Adenocarcinoma of the endometrium treated with combined irradiation and surgery: study of 437 patients

Stage IIIC endometrial cancer: the need for novel subgrouping according to the ratio of metastatic lymph nodes

INTRODUCTION

The survival rates in endometrial cancer (EC) patients with lymph node (LN) metastasis vary greatly. Many other factors may have impact on the prognosis within this special group. The purpose of this study was to determine factors predicting the progression or death in patients with stage IIIC EC.

MATERIALS AND METHODS

A single tertiary center, retrospective analysis was conducted in a total of 38 consecutive patients who surgically treated for EC between January 2005 and January 2013. The primary endpoint was the determination of factors predicting the progression, recurrence, or death of any cause. The secondary endpoints were progression-free survival (PFS) and overall survival (OS).

RESULTS

The median age at diagnosis was 64 years, and the median follow-up time was 32.50 months (95 % CI 28.75-40.56). The median number of metastatic positive LNs (pelvic and/or paraaortic) was 2, and the LN ratio, expressed as the percentage of positive nodes to total LNs identified, was 6.3 %. The LN ratio (≥ 6.5 %) was the only independent parameter for progression or death in multiple logistic regression analysis. Patients were stratified according to the LN ratio (<6.5 vs. ≥ 6.5 %) for survival comparisons. The estimated 32-month PFS rates were 90 and 64.8 %, respectively [HR (95 % CI) = 5.07 (1.05-24.56), P = 0.025]. However, the estimated 32-month OS rates were comparable (94.1 vs. 94.1 %), [HR (95 % CI) = 4.26 (0.44-41.30), P = 0.21].

DISCUSSION

The stratification of patients with stage IIIC disease according to the LN ratio may allow better identification of prognostic information and selection of individualized patient-tailored adjuvant treatment modalities.

Survival Analysis of Endometrial Cancer Patients With Positive Lymph Nodes

Objective

Patients with endometrial cancer with positive lymph nodes (International Federation of Gynecology and Obstetrics stage IIIC) have a substantially worse prognosis. This study investigates how tumor characteristics and adjuvant treatments influence overall survival (OS) in stage IIIC patients.

Methods

This multi-institution, institutional review board–approved study is a retrospective review of 116 patients with surgically staged endometrial cancer with positive lymph nodes treated from 1995 to 2008. The study cohort was evaluated using Kaplan-Meier estimates of OS and proportional hazard modeling.

Results

The 5-year OS for all patients was 51%. Administration of adjuvant therapy was associated with improved OS when compared with surgery alone (P = 0.007). Five-year OS was 40% for patients treated with surgery alone (n = 26), 50% with surgery and chemotherapy (n = 8), 58% with surgery and radiotherapy (n = 43), and 54% with surgery followed by both radiotherapy and chemotherapy (n = 39). Patients who received radiotherapy (n = 82) had improved OS (57%) when compared with patients who did not (n = 34, OS = 42%; P = 0.001). Radiotherapy was associated with improved OS for patients with endometrioid histology, high-grade tumors, and positive para-aortic lymph nodes. Patients with nonendometrioid histology and low-grade tumors who received radiotherapy had a similar OS as those who did not. High-grade tumors (P < 0.001), nonendometrioid histology (P = 0.004), and more than 2 positive lymph nodes (P = 0.01) were associated with a poorer OS. After controlling for patient demographics and tumor characteristics, patients with high-grade tumors and more than 2 positive lymph nodes had a poorer OS, whereas patients who received radiotherapy had improved OS.

Conclusions

This large institutional study of patients with lymph node–positive endometrial cancer identified prognostic factors associated with a poor OS. Radiotherapy was associated with improved survival and may be specifically indicated for patients with endometrioid histology, high-grade tumors, and positive para-aortic lymph nodes. We recommend further investigation of adjuvant therapies in randomized clinical trials.

Adjuvant radiotherapy for stage I endometrial cancer

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 2, 2007. The role of radiotherapy (both pelvic external beam radiotherapy (EBRT) and vaginal intracavity brachytherapy (VBT)) in stage I endometrial cancer following hysterectomy remains controversial.

OBJECTIVES

To assess the efficacy of adjuvant radiotherapy following surgery for stage I endometrial cancer.

SEARCH METHODS

We searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Specialised Register to end-2005 for the original review, and extended the search to January 2012 for the update.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared post-operative adjuvant radiotherapy (either EBRTor VBT, or both) versus no radiotherapy or VBT in women with stage I endometrial cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials and extracted data to a specifically designed data collection form. The primary outcome was overall survival. Secondary outcomes were endometrial cancer-related deaths, locoregional recurrence and distant recurrence. Meta-analyses were performed using Cochrane Review Manager Software 5.1.

MAIN RESULTS

We included eight trials. Seven trials (3628 women) compared EBRT with no EBRT (or VBT), and one trial (645 women) compared VBTwith no additional treatment. We considered six of the eight trials to be of a high quality. Time-to-event data were not available for all trials and all outcomes.EBRT (with or without VBT) compared with no EBRT (or VBT alone) for stage I endometrial carcinoma significantly reduced locoregional recurrence (time-to-event data: five trials, 2965 women; Hazard Ratio (HR) 0.36, 95% Confidence Interval (CI) 0.25 to 0.52; and dichotomous data: seven trials, 3628 women; Risk Ratio (RR) 0.33, 95% CI 0.23 to 0.47). This reduced risk of locoregional recurrence did not translate into improved overall survival (time-to-event data: five trials, 2,965 women; HR 0.99, 95% CI 0.82 to1.20; and dichotomous data: seven trials, 3628 women; RR 0.98, 95% CI 0.83 to 1.15) or improved endometrial cancer-related survival (time-to-event data: five trials, 2965 women; HR 0.96, 95% CI 0.72 to 1.28; and dichotomous data: seven trials, 3628 women; RR 1.02, 95% CI 0.81 to 1.29) or improved distant recurrence rates (dichotomous data: seven trials, 3628 women; RR 1.04, 95% CI 0.80 to 1.35).EBRT did not improve survival outcomes in either the intermediate-risk or high-risk subgroups, although high-risk data were limited, and a benefit of EBRT for high-risk women could not be excluded. One trial (PORTEC-2) compared EBRT with VBT in the high-intermediate risk group and reported that VBT was effective in ensuring vaginal control with a non-significant difference in loco-regional relapse rate compared to EBRT (5.1% versus 2.1%; HR 2.08, 95% CI 0.71 to 6.09; P = 0.17). In the subgroup of low-risk patients (IA/B and grade 1/2), EBRT increased the risk of endometrial carcinoma-related deaths (including treatment-related deaths) (two trials, 517 women; RR 2.64, 95% CI 1.05 to 6.66) but there was a lack of data on overall survival. We considered the evidence for the low-risk subgroup to be of a low quality.EBRT was associated with significantly increased severe acute toxicity (two trials, 1328 patients, RR 4.68, 95% CI 1.35 to 16.16), increased severe late toxicity (six trials, 3501 women; RR 2.58, 95% CI 1.61 to 4.11) and significant reductions in quality of life scores and rectal and bladder function more than 10 years after randomisation (one trial, 351 women) compared with no EBRT.One trial of VBT versus no additional treatment in women with low-risk lesions reported a non-significant reduction in locoregional recurrence in the VBT group compared with the no additional treatment group (RR 0.39, (95% CI 0.14 to 1.09). There were no significant differences in survival outcomes in this trial.

AUTHORS' CONCLUSIONS

EBRT reduces the risk of locoregional recurrence but has no significant impact on cancer-related deaths or overall survival. It is associated with significant morbidity and a reduction in quality of life. There is no demonstrable survival advantage from adjuvant EBRT for high-risk stage I endometrial cancer, however, the meta-analyses of this subgroup were underpowered and also included high-intermediate risk women, therefore we cannot exclude a small benefit in the high-risk subgroup. EBRT may have an adverse effect on endometrial cancer survival when used to treat uncomplicated low-risk (IA/B grade 1/2) endometrial cancer. For the intermediate to high-intermediate risk group, VBT alone appears to be adequate in ensuring vaginal control compared to EBRT. Further research is needed to guide practice for lesions that are truly high risk. In addition, the definitions of risk should be standardised.

Contemporary management of endometrial cancer

The treatment of endometrial cancer has changed substantially in the past decade with the introduction of a new staging system and surgical approaches accompanied by novel adjuvant therapies. Primary surgical treatment is the mainstay of therapy but the effectiveness and extent of lymphadenectomy has been challenged, and its acceptance as a routine procedure varies by country. The role of radiation has evolved and chemotherapy has been incorporated, either alone or combined with radiation, to treat the many patients in whom cancer recurs because of a tumour outside the originally radiated pelvic and lower abdominal area. Use of traditional adjuvant chemotherapeutics has been challenged in clinical trials of new agents with improved side-effect profiles. Novel agents and targeted therapies are being investigated. Research into genetic susceptibility to endometrial cancer and the potential genetic aberrations that might translate into therapeutic interventions continues to increase. Substantial global variability in the treatment of endometrial cancer has led to examination of long-accepted norms, which has resulted in rapidly changing standards. International cooperation in clinical trials will hasten progress in treatment of this ubiquitous cancer.

Adjuvant radiotherapy for stage I endometrial cancer

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 2, 2007. The role of radiotherapy (both pelvic external beam radiotherapy (EBRT) and vaginal intracavity brachytherapy (VBT)) in stage I endometrial cancer following hysterectomy remains controversial.

OBJECTIVES

To assess the efficacy of adjuvant radiotherapy following surgery for stage I endometrial cancer.

SEARCH METHODS

We searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Specialised Register to end-2005 for the original review, and extended the search to January 2012 for the update.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared post-operative adjuvant radiotherapy (either EBRT or VBT, or both) versus no radiotherapy or VBT in women with stage I endometrial cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials and extracted data to a specifically designed data collection form. The primary outcome was overall survival. Secondary outcomes were endometrial cancer-related deaths, locoregional recurrence and distant recurrence. Meta-analyses were performed using Cochrane Review Manager Software 5.1.

MAIN RESULTS

We included eight trials. Seven trials (3628 women) compared EBRT with no EBRT (or VBT), and one trial (645 women) compared VBT with no additional treatment. We considered six of the eight trials to be of a high quality. Time-to-event data were not available for all trials and all outcomes.EBRT (with or without VBT) compared with no EBRT (or VBT alone) for stage I endometrial carcinoma significantly reduced locoregional recurrence (time-to-event data: five trials, 2965 women; Hazard Ratio (HR) 0.36, 95% Confidence Interval (CI) 0.25 to 0.52; and dichotomous data: seven trials, 3628 women; Risk Ratio (RR) 0.33, 95% CI 0.23 to 0.47). This reduced risk of locoregional recurrence did not translate into improved overall survival (time-to-event data: five trials, 2,965 women; HR 0.99, 95% CI 0.82 to 1.20; and dichotomous data: seven trials, 3628 women; RR 0.98, 95% CI 0.83 to 1.15) or improved endometrial cancer-related survival (time-to-event data: five trials, 2965 women; HR 0.96, 95% CI 0.72 to 1.28; and dichotomous data: seven trials, 3628 women; RR 1.02, 95% CI 0.81 to 1.29) or improved distant recurrence rates (dichotomous data: seven trials, 3628 women; RR 1.04, 95% CI 0.80 to1.35).EBRT did not improve survival outcomes in either the intermediate-risk or high-risk subgroups, although high-risk data were limited, and a benefit of EBRT for high-risk women could not be excluded. In the subgroup of low-risk patients (IA/B and grade 1/2), EBRT increased the risk of endometrial carcinoma-related deaths (including treatment-related deaths) (two trials, 517 women; RR 2.64, 95% CI 1.05 to 6.66) but there was a lack of data on overall survival. We considered the evidence for the low-risk subgroup to be of a low quality.EBRT was associated with significantly increased severe acute toxicity (two trials, 1328 patients, RR 4.68, 95% CI 1.35 to 16.16), increased severe late toxicity (six trials, 3501 women; RR 2.58, 95% CI 1.61 to 4.11) and significant reductions in quality of life scores and rectal and bladder function more than 10 years after randomisation (one trial, 351 women) compared with no EBRT.One trial of VBT versus no additional treatment in women with low-risk lesions reported a non-significant reduction in locoregional recurrence in the VBT group compared with the no additional treatment group (RR 0.39, (95% CI 0.14 to 1.09). There were no significant differences in survival outcomes in this trial.

AUTHORS' CONCLUSIONS

EBRT reduces the risk of locoregional recurrence but has no significant impact on cancer-related deaths or overall survival. It is associated with significant morbidity and a reduction in quality of life, and bladder and rectal function. EBRT may have an adverse effect on endometrial cancer survival when used to treat uncomplicated low-risk (IA/B grade 1/2) endometrial cancer. There is no demonstrable survival advantage from adjuvant EBRT for high-risk stage I endometrial cancer, however, the meta-analyses of this subgroup were underpowered and also included high-intermediate risk women. Further research is likely to have an important impact on our confidence in the estimates of effects and may change the estimates. Therefore, whilst there appears to be no survival benefit in the routine use of EBRT in women with stage I endometrial cancer, we cannot exclude a benefit in high-risk women. VBT is potentially useful in intermediate-risk and high-risk subgroups but evidence from further RCTs is needed. In addition, the definitions of risk should be standardised.

Prognostic discrimination of subgrouping node-positive endometrioid uterine cancer: location vs nodal extent

BACKGROUND

The 2009 International Federation of Gynecologists and Obstetricians elected to substage patients with positive retroperitoneal lymph nodes as IIIC 1 (pelvic lymph node metastasis only) and IIIC 2 (paraaortic node metastasis with or with positive pelvic lymph nodes). We have investigated the discriminatory ability of subgrouping patients with retroperitoneal nodal involvement based on location, number, and ratio of positive nodes.

METHODS

For 1075 patients with stage IIIC endometrioid corpus cancer abstracted from the Surveillance, Epidemiology, and End Results databases for 2003-2007, Kaplan-Meier analyses, Cox proportional hazard models, and other quantitative measures were used to compare the prognostic discrimination for disease-specific survival (DSS) of nodal subgroupings.

RESULTS

In univariate analysis, the 3-year DSS were significantly different for subgroupings by location (IIIC 1 vs IIIC 2; 80.5% vs 67.0%, respectively, P=0.001), lymph node ratio (≤ 23.2% vs >23.2%; 80.8% vs 67.6%; P<0.001), and number of positive lymph nodes (1, 2-5, >5; 79.5, 75.4, 62.9%, P=0.016). The ratio of positive nodes showed superior discriminatory substaging in Cox models.

CONCLUSION

Subgrouping of stage IIIC patients by the ratio of positive nodes, either as a dichotomized or continuous parameter, shows the strongest ability to discriminate the survival, controlling for other confounding factors.

[High dose rate vaginal brachytherapy in endometrial cancer after surgery]

PURPOSE

This study aimed at analyzing the evolution and type of recurrence in patients treated for stage I endometrial carcinomas, in order to define the respective roles of adjuvant radiotherapy and brachytherapy.

PATIENTS AND METHODS

This monocentric retrospective study was conducted at Centre Alexis-Vautrin, Nancy, France, between January 1995 and December 2000 on all the patients surgically treated for an endometrial cancer, and then treated with high dose rate vaginal brachytherapy. The brachytherapy was delivered in two or three fractions of 7 Gy at 5 mm from the applicator.

RESULTS

In the good prognosis group, the specific and overall survivals at 5 years were respectively 96.5 and 94.2% with no local recurrence demonstrated. In the intermediate prognostic group, the specific and overall survivals at 5 years were respectively 88 and 85%, with six locoregional recurrences observed among those who did not undergo lymphadenectomy; the overall survival at 5 years was significantly decreased in the absence of external radiation. In the group of poor prognosis (stages II and III), the specific survival at 5 years was respectively 72.8 and 67 %, and the overall survival at 5 years 66.7 and 56.4%.

CONCLUSION

Results for local control and survival as well as for tolerance were good. So we have decided to deliver high rate brachytherapy for all intermediate or poor prognosis patients and we have abandoned pelvic radiotherapy for good prognosis tumours (stages IA: no myometrium invasion with grade 3 and >50% of myometrium invasion with grades 1 and 2), whatever the lymph nodes surgery they had. We now propose pelvic radiotherapy only for intermediate prognosis tumours (such as IA>50% of myometrium invasion with grade 3 and IB stages), if patients did not have any lymphatic surgery, or for bad prognosis tumours.

Node-positive adenocarcinoma of the endometrium: outcome and patterns of recurrence with and without external beam irradiation

OBJECTIVE

To evaluate treatment outcomes and patterns of recurrence in patients with node-positive (International Federation of Obstetrics and Gynecology stage IIIC) adenocarcinoma of the uterus without serous or clear cell differentiation.

METHODS

The records of 71 women who were treated for stage IIIC endometrial adenocarcinoma at our institution between 1984 and 2005 were reviewed. All patients underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy. Fifty patients received definitive pelvic or extended-field radiotherapy with or without systemic therapy (regional RT group). Eighteen received adjuvant systemic platinum-based chemotherapy or hormonal therapy without external beam RT. The median follow-up for patients not dying of disease was 67 months. Survival rates were calculated using the Kaplan-Meier method; differences were assessed using log-rank tests.

RESULTS

Thirty-nine percent (28/71) of patients had involved paraaortic lymph nodes while 61% (43/71) had only pelvic lymph nodes. Five- and 10-year disease-specific survival (DSS) rates were 63% and 54%, respectively; corresponding overall survival rates were 60% and 47%. Grade was strongly associated with DSS (76% vs 46% at 5 years for low-grade vs high-grade tumors, P=0.004). Cervical or adnexal involvement was associated with decreased DSS, but lymph-vascular space invasion, age, race, body mass index, and number and location of positive nodes were not. Five-year pelvic-relapse-free survival (98% vs 61%, P=0.001), DSS (78% vs 39%, P=0.01), and overall survival (73% vs 40%, P=0.03) were significantly better for the regional RT group than the systemic therapy group. In patients treated without regional RT, the most common site of relapse was the pelvis. DSS was not significantly correlated with number of nodes removed in the regional RT group but was in patients treated without regional RT (P=0.001).

CONCLUSIONS

Patients treated without regional RT had a high rate of locoregional recurrence. Patients with stage IIIC endometrial adenocarcinoma who underwent surgical staging followed by external beam irradiation had a high rate of cure. Relapses in patients treated with EBRT primarily occurred in patients with grade 3 cancer who may be most likely to benefit from combined-chemoradiation treatment.

Role of complete para-aortic lymphadenectomy in endometrial cancer

PURPOSE OF REVIEW

Many reports suggest the significance of pelvic lymph-node (PLN) adenectomy in patients with endometrial cancer. However, among these, there is controversy regarding not only what type of patients should have lymphadenectomy performed, but also what extent lymphadenectomy should be performed.

RECENT FINDINGS

It has been reported that PLN adenectomy has therapeutic significance in stage I grade 3 and more advanced endometrioid uterine cancer. However, the effects of para-aortic lymph-node adenectomy on its prognostic benefit have not been discussed.

SUMMARY

Patients with low-risk disease might not benefit from PLN adenectomy. However, PLN adenectomy might still have merit in low-risk patients, as there are inaccuracies of preoperative and intraoperative assessments. A complete lymphadenectomy is safe with minimum complications. At this point, hysterectomy and bilateral salpingo-oophorectomy with complete PLN adenectomy as the standard surgical procedure for endometrial cancer is thought to be reasonable. At present, the addition of p-aortic lymph-node adenectomy is regarded as an investigated protocol for endometrial cancer. However, p-aortic lymph-node adenectomy may have a therapeutic role for stage IIIC patients. Prospective randomized controlled trial composed of intermediate/high-risk patients should be conducted to clearly demonstrate prognostic improvement by p-aortic lymph-node adenectomy itself.

Adjuvant Brachytherapy Removes Survival Disadvantage of Local Disease Extension in Stage IIIC Endometrial Cancer: A SEER Registry Analysis

PURPOSE

To assess the role of radiotherapy (RT) in women with Stage IIIC endometrial cancer.

METHODS AND MATERIALS

The 17-registry Survival, Epidemiology, and End Results (SEER) database was searched for patients with lymph node-positive non-Stage IV epithelial endometrial cancer diagnosed and treated between 1988 and 1998. Two subgroups were identified: those with organ-confined Stage IIIC endometrial cancer and those with Stage IIIC endometrial cancer with direct extension of the primary tumor. RT was coded as external beam RT (EBRT) or brachytherapy (BT). Observed survival (OS) was reported with a minimum of 5 years of follow-up; the survival curves were compared using the log-rank test.

RESULTS

The therapy data revealed 611 women with Stage IIIC endometrial cancer during this period. Of these women, 51% were treated with adjuvant EBRT, 21% with EBRT and BT, and 28% with no additional RT (NAT). Of the 611 patients, 293 had organ-confined Stage IIIC endometrial cancer and 318 patients had Stage IIIC endometrial cancer with direct extension of the primary tumor. The 5-year OS rate for all patients was 40% with NAT, 56% after EBRT, and 64% after EBRT/BT. Adjuvant RT improved survival compared with NAT (p <0.001). In patients with organ-confined Stage IIIC endometrial cancer, the 5-year OS rate was 50% for NAT, 64% for EBRT, and 67% for EBRT/BT. Again, adjuvant RT contributed to improved survival compared with NAT (p = 0.02). In patients with Stage IIIC endometrial cancer and direct tumor extension, the 5-year OS rate was 34% for NAT, 47% for EBRT, and 63% for EBRT/BT. RT improved OS compared with NAT (p <0.001). Also, in this high-risk subgroup, adding BT to EBRT was superior to EBRT alone (p = 0.002).

CONCLUSION

Women with Stage IIIC endometrial cancer receiving adjuvant EBRT and EBRT/BT had improved OS compared with patients receiving NAT. When direct extension of the primary tumor was present, the addition of BT to EBRT was even more beneficial.

Role of complete lymphadenectomy in endometrioid uterine cancer

Although surgical pathological staging is the standard of care for uterine carcinoma, the benefits of a complete lymphadenectomy remain controversial. Evidence suggests that this procedure provides prognostic information and directs the use of appropriate adjuvant treatment in patients who are node-positive. Furthermore, it eliminates the need for adjuvant treatment in low-risk patients with negative nodes and no extrauterine spread of disease. Although the complications associated with this procedure raise the question as to whether all low-risk patients need a complete lymphadenectomy, the limitations of preoperative and intraoperative pathological analyses mean that lymphadenectomy in low-risk patients might still have merit. Future advances are warranted to enhance preoperative radiological and intraoperative pathological assessment to establish the risk of nodal disease. In this review, we assess the evidence on the prognostic and therapeutic benefits of a complete versus selective lymphadenectomy. Moreover, we discuss the complications associated with lymphadenectomy and identify subsets of low-risk patients who might not need to undergo this procedure.

Adjuvant radiotherapy for stage I endometrial cancer

BACKGROUND

The role of adjuvant radiotherapy (both pelvic external beam radiotherapy and vaginal intracavity brachytherapy) in stage I endometrial cancer following total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH and BSO) remains unclear.

OBJECTIVES

To assess the efficacy of adjuvant radiotherapy following surgery for stage I endometrial cancer.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CancerLit, Physician Data Query (PDQ) of National Cancer Institute. Handsearching was also carried out where appropriate.

SELECTION CRITERIA

Randomised controlled trials (RCTs) which compared adjuvant radiotherapy versus no radiotherapy following surgery for patients with stage I endometrial cancer were included.

DATA COLLECTION AND ANALYSIS

Quality of the studies was assessed and data collected using a predefined data collection form. The primary endpoint was overall survival. Secondary endpoints were locoregional recurrence, distant recurrence and endometrial cancer death. Data on quality of life (QOL) and morbidity were also collected. A meta-analysis on included trials was performed using the Cochrane Collaboration Review Manager Software 4.2.

MAIN RESULTS

The meta-analysis was performed on four trials (1770 patients). The addition of pelvic external beam radiotherapy to surgery reduced locoregional recurrence, a relative risk (RR) of 0.28 (95% confidence interval (CI) 0.17 to 0.44, p < 0.00001), which is a 72% reduction in the risk of pelvic relapse (95% CI 56% to 83%) and an absolute risk reduction of 6% (95% CI of 4 to 8%). The number needed to treat (NNT) to prevent one locoregional recurrence is 16.7 patients (95% CI 12.5 to 25). The reduction in the risk of locoregional recurrence did not translate into either a reduction in the risk of distant recurrence or death from all causes or endometrial cancer death. A subgroup analysis of women with multiple high risk factors (including stage 1c and grade 3) showed a trend toward the reduction in the risk of death from all causes and endometrial cancer death in patients who underwent adjuvant external beam radiotherapy.

AUTHORS' CONCLUSIONS

Patients with stage I endometrial carcinoma have different risks of local and distant recurrence depending on the presence of risk factors including stage 1c, grade 3, lymphovascular space invasion and age. Though external beam pelvic radiotherapy reduced locoregional recurrence by 72%, there is no evidence to suggest that it reduced the risk of death. In patients with multiple high risk factors, including stage 1c and grade 3, there was a trend towards a survival benefit and adjuvant external beam radiotherapy may be justified. For patients with only one risk factor, grade 3 or stage 1c, no definite conclusion can be made and data from ongoing studies ( ASTEC; Lukka) are awaited. External beam radiotherapy carries a risk of toxicity and should be avoided in stage 1 endometrial cancer patients with no high risk factors.

La chimiothérapie concomitante de la radiothérapie augmente la toxicité tardive après chirurgie conservatrice du cancer du sein

PURPOSE

In 1996, a multicenter randomized study comparing after breast-conservative surgery, sequential vs concurrent adjuvant chemotherapy (CT) with radiation therapy (RT) was initiated (ARCOSEIN study). Seven hundred sixteen patients were included in this trial. After a median follow-up of 6.7 (4.3-9) years, we decided to prospectively evaluate the late effects of these two strategies.

PATIENTS AND METHODS

A total of 297 patients were asked to follow-up from the five larger including institutions. Seventy-two percent (214 patients) were eligible for late toxicity. After breast-conserving surgery with axillary dissection, patients were treated either with sequential treatment with CT first followed by RT (arm A) or CT administered concurrently with RT (arm B). In all patients, CT regimen combined mitoxantrone (12 mg/m(2)), 5-FU (500 mg/m(2)), and cyclophosphamide (500 mg/m(2)), 6 cycles (day 1-day 21). In arm B, patients received concurrently the first 3 cycles of CT with RT. In arm A, RT started 3 to 5 weeks after the 6th cycle of CT. Conventional RT was delivered to the whole breast using a 2 Gy-fraction protocol to a total dose of 50 Gy (+/-boost to the primary tumour bed). The assessment of toxicity was blinded to treatment and was graded by the radiation oncologist according to the LENT-SOMA scale. Skin pigmentation was also evaluated using a personal 5-points scoring system (excellent, good, moderate, poor, very poor).

RESULTS

Among the 214 evaluated patients, 107 were treated in each arm. The two populations were homogeneous for patients', tumors' and treatment characteristics. Subcutaneous fibrosis (SF), telengectasia (T), skin pigmentation (SP), and breast atrophy (BA) were significantly increased in arm B. Twenty patients experienced grade superior or equal to 2 (SF) in arm B vs five in arm A (P=0.003). Twenty-five and seven patients showed grade superior or equal to 2 (T) in arm B and A, respectively (P=0.001). Forty-four and twenty patients showed grade superior or equal to 2 (BA) in arm B and A, respectively (P=0.0006). Thirty patients experienced grade superior or equal to 3 (SP) in arm B vs fifteen in arm A (P=0.02). No statistical difference was observed between the two arms concerning grade superior or equal to 2 pain, breast oedema, and lymphoedema. No deaths were caused by late toxicity.

CONCLUSION

Following breast conserving surgery, the concurrent use of CT with RT is significantly associated with an increase incidence of grade 2 or greater late side effects.

Concurrent administration of adjuvant chemotherapy and radiotherapy after breast-conserving surgery enhances late toxicities: Long-term results of the ARCOSEIN multicenter randomized study

PURPOSE

In 1996, a multicenter randomized study was initiated that compared sequential vs. concurrent adjuvant chemotherapy (CT) with radiation therapy (RT) after breast-conserving surgery (ARCOSEIN study). After a median follow-up of 6.7 years (range, 4.3-9 years), we decided to prospectively evaluate the late effects of these 2 strategies.

METHODS AND MATERIALS

A total of 297 patients from the 5 larger participating institutions were asked to report for a follow-up examination. Seventy-two percent (214 patients) were eligible for evaluation of late toxicity. After breast-conserving surgery, patients were treated either with sequential treatment with CT first followed by RT (Arm A) or CT administered concurrently with RT (Arm B). In all patients, CT regimen consisted of mitoxantrone (12 mg/m2), 5-FU (500 mg/m2), and cyclophosphamide (500 mg/m2), 6 cycles (Day 1 to Day 21). Conventional RT was delivered to the whole breast by administration of a 2 Gy per fraction protocol to a total dose of 50 Gy (+/- boost to the primary tumor bed). The assessment of toxicity was blinded to treatment and was graded by the radiation oncologist, according to the LENT/SOMA scale. Skin pigmentation was also evaluated according to a personal 5-points scoring system (excellent, good, moderate, poor, very poor).

RESULTS

Among the 214 evaluable patients, 107 were treated in each arm. The 2 populations were homogeneous for patient, tumor, and treatment characteristics. Subcutaneous fibrosis (SF), telangectasia (T), skin pigmentation (SP), and breast atrophy (BA) were significantly increased in Arm B. No statistical difference was observed between the 2 arms of the study concerning Grade 2 or higher pain, breast edema, or lymphedema. No deaths were caused by late toxicity.

CONCLUSION

After breast-conserving surgery, the concurrent use of CT with RT is significantly associated with an increase incidence of Grade 2 or greater late side effects.

Microsatellite instability in endometrioid endometrial carcinoma: correlation with clinically relevant pathologic variables

This study of 218 patients with endometrioid endometrial carcinoma explores the relationship between microsatellite instability (MSI) as established by the BAT26 method and the common pathologic variables of prognostic and therapeutic significance. MSI was positively correlated with grade, associated endometrial atrophy, squamous metaplasia, isthmic involvement, depth of myoinvasion, vascular invasion-associated changes, extrauterine tumor spread, and extramyometrial angiolymphatic spread. There was no significant correlation with carcinoma developing in adenomyosis, mucinous metaplasia, tumor size, cornual involvement, cervical extension, uterine serosal involvement, and targeted lymphoid response. The positive correlations are discussed in terms of molecular genetics.

Radioterapia adjuvante no tratamento do câncer de endométrio: experiência com a associação de radio-terapia externa e braquiterapia de alta taxa de dose

OBJETIVO: Analisar, retrospectivamente, os resultados da radioterapia externa (RT) combinada a braquiterapia de alta taxa de dose (BATD), adjuvantes à cirurgia para o carcinoma de endométrio. MATERIAIS E MÉTODOS: Avaliamos 141 pacientes tratados com RT e BATD adjuvantes à cirurgia, no período de janeiro de 1993 a janeiro de 2001. RT pélvica foi realizada com dose mediana de 45 Gy, e BATD realizada na dose mediana de 24 Gy, em quatro inserções semanais de 6 Gy. A idade mediana das pacientes foi de 63 anos e a distribuição por estádio clínico (EC) foi: EC I (FIGO), 52,4%; EC II, 13,5%; EC III, 29,8%; EC IV, 4,3%. RESULTADOS: Com seguimento mediano de 53,7 meses, a sobrevida livre de doença (SLD) em cinco anos foi: EC I, 88,0%; EC II, 70,8%; EC III, 55,1%; EC IV, 50,0% (p = 0,0003). A sobrevida global em cinco anos foi: EC I, 79,6%; EC II, 74,0%; EC III, 53,6%; EC IV, 100,0% (p = 0,0062). Fatores que influíram na SLD foram grau histológico e histologia seropapilífera. Dos 33 casos que apresentaram recidiva da doença, em 13 (9,2%) esta ocorreu na pelve, vagina ou cúpula vaginal. RT + BATD do fundo vaginal permitiram o controle da doença em 90,8% dos casos. CONCLUSÃO: A RT exerce papel fundamental no controle loco-regional do câncer de endométrio e permite excelentes taxas de cura nos estádios iniciais. Para os estádios mais avançados, a falha terapêutica tende a ser a distância, sugerindo a necessidade de complementação terapêutica sistêmica, com introdução de novas modalidades de tratamento, em particular a quimioterapia.

Intravaginal high-dose-rate brachytherapy for stage I endometrial cancer: a randomized study of two dose-per-fraction levels

PURPOSE

To compare two different fractionation schedules for postoperative vaginal high-dose-rate (HDR) irradiation in endometrial carcinomas.

METHODS AND MATERIALS

In a complete geographic series of 290 low-risk endometrial carcinomas, the efficacy and side effects of two different fractionation schedules for postoperative vaginal irradiation were evaluated. The patients were treated during the years 1989-2003. The tumors were in International Federation of Gynecology and Obstetrics Stages IA-IB and Grades 1-2. The HDR MicroSelectron afterloading equipment (iridium-192) was used. Perspex vaginal applicators with diameters of 20-30 mm were used, and the dose was specified at 5 mm from the surface of the applicator. Six fractions were given, and the overall treatment time was 8 days. The size of the dose per fraction was randomly set to 2.5 Gy (total dose of 15.0 Gy) or 5.0 Gy (total dose of 30.0 Gy). One hundred forty-four patients were treated with the 2.5-Gy fraction and 146 patients with the 5.0-Gy fraction.

RESULTS

The overall locoregional recurrence rate of the complete series was 1.4% and the rate of vaginal recurrences 0.7%. There was no difference between the two randomized groups. The vaginal shortening measured by colpometry was not significant (p = 0.159) in the 2.5-Gy group (mean, 0.3 cm) but was highly significant (p < 0.000001) in the 5.0-Gy group (mean 2.1 cm) after 5 years. Mucosal atrophy and bleedings were significantly more frequent in the 5.0-Gy group. Symptoms noted in the 2.5-Gy group were not different from what could be expected in a normal group of postmenopausal women.

CONCLUSION

The fractionation schedule recommended for postoperative vaginal irradiation in low-risk endometrial carcinoma is six fractions of 2.5 Gy when the HDR technique is used.

Dose-volume histogram evaluation of prone and supine patient position in external beam radiotherapy for cervical and endometrial cancer

BACKGROUND AND PURPOSE

To evaluate the influence of patient positioning on dose-volume histograms of organs at risk in external beam radiotherapy for cervical and endometrial cancer.

MATERIALS AND METHODS

In 20 patients scheduled for definitive (7) or postoperative (13) external beam radiotherapy of the pelvis treatment planning CT scans were performed in supine and prone (belly board) positions. After volume definition of target and organs at risk treatment plans were calculated applying the four-field box technique. The dose-volume histograms of organs at risk were compared.

RESULTS

Radiotherapy in prone position causes a reduction of the bladder portion (mean 15%, p<0.001) and an increase of the rectum portion (mean 11%, p<0.001) within the 90% isodose. A reduction of the bowel portion could only be observed in postoperatively treated patients (mean 13%, p<0.001). In definitive radiotherapy the target volume increases in supine position (mean 7%, p=0.02) due to an anterior tumour/uterus movement, so that bowel portions within the 90% isodose are similar. The bladder filling correlates with a reduction of bladder and bowel (postoperatively treated patients) dose.

CONCLUSIONS

External beam radiotherapy of the pelvis should be performed in prone position in postoperative patients because of best bowel protection. Considering the additional HDR brachytherapy rectum protection takes the highest priority in definitive treatment-the requirements are best met in supine position. An adequate bladder filling is important to reduce the irradiated bladder and bowel volumes.

[Endometrial cancer: what's new?]

OBJECTIVES

New and much debated data of the endometrial cancer concerning the preoperative assessment of myometrial invasion, the surgical staging, and the adjuvant treatment.

PATIENTS AND METHODS

Medline (1998-2002): searching for "endometrial carcinoma".

RESULTS

The pap smears are useful when it is difficult to have a transvaginal ultrasonography or an MRI. We can perform the pap smears and the endometrial biopsy in the clinic. If a patient has pap smears with malignant cells or elevated preoperative CA 125, it probably is a cancer with poor prognostic factors. Surgical staging with abdominal and node evaluation is necessary. The MRI seems to be the best preoperative imaging because we have information about adnexal and abdominal metastases, pelvic or aortic nodes and the invasion of the myometrium. So it gives us information on the surgical route, and provides indication for a lymphadenectomy. The surgical staging is a part of the treatment of the endometrial cancer: an exploration of the peritoneal cavity, a pelvic lymphadenectomy, a para-aortic lymphadenectomy if the pelvic nodes are positive or if there are factors of bad prognosis (deep stage IC, grade 3, adnexal or abdominal involvement, serous carcinoma of the endometrium). It can be performed if technical conditions are correct. The adjuvant teletherapy in the documented stage IpN0 (surgical staging with pelvic lymphadenectomy) does not seem to be necessary. But we can perform an adjuvant brachytherapy (high-dose rate if it is possible) in patients with a high local recurrence (stage IC, stage I with grade 3, stage IB grade 2).

CONCLUSION

The preoperative MRI is useful choosing the surgical approach, and the depth of the myometrial invasion, which can be an indication for a pelvic lymphadenectomy. The surgical staging must be a part of the treatment of the endometrial cancer. So the adjuvant teletherapy in patients with stage IpN0 documented should not be used.

Long-term radiation sequelae after breast-conserving therapy in women with early-stage breast cancer: an observational study using the LENT-SOMA scoring system

PURPOSE

To evaluate the long-term toxicity after breast-conserving therapy in women with early-stage breast cancer.

METHODS AND MATERIALS

Late toxicity according to the late effects of normal tissue-subjective, objective, management, and analytic (LENT-SOMA) criteria and cosmetic outcome (graded by physicians) were evaluated in 590 of 2943 women with early-stage breast cancