017 were abstracted from the French FRANCOGYN Research Group database. Clinical and pathologic variables were compared between the two groups (PCR vs. NPCR). Multivariate analysis was performed to define prognostic factors for peritoneal recurrence. Overall survivals (OS) of patients after recurrence were compared using the Kaplan-Meier method.

RESULTS

The study analyzed 1466 patients, and 257 of these patients (17.5%) had recurrence. At presentation, 63 of these patients had PC. International Federation of Gynecology and Obstetrics (FIGO) stages 3 and 4 disease were significantly associated with PCR versus NPCR (odds ratio 2.24; 95% confidence interval 1.23-4.07; p = 0.008). The death rate for the patients with PC was 47.6%, with a median survival of 12 months after diagnosis of recurrence. According to the histologic subtype, OS was 29 months (Q1-Q3, 13-NA) for endometrioid carcinomas, 7.5 months (Q1-Q3, 4-15) for serous carcinomas, and 10 months (Q1-Q3, 5-15) for clear cell carcinomas. Chemotherapy for treatment of PCR was associated with improved OS after recurrence (OSAR; p = 0.0025).

CONCLUSION

An initial advanced stage of EC is a risk factor for PCR. For women with PCR, a diagnosis of type 1 EC recurrence more than 12 months after the initial treatment and management of PCR with chemotherapy is associated with improved OSAR. Prospective studies are needed to determine the precise optimal management required in this clinical situation and to assess the relevance of biomarkers to predict the risk of PCR for EC patients.

Adjuvant chemotherapy after radiotherapy or concurrent chemoradiotherapy for pelvic lymph node-positive patients with locally advanced cervical cancer: a propensity score matching analysis

Objective

The benefit of adjuvant chemotherapy after definitive chemoradiotherapy in patients with pelvic lymph node-positive cervical cancer has been poorly studied. This study aimed to test the hypothesis that the addition of adjuvant chemotherapy to definitive radiotherapy or concurrent chemoradiotherapy improves survival in patients with pelvic lymph node-positive cervical squamous cell carcinoma.

Methods

This retrospective study enrolled patients with stage IB–IVA pelvic lymph node-positive cervical squamous cell carcinoma, without para-aortic lymph node metastases and initially treated with definitive radiotherapy or concurrent chemoradiotherapy between March 2007 and February 2018. Patients were classified into the adjuvant chemotherapy (5-fluorouracil or paclitaxel, plus cisplatin) and no-adjuvant chemotherapy groups. Treatment outcomes were compared between the two groups before and after 1:1 ratio propensity score matching.

Results

Medical records of 951 patients were reviewed and 792 patients were excluded. Finally, 159 patients were enrolled for analysis. Of these, 42 patients received a median of two cycles (range, 1–6) of adjuvant chemotherapy and 117 patients under observation after primary treatment. The median follow-up period was 33.8 months (range, 2.9–113.0). Before propensity score matching, no significant difference was observed in survivals between the two groups (P>0.05). After propensity score matching, 37 pairs of patients were selected. The 3-year rates of progression-free survival, overall survival, local control, and distant metastasis-free survival in the adjuvant chemotherapy and no-adjuvant chemotherapy groups were 80.2% and 60.4% (P=0.07), 83.0% and 63.7% (P=0.17), 94.0% and 81.9% (P=0.12), and 85.9% and 60.1% (P=0.04), respectively. The incidences of grade 3–4 acute and late toxicities were comparable between the two groups (P>0.05).

Discussion

Adjuvant chemotherapy significantly improved 3-year distant metastasis-free survival in patients with pelvic lymph node-positive cervical squamous cell carcinoma. Further prospective studies are needed to provide supportive evidence for the therapeutic efficacy of adjuvant chemotherapy.

Preferences for follow up in long-term survivors after cervical cancer

INTRODUCTION

An increasing number of cervical cancer survivors combined with lack of data on the efficacy of long-term surveillance, challenges existing follow-up models. However, before introducing new follow-up models, cervical cancer survivors' own views on follow up are important. We aimed to explore preferences for follow up in long-term cervical cancer survivors and their associations with self-reported late-effects.

MATERIAL AND METHODS

In 2013, we mailed 974 Norwegian long-term cervical cancer survivors treated during 2000-2007 a questionnaire with items covering preferences for follow up after treatment, clinical variables and validated questionnaires covering anxiety, neuroticism and depression.

RESULTS

We included 471 cervical cancer survivors (response rate 57%) with a median follow up of 11 years. In all, 77% had FIGO stage I disease, and 35% were attending a follow-up program at the time of survey. Of the patients, 55% preferred more than 5 years of follow up. This was also preferred by 57% of cervical cancer survivors who were treated with conization only. In multivariable analyses, chemo-radiotherapy or surgery with radiation and/or chemotherapy (heavy treatment) and younger age were significantly associated with a preference for more than 5 years' follow up. Late effects were reported by more than 70% of the cervical cancer survivors who had undergone heavy treatment.

CONCLUSIONS

Our study reveals the need for targeted patient education about the benefits and limitations of follow up. To meet increasing costs of cancer care, individualized follow-up procedures adjusted to risk of recurrence and late-effects in cervical cancer survivors are warranted.

Impact of a reduction in follow-up frequency on life expectancy in uterine cervical cancer patients

BACKGROUND

The appropriate interval of post-treatment follow-up appointments for uterine cervical cancer is unclear. The aim of this study was to investigate the impact of reducing the frequency of post-treatment follow-up examinations on life expectancy and medical expenses in cervical cancer patients.

METHODS

Cervical cancer patients who were treated with radiotherapy between 2008 and 2017, underwent a less frequent follow-up program, and subsequently developed recurrent disease were included in consecutive group (CG). Non-randomized groups of cervical cancer patients who underwent a frequent follow-up program after radiotherapy between 1997 and 2007, and subsequently developed recurrent disease were also identified through a chart review and served as a comparison group (primary group [PG]). Clinical data regarding the primary disease, follow-up, recurrence, and survival were collected. Univariate and multivariate analyses of predictors of survival were performed.

RESULTS

A total of 263 recurrent cervical cancer patients (PG: 154, CG: 109) were included in the current study. A reduction in follow-up frequency of up to 40% did not increase the frequency of symptomatic recurrence (PG: vs. CG: 31.2% vs. 35.8%, p = 0.43) or reduce the median overall survival periods of recurrent cervical cancer patients (PG vs. CG: 32 months vs. 36 months, p = 0.15). However, the reduction in the follow-up frequency significantly reduced follow-up costs.

CONCLUSION

Reducing the frequency of follow-up by up to 40% did not result in shorter overall survival compared with a conventional follow-up program. The results of this study provide a rationale for future studies investigating the optimal follow-up schedule for patients with cervical cancer.

Significance of the number of high-risk factors in patients with cervical cancer treated with radical hysterectomy and concurrent chemoradiotherapy

OBJECTIVE

The purpose of this study was to evaluate the impact of high-risk factors on the survival of patients with cervical cancer treated with surgery followed by adjuvant chemoradiotherapy.

METHODS

From 2000 to 2014, medical records of 897 patients with International Federation of Gynecology and Obstetrics stage IB-IIA disease treated with surgery were retrospectively reviewed. Among them, 483 patients with high-risk factors, including pelvic lymph node metastasis, parametrial invasion, or resection margin involvement, were analyzed.

RESULTS

The median follow-up time was 57 months (range, 6-205 months). For patients with single and multiple high-risk factors, the 5-year DFS rates were 80.4% and 65.7%, respectively (p < 0.001), and 5-year OS rates were 87.3% and 75.1%, respectively (p = 0.001). Distant metastasis was the most common pattern of recurrence (86.1%). Furthermore, distant metastasis-free survival significantly differed with the number of high-risk factors present (single 82.7% vs. multiple 68.8%, p < 0.001). In the multivariate analysis, while parametrial invasion and resection margin involvement showed no association, the adenocarcinoma histology, pelvic lymph node metastasis, higher metastatic lymph node ratio, and multiple high-risk factors were independent prognosticators associated with poor DFS and OS.

CONCLUSIONS

Patients with early-stage cervical cancer having multiple high-risk factors, adenocarcinoma histologic type, and pelvic lymph node metastasis accompanied by a higher lymph node ratio after surgery are more likely to have occult distant metastasis. Further, consolidation with systemic chemotherapy after adjuvant therapy might be considered to improve the survival outcome in this patient population.

Selection criteria and colpotomic approach for safe minimally invasive radical hysterectomy in early-stage cervical cancer

OBJECTIVE

To evaluate oncologic outcomes of minimally invasive radical hysterectomy (RH) in early cervical cancer before and after the application of parametrial invasion (PMI) criterion on magnetic resonance imaging (MRI) and vaginal colpotomy (VC).

METHODS

A total of 216 International Federation of Gynecology and Obstetrics stage IB-IIA cervical cancer patients who underwent minimally invasive RH was identified between April 2006 and October 2018. Patients were classified into the pre-PMI intracorporeal or VC (IVC) (n=117) and post-PMI VC groups (n=99). In the pre-PMI IVC group, PMI criterion (intact stromal ring) on MRI was not applied and the patients received IVC. In the post-PMI VC group, surgical candidates were selected using the PMI criterion on MRI and all patients received VC only. Oncologic outcomes and prognostic factors associated with disease recurrence were analyzed.

RESULTS

The rate of positive vaginal cuff margins in the pre-PMI IVC group was higher than that in the post-PMI VC group (11.1% vs. 1.0%, p=0.003). Two-year disease-free survival was different between the 2 groups (84.5% in pre-PMI IVC vs. 98.0% in post-PMI VC groups, p=0.005). Disrupted stromal ring on MRI (hazard ratio [HR]=20.321; 95% confidence interval [CI]=4.903-84.218; p<0.001) and intracorporeal colpotomy (HR=3.059; 95% CI=1.176-7.958; p=0.022) were associated with recurrence.

CONCLUSION

The intact cervical stromal ring on MRI might identify the low-risk group of patients in terms of PMI and lymphovascular/stromal invasion in early cervical cancer. Minimally invasive RH should be performed in optimal candidates with an intact stromal ring on MRI, using VC.

Hyaluronate gel injection for rectum dose reduction in gynecologic high-dose-rate brachytherapy: initial Japanese experience

Perirectal hyaluronate gel injection (HGI) appears to be a promising technique for healthy tissue dose sparing in pelvic radiotherapy. In this analysis, we report our initial experience of HGI in gynecologic brachytherapy, focusing on its safety and effectiveness for dose reduction to the rectum. Between July 2013 and May 2014, 36 patients received HGI for primary/salvage gynecologic brachytherapy. Dosimetric effect analysis was based on pre- and post-HGI computed tomography dataset registration with corresponding dose-volume histogram evaluation. The maximum dose to the most exposed 0.1 cm3 (D0.1cm3) and 2.0 cm3 (D2.0cm3) were used as index values for rectum and bladder dose evaluation. The dose indexes for target volume (TV) coverage were TV D90/V100. In all cases, HGI was well tolerated, with no acute or late adverse events documented at a median follow-up of 220 days (range, 18-1046 days). Rectum D2.0cm3 and D0.1cm3 were significantly decreased by HGI (P < 0.001 and P = 0.003, respectively), with no significant impact on dosimetric parameters of bladder and TV coverage. Factors correlating negatively with the dosimetric effect of HGI were an increasing number of interstitial catheters (P = 0.003) as well as Lcranial100% (P = 0.014) and Lcranial80% (P = 0.001) [i.e. the length from the anal verge to the most cranial point at which the 100% and 80% isodose lines, respectively, crossed the rectum]. The concept of HGI for gynecologic brachytherapy is plausible, and our initial experience indicates it to be an effective technique for rectal dose reduction in radiotherapy of intrapelvic tumours.

Use of Aggressive Surveillance for Locoregional Endometrial Cancer After Local Therapy

PURPOSE/OBJECTIVES

Current guidelines do not recommend routine surveillance imaging as part of follow-up care for patients treated for locoregional endometrial carcinoma. This study seeks to determine the potential benefit of routine surveillance imaging by evaluating outcomes of patients whose recurrences were detected on routine surveillance compared to those whose recurrences were identified after presenting with symptoms.

MATERIALS/METHODS

We conducted a retrospective review of patients who developed recurrence after surgical treatment, with or without adjuvant therapy, for locoregional endometrial carcinoma. A total of 149 patients were identified with adequate clinical information regarding the recurrence. Cox proportional hazards regression analysis was used to estimate overall survival and progression-free survival.

RESULTS

The median age of patients at diagnosis was 69.2 years (range, 38.0-99.5 years). Initial stages included stage I, 49.7%; stage II, 10.1%; stage III, 38.3%; and stage IV, 1.3%. Histologic diagnoses included endometrioid adenocarcinoma, 48.3%; and other diagnoses (including papillary serous carcinoma, clear cell carcinoma, and carcinosarcoma), 51.7%. Patients were initially treated with a variety of therapies: surgery alone in 20.8%, surgery and radiation in 25.5%, surgery and chemotherapy in 12.1%, and trimodality therapy in 41.6%. Sites of recurrence included 20.8% vaginal, 14.8% pelvic and 64.4% distant sites. Recurrences were detected asymptomatically in 86 patients (57.7%) and symptomatically in 63 patients (42.3%). Of those detected asymptomatically, 80.2% were detected by imaging. Overall, when comparing symptomatic versus asymptomatic recurrences, there was no difference in overall survival (hazard ratio, 1.24; 95% confidence interval, 0.84-1.83; P = 0.29) or progression-free survival (hazard ratio, 1.14; 95% confidence interval, 0.77-1.70; P = 0.52).

CONCLUSIONS

Patients who develop asymptomatic recurrences of their endometrial carcinoma do not seem to have a better prognosis than those who present with symptomatic recurrences. Thus, these results do not support routine imaging surveillance for patients treated for locoregional endometrial carcinoma. Further prospective evaluation is needed.

How Do We Follow Up Patients With Endometrial Cancer?

PURPOSE OF REVIEW

In this review, we present the existing evidence regarding follow-up care after endometrial cancer, including content of follow-up and type of provider. We furthermore discuss the future perspectives for follow-up care and research in the field.

RECENT FINDINGS

Recently published randomized controlled trials show that nurse-led telephone follow-up and patient-initiated follow-up are feasible alternatives to routine hospital-based follow-up. No randomized or prospective study has evaluated the effect of routine follow-up on survival. Hence, current knowledge is derived from retrospective studies with the inherent risk of bias. The most important method for recurrence detection is a review of symptoms. There is no evidence to support a survival benefit from the use of routine physical examinations, additional tests, or imaging. One in three of the women attending hospital-based follow-up experience unmet needs, and alternative models for follow-up focused on survivorship care and empowerment should be tested.

Cancer of the corpus uteri

Endometrial cancer is the most common gynecological malignancy in high-income countries. Although the overall prognosis is relatively good, high-grade endometrial cancers have a tendency to recur. Recurrence needs to be prevented since the prognosis for recurrent endometrial cancer is dismal. Treatment tailored to tumor biology is the optimal strategy to balance treatment efficacy against toxicity. Standard treatment consists of hysterectomy and bilateral salpingo-oophorectomy. Lymphadenectomy (with ongoing studies of sentinel node biopsy) enables identification of lymph node positive patients who need adjuvant treatment, including radiotherapy and chemotherapy. Adjuvant radiotherapy is used for Stage I-II patients with high-risk factors and Stage III lymph node negative patients. In advanced disease, a combination of surgery to no residual disease and chemotherapy results in the best outcome. Surgery for recurrent disease is only advocated in patients with a good performance status with a relatively long disease-free interval.

Interdisciplinary Diagnosis, Therapy and Follow-up of Patients with Endometrial Cancer. Guideline (S3-Level, AWMF Registry Number 032/034-OL, April 2018) - Part 2 with Recommendations on the Therapy and Follow-up of Endometrial Cancer, Palliative Care, Psycho-oncological/Psychosocial Care/Rehabilitation/Patient Information and Healthcare Facilities

Summary The first German interdisciplinary S3-guideline on the diagnosis, therapy and follow-up of patients with endometrial cancer was published in April 2018. Funded by German Cancer Aid as part of an Oncology Guidelines Program, the lead coordinators of the guideline were the German Society of Gynecology and Obstetrics (DGGG) and the Gynecological Oncology Working Group (AGO) of the German Cancer Society (DKG). Purpose Using evidence-based, risk-adapted therapy to treat low-risk women with endometrial cancer avoids unnecessarily radical surgery and non-useful adjuvant radiotherapy and/or chemotherapy. This can significantly reduce therapy-induced morbidity and improve the patient's quality of life as well as avoiding unnecessary costs. For women with endometrial cancer and a high risk of recurrence, the guideline defines the optimal extent of surgical radicality together with the appropriate chemotherapy and/or adjuvant radiotherapy if required. An evidence-based optimal use of different therapeutic modalities should improve the survival rates and quality of life of these patients. This S3-guideline on endometrial cancer is intended as a basis for certified gynecological cancer centers. The aim is that the quality indicators established in this guideline will be incorporated in the certification processes of these centers. Methods The guideline was compiled in accordance with the requirements for S3-level guidelines. This includes, in the first instance, the adaptation of source guidelines selected using the DELBI instrument for appraising guidelines. Other consulted sources included reviews of evidence, which were compiled from literature selected during systematic searches of literature databases using the PICO scheme. In addition, an external biostatistics institute was commissioned to carry out a systematic search and assessment of the literature for one part of the guideline. Identified materials were used by the interdisciplinary working groups to develop suggestions for Recommendations and Statements, which were then subsequently modified during structured consensus conferences and/or additionally amended online using the DELPHI method, with consent between members achieved online. The guideline report is freely available online. Recommendations Part 2 of this short version of the guideline presents recommendations for the therapy of endometrial cancer including precancers and early endometrial cancer as well as recommendations on palliative medicine, psycho-oncology, rehabilitation, patient information and healthcare facilities to treat endometrial cancer. The management of precancers of early endometrial precancerous conditions including fertility-preserving strategies is presented. The concept used for surgical primary therapy of endometrial cancer is described. Radiotherapy and adjuvant medical therapy to treat endometrial cancer and uterine carcinosarcomas are described. Recommendations are given for the follow-up care of endometrial cancer, recurrence and metastasis. Palliative medicine, psycho-oncology including psychosocial care, and patient information and rehabilitation are presented. Finally, the care algorithm and quality assurance steps for the diagnosis, therapy and follow-up of patients with endometrial cancer are outlined.

A Proposal for a Classification for Recurrent Endometrial Cancer: Analysis of a French Multicenter Database From the FRANCOGYN Study Group

OBJECTIVE

Endometrial cancer (EC) recurrences are relatively common with no standardized way of describing them. We propose a new classification for them called locoregional, nodal, metastasis, carcinomatosis recurrences (rLMNC).

PATIENTS AND METHODS

The data of 1230 women with EC who were initially treated by primary surgery were included in this French multicenter retrospective study. Recurrences were classified based on dissemination pathways: (1) locoregional recurrence (rL); (2) nodal recurrence (rN) for lymphatic pathway; (3) distant organ recurrence (rM) for hematogenous pathway; and (4) carcinomatosis recurrence (rC) for peritoneal pathway. These pathways were further divided into subgroups. We compared recurrence free survival and overall survival (OS) between the 4 groups (rL/rN/rM/rC).

RESULTS

The median follow-up was 35.6 months (range, 1.70-167.60). One hundred ninety-eight women (18.2%) experienced a recurrence: 150 (75.8%) experienced a single-pathway recurrence and 48 (24.2%) a multiple-pathway recurrence. The 5-year OS was 34.1% (95% confidence interval [CI], 27.02%-43.1%), and the median time to first recurrence was 18.9 months (range, 0-152 months). The median survival after recurrence was 14.8 months (95% CI, 11.7-18.8). Among women with single pathway of recurrence, a difference in 5-year OS (P < 0.001) and survival after recurrence (P < 0.01) was found between the 4 rLNMC groups. The carcinomatosis group had the worst prognosis compared with other single recurrence pathways. Women with multiple recurrences had poorer 5-year OS (P < 0.001) and survival after recurrence (P < 0.01) than those with single metastasis recurrence, other than women with peritoneal carcinomatosis.

CONCLUSIONS

This easy-to-use and intuitive classification may be helpful to define EC recurrence risk groups and develop guidelines for the management of recurrence. Its prognosis value could also be a tool to select homogenous populations for further trials.

Cervical Cancer Posttreatment Follow-up: Critical Analysis

OBJECTIVE

The aim of this study was to evaluate the role of follow-up tests and examinations in diagnosing symptomatic and asymptomatic relapses after treatment for cervical cancer.

METHODS

Data were collected from medical records for all patients diagnosed as having cervical cancer from January 1985 to June 2010. The significance level was P < 0.005.

RESULTS

Sixty-four (17.8%) of the 358 patients investigated suffered tumor relapse. Thirty-four (53.1%) were symptomatic, and 30 (46.9%) were asymptomatic. Most patients had tumor relapse diagnosed during physical examination, both among the symptomatic patients (50%) and the asymptomatic patients (66.7%) (P = 0.27). Cytopathology was responsible for detecting relapse in only 1 case in each group, corresponding to 2.9% and 3.3%, respectively (P = 0.99). Imaging examinations confirmed 10 relapses (29.4%) among symptomatic patients and 8 cases (26.6%) among asymptomatic patients (P = 0.77). There were no statistically significant differences between the 2 groups or between the different methods of detecting relapses. There was still no association after adjustment for potential confounding factors such as age and type of treatment.

CONCLUSIONS

Physical examination was the preeminent method for detecting tumor relapse in this study. None of the other tests or examinations were capable of detecting relapses in both symptomatic and asymptomatic patients. These results highlight the urgent need for prospective studies that compare the efficacy of different follow-up regimens, analyzing factors such as global survival, quality of life, and cost.

A national, prospective observational study of first recurrence after primary treatment for gynecological cancer in Norway

INTRODUCTION

Gynecological cancer patients are routinely followed up for five years after primary treatment. However, the value of such follow up has been debated, as retrospective studies indicate that first recurrence is often symptomatic and occurs within two to three years of primary treatment. We prospectively investigated time to first recurrence, symptoms at recurrence, diagnostic procedures, and recurrence treatment in gynecological cancer patients after primary curative treatment.

MATERIAL AND METHODS

Clinicians from 21 hospitals in Norway interviewed 680 patients with first recurrence of gynecological cancer (409 ovarian, 213 uterine, and 58 cervical cancer patients) between 2012 and 2016. A standardized questionnaire was used to collect information on self-reported and clinical variables.

RESULTS

Within two years of primary treatment, 72% of ovarian, 64% of uterine, and 66% of cervical cancer patients were diagnosed with first recurrence, and 54, 67, and 72%, respectively, had symptomatic recurrence. Of symptomatic patients, 25-50% failed to make an appointment before their next scheduled follow-up visit. Computer tomography was the most common diagnostic procedure (89% of ovarian, 76% of uterine, and 62% of cervical cancer patients), and recurrence treatment in terms of chemotherapy was most frequently planned (86% of ovarian, 46% of uterine, and 62% of cervical cancer patients).

CONCLUSIONS

A majority of patients experienced symptomatic recurrence, but many patients failed to make an appointment earlier than scheduled. Most first recurrences occurred within two years of primary treatment; the mean annual incidence rate for years 3-5 after primary treatment was <7%. New models for follow up of gynecological cancer patients could be considered.

Surveillance Imaging in Patients With Endometrial Cancer in First Remission

OBJECTIVE

The clinical benefit of surveillance imaging in endometrial cancer remains undefined. This retrospective study was conducted to evaluate the positive predictive value (PPV) of surveillance imaging in endometrial cancer.

METHODS

A total of 128 patients in first remission after treatment for endometrial cancer (uterine papillary serous, clear cell, stage III endometroid) who had surveillance imaging were retrospectively identified. The surveillance period was defined from the time of first-negative scan after treatment to the time when treatment was started for recurrent disease. Reports of surveillance scans were reviewed for the presence or absence of findings. The primary outcome was PPV of surveillance imaging. Cost and radiation exposure from surveillance imaging were also evaluated.

RESULTS

A total of 128 patients had 707 surveillance scans (computed tomography, positron emission tomography-computed tomography with 2-deoxy-2-[¹⁸F]fluoro-d-glucose, magnetic resonance image, and bone scans). Median follow-up was 54 months (range: 9-173). Of all, 47 patients (37%) started therapy for recurrent endometrial cancer at the discretion of the treating physician. PPV of all surveillance imaging was 57.7%. Per patient, the mean number of surveillance scans was 5.6 (range: 2-21). The mean cost of imaging was $4200 (range: $1200-$18,700) and mean radiation exposure was 109.6mSV (range: 16-445mSv).

CONCLUSIONS

Surveillance imaging detected a significant number of recurrences in patients with high-risk endometrial cancer at a reasonable cost related to the overall risk. Well-designed prospective imaging trials are warranted to assess the clinical benefit of surveillance imaging.

Is Routine Curettage a Useful Tool to Evaluate Persistent Tumor in Patients Who Underwent Primary Chemoradiation for Locally Advanced and/or Lymph Node Positive Cervical Cancer?

Objective

Response evaluation after primary chemoradiation (RCTX) in patients with cervical cancer remains difficult. Routine hysterectomy after primary RCTX is associated with considerable surgical morbidity without impact on survival. The purpose of the present study was to evaluate value of routine curettage after RCTX to detect persistent tumor.

Methods

Between 2006 and 2012, patients (n = 217) with cervical cancer in International Federation of Gynecology and Obstetrics stages IB1 N1 (14%), IB2 (9%), IIA (5%), IIB (46%), IIIA (4%), IIIB (15%), IVA (6%), and IVB (1%), respectively, underwent primary RCTX. After RCTX, curettage was recommended to all patients to evaluate response.

Results

In 136 (63%) of patients with cervical cancer, 1 or 2 consecutive curettages were performed at least 6 weeks after primary RCTX without any complications. In 21 (15%) patients, at least 1 curettage was positive for cervical cancer. In 7 patients, secondary hysterectomy was performed after 1 positive finding and persistent tumor was found in all of them. In the remaining 14 patients, there were 2 positive curettages in 5, 1 undetermined result followed by 1 positive in 3, and 1 positive followed by 1 negative in 6 patients, respectively. In the latter group, no tumor was detected in the uterus, whereas in all other patients with 2 curettages except one, residual carcinoma was detected. Five (24%) of 21 patients with positive histology are free of disease during follow-up. Decision for or against secondary hysterectomy was correct due to histological finding of curettage in 99%.

Conclusions

Routine curettage is a useful tool to guide decision for secondary hysterectomy with high accuracy after primary RCTX and avoids overtreatment.

Detection of recurrence in early stage endometrial cancer - the role of symptoms and routine follow-up

BACKGROUND

Considerable controversy remains as to the optimal organization of endometrial cancer follow-up.

AIM

To evaluate the relationship between the way recurrence was detected and survival after treatment for endometrial cancer. Further, to identify characteristics associated with a pre-scheduled examination in women with symptomatic recurrence.

MATERIAL AND METHODS

All women with early stage endometrial cancer during 2005-2009 were included in a population-based historical cohort derived from the Danish Gynecological Cancer Database. Women diagnosed with recurrence within three years after primary surgery and the mode of recurrence detection were identified from hospital charts: asymptomatic recurrence detected at regular follow-up, symptomatic recurrence detected at regular follow-up or symptomatic recurrence detected in between follow-up. Survival of women with symptomatic and asymptomatic disease was compared. Furthermore, characteristics associated with self-referral as compared to presenting symptoms at regular follow-ups were identified using univariate analyses.

RESULTS

In total, 183 cases of recurrence (7%) were identified in the cohort of 2612 women. Of these, 65.5% were symptomatic with vaginal bleeding as the most prevalent symptom. Asymptomatic women had a significantly better three-year survival rate compared to symptomatic women (80.3% vs. 54.3%, p < 0.01). A total of 2.3% of the entire population had an asymptomatic recurrence. Women diagnosed at a pre-scheduled visit due to symptoms had a higher educational level (p = 0.03) and more often high-risk disease (p = 0.02) than symptomatic women diagnosed at regular follow-up.

CONCLUSION

Early stage endometrial cancer carries a low risk of recurrence. Survival appears to be superior in asymptomatic patients, but length-time bias, i.e. the effect of aggressive tumor biology in symptomatic recurrences, may bias results in non-randomized controlled trials. Well educated patients with symptoms of recurrence more often sought medical attendance compared to less educated counterparts. This should be considered if patient-initiated follow-up is the standard care.

Prognosis of endometrial cancer patients with and without symptoms at recurrence

AIM

During routine follow-up for postoperative endometrial cancer, we have encountered patients with and without symptoms at recurrence. In this study, we investigated whether or not there is a difference in the prognosis between patients with and without symptoms at recurrence.

METHODS

We reviewed endometrial cancer patients who had been treated in our hospital between 1998 and 2007. Routine follow-up was conducted by our facility criteria. We investigated recurrence-free survival (RFS), presence or absence of symptoms at recurrence, overall survival from recurrence (OSFR), and overall survival (OS).

RESULTS

The subjects were 293 patients. Recurrence was detected in 46 patients. The median RFS was 15 (1-103) months. At the time of recurrence, symptoms were present in 14 patients and absent in 32 patients. In groups with and without symptoms at recurrence, the median OSFR were 36 (2-100) and 45 (2-139) months, respectively. The median OS were 55 (6-163) and 100 (11-178) months, respectively. There were no significant differences in either parameter. Independent prognostic factors for OSFR and OS were histopathologic types other than endometrioid carcinoma (vs endometrioid carcinoma, hazard ratio = 3.102 and 3.008, respectively) and RFS of 14 months or shorter (vs 15 months or longer, hazard ratio = 2.378 and 3.739, respectively).

CONCLUSION

There was no difference in the prognosis between the groups with and without symptoms at recurrence. Independent prognostic factors of recurrent patients were histopathologic types and RFS. A large-scale study should be conducted to examine the necessity of routine follow-up for detecting recurrence in the absence of symptoms.

Detecting Asymptomatic Recurrence in Early-Stage Endometrial Cancer: The Value of Vaginal Cytology, Imaging Studies, and CA-125

OBJECTIVE

The aim of this study was to evaluate the value of vaginal cytology, imaging modalities, and serum CA-125 in detecting asymptomatic recurrence during posttreatment surveillance for early-stage endometrial cancer.

METHODS

A retrospective analysis was conducted on patients with stage I to II endometrial cancer who received primary surgical treatment at Seoul National University Hospital between 2000 and 2011. Clinicopathologic characteristics and surveillance test data were obtained from medical records. The total numbers of vaginal cytologies, imaging studies, and serum CA-125 levels performed during surveillance or until recurrence were evaluated, and the number of tests needed to detect each asymptomatic recurrence was calculated.

RESULTS

A total of 389 patients were identified, together with a total of 3323 vaginal cytologies, 1025 chest x-rays, 1177 abdominal computed tomography (CT) scans, 98 magnetic resonance imaging scans, 163 positron emission tomography/CT scans, 298 ultrasonographies, and 3335 serum CA-125 results obtained during the surveillance period. Recurrence was detected in 14 patients (3.6%). Ten of these cases were asymptomatic, of which six were identified through CT scans and four were identified through elevated serum CA-125 levels. Most of the patients (7/10) with asymptomatic recurrences had localized recurrence patterns, five of whom underwent curative-intent resection and survived. The number of CA-125 tests needed to identify 1 asymptomatic recurrence was 839, whereas the number of CT scans needed to achieve the same result was 196. Other imaging modalities and vaginal cytology did not detect asymptomatic recurrence.

CONCLUSIONS

For posttreatment surveillance in early-stage endometrial cancer, vaginal cytology and imaging modalities such as chest x-ray, magnetic resonance imaging, positron emission tomography/CT, and ultrasonography have low utility. Routine CT scans and serum CA-125 testing may be useful for detecting asymptomatic recurrence.

Neoadjuvant chemotherapy followed by surgery has no therapeutic advantages over concurrent chemoradiotherapy in International Federation of Gynecology and Obstetrics stage IB-IIB cervical cancer

Objective

We aimed to assess the efficacy of neoadjuvant chemotherapy followed by surgery (NACT+S), and compared the clinical outcome with that of concurrent chemoradiotherapy (CCRT) in patients with International Federation of Gynecology and Obstetrics (FIGO) IB–IIB cervical cancer.

Methods

We reviewed 85 patients with FIGO IB–IIB cervical cancer who received NACT+S between 1989 and 2012, and compared them to 358 control patients who received CCRT. The clinical application of NACT was classified based on the following possible therapeutic benefits: increasing resectability after NACT by reducing tumor size or negative conversion of node metastasis; downstaging adenocarcinoma regarded as relatively radioresistant; and preservation of fertility through limited surgery after NACT.

Results

Of 85 patients in the NACT+S group, the pathologic downstaging and complete response rates were 68.2% and 22.6%, respectively. Only two young patients underwent limited surgery for preservation of fertility. Patients of the NACT+S group were younger, less likely to have node metastasis, and demonstrated a higher proportion of FIGO IB cases than those of the CCRT group (p≤0.001). The 5-year locoregional control, progression-free survival, and overall survival rates in the NACT+S group were 89.7%, 75.6%, and 92.1%, respectively, which were not significantly different from the rates of 92.5%, 74%, and 84.9% observed in the CCRT group, respectively (p>0.05).

Conclusion

NACT+S has no therapeutic advantages over CCRT, the standard treatment. Therefore, NACT+S should be considered only in selected patients through multidisciplinary discussion or clinical trial setting.

Follow-up for cervical cancer: a Program in Evidence-Based Care systematic review and clinical practice guideline update

BACKGROUND

In 2009, the Program in Evidence-based Care (pebc) of Cancer Care Ontario published a guideline on the follow-up of cervical cancer. In 2014, the pebc undertook an update of the systematic review and clinical practice guideline for women in this target population.

METHODS

The literature from 2007 to August 2014 was searched using medline and embase [extended to 2000 for studies of human papillomavirus (hpv) dna testing]. Outcomes of interest were measures of survival, diagnostic accuracy, and quality of life. A working group evaluated the need for changes to the earlier guidelines and incorporated comments and feedback from internal and external reviewers.

RESULTS

One systematic review and six individual studies were included. The working group concluded that the new evidence did not warrant changes to the 2009 recommendations, although hpv dna testing was added as a potentially more sensitive method of detecting recurrence in patients treated with radiotherapy. Comments from internal and external reviewers were incorporated.

RECOMMENDATIONS SUMMARY

Follow-up care after primary treatment should be conducted and coordinated by a physician experienced in the surveillance of cancer patients. A reasonable follow-up strategy involves visits every 3-4 months within the first 2 years, and every 6-12 months during years 3-5. Visits should include a patient history and complete physical examination, with elicitation of relevant symptoms. Vaginal vault cytology examination should not be performed more frequently than annually. Combined positron-emission tomography and computed tomography, other imaging, and biomarker evaluation are not advocated; hpv dna testing could be useful as a method of detection of recurrence after radiotherapy. General recommendations for follow-up after 5 years are also provided.

Stage IB cervix cancer with nodal involvement treated with primary surgery or primary radiotherapy: Patterns of failure and outcomes in a contemporary population

INTRODUCTION

The purpose of this study is to evaluate patterns of failure, overall survival (OS), disease-free survival (DFS), prognostic factors and late toxicities in node positive International Federation of Gynaecology and Obstetrics (FIGO) stage IB cervix cancer treated with curative intent.

METHODS

Patients with FIGO stage IB cervix cancer and positive nodes were identified from the Peter MacCallum Cancer Centre prospective gynaecology database. Patients were treated with primary surgery and adjuvant radiotherapy (S + RT) or primary radiotherapy (primary RT). Prognostic factors examined were tumour size, histology, grade, lymphovascular invasion or corpus uterine invasion, MRI tumour volume, number of nodes involved, highest site of nodal involvement, treatment modality, age and smoking.

RESULTS

Of the 103 eligible patients, 43 patients had S + RT and 60 patients had primary RT. Tumours were significantly smaller in the S + RT group (mean 3.0 cm vs. 4.5 cm, P < 0.001). Five-year OS (95% confidence interval) and DFS (95% confidence interval) for the whole cohort was 67.6% (56.5-76.4%) and 66.1% (55.7-74.6%), respectively. Tumour diameter and number of positive nodes were significant prognostic factors for OS and DFS and smoking was related to DFS. Treatment modality was not a significant prognostic factor in OS and DFS. Of 33 patients that relapsed, 32 patients relapsed outside the pelvis. One patient failed in the pelvis only.

CONCLUSIONS

Early stage cervix cancer with nodal involvement is associated with excellent pelvic disease control following curative intent treatment. Almost all relapses occurred beyond the pelvis and therefore more aggressive local treatment is unlikely to improve survival in these patients.

Addressing challenges in future surveillance after surgery for early-stage cervical cancer

OBJECTIVE

This study examines surveillance after early-stage cervical cancer surgery. Since the 1980s, the value of surveillance has been discussed continuously. The main question explored is whether surveillance serves the purpose of ensuring early diagnosis of recurrence.

MATERIALS AND METHODS

A retrospective cohort study included 389 women with cervical cancer who underwent surgery as the primary treatment modality at the Department of Obstetrics and Gynecology, Aarhus University Hospital, Denmark, from 1996 to 2011. We used data from patient files and the Danish National Pathology Data Bank. The cumulative risk was estimated by the Kaplan-Meier method and tested by the log-rank test.

RESULTS

Forty-three women (11%) had recurrence. Only 27% of the recurrent cases were diagnosed at a scheduled surveillance appointment, but they were often asymptomatic and seemed to have a better outcome after treatment compared with the recurrent cases diagnosed at self-referral.The 5-year survival was overall 91.3%, recurrence-free survival was 96%, and cancer-specific survival was 54%. The median recurrence-free interval was 23 months (range, 4-144) for the symptomatic patients and 14 months (range, 4-48) for the asymptomatic patients. The median survival after recurrence was 12 months (range, 2-132) for the symptomatic patients and 156 months (range, 40-180) for the asymptomatic patients.

CONCLUSIONS

At the moment, neither the value of surveillance nor the significance of self-referral related to survival after recurrence is known. In this study, those who are diagnosed with recurrence before symptom onset seem to fare better in terms of 5-year survival than those who are diagnosed after self-referral because of symptoms.

Clinical implication of surgically treated early-stage cervical cancer with multiple high-risk factors

Objective

Presence of high-risk factor in cervical cancer is known to be associated with decreased survival outcomes. However, the significance of multiple high-risk factors in early-stage cervical cancer related to survival outcomes, recurrence patterns, and treatment implications is not well elucidated.

Methods

A retrospective study was conducted for surgically treated cervical cancer patients (stage IA2-IIB, n=540). Surgical-pathological risk factors were examined and tumors expressing ≥1 high-risk factors (nodal metastasis, parametrial involvement, or positive surgical margin) were eligible for analysis (n=177, 32.8%). Survival analysis was performed based on the number of high-risk factors and the type of adjuvant therapy.

Results

There were 68 cases (38.4%) expressed multiple high-risk factors (2 high-risk factors: n=58, 32.8%; 3 high-risk factors: n=10, 5.6%). Multiple high-risk factors remained an independent prognosticator for decreased survival outcomes after controlling for age, histology, stage, and treatment type (disease-free survival: hazard ratio [HR], 2.34; p=0.002; overall survival: HR, 2.32; p=0.007). Postoperatively, 101 cases (57.1%) received concurrent chemoradiotherapy (CCRT) and 76 cases (42.9%) received radiotherapy (RT) alone. CCRT was beneficial in single high-risk factor cases: HRs for CCRT over RT alone for cumulative risk of locoregional and distant recurrence, 0.27 (p=0.022) and 0.27 (p=0.005), respectively. However, tumor expressing multiple high-risk factors completely offset the benefit of CCRT over RT alone for the risk of distant recurrence: HR for locoregional and distant recurrence, 0.31 (p=0.071) and 0.99 (p=0.980), respectively.

Conclusion

Special consideration for the significance of multiple high-risk factors merits further investigation in the management of surgically treated early-stage cervical cancer.

[Follow-up of endometrial cancer]

Available data on appropriate follow-up in endometrial cancer highlight the need of well-conducted studies. Most recurrences tend to occur within three years and involve symptoms. Routine tests are not advocated without symptoms. In case of suspicious recurrence, TEP/CT seems to be the most sensitive and specific method. There is limited evidence to decide whether follow-up schedules with multiple visits result in survival benefits. An appropriate follow-up should be discussed based upon the risk of recurrence. Counselling on the potential symptoms of recurrence should be a major aim.

Which imaging technique should we use in the follow up of gynaecological cancer?

Follow-up routines after gynaecological cancer vary. The optimal approach is unknown, and no randomised-controlled trials comparing surveillance protocols have been published. In this chapter, we summarise the diagnostic performance of ultrasound, computed tomography, and magnetic resonance imaging in the follow up of women treated for ovarian or uterine cancers. Computed tomography is today the standard imaging method for the follow up of women treated for endometrial, cervical, or ovarian cancer. Six-monthly or annual follow-up examinations have not been shown to positively affect survival. Instead, a combination of transvaginal and transabdominal ultrasound examination with clinical examination might be a more cost-effective strategy for early detection of recurrence. Positron-emission tomography might play a role in women with clinical or serological suspicion of recurrence but without evidence of disease at conventional diagnostic imaging. To create guidelines, more studies, preferably randomised-controlled trials, on follow-up strategies are needed.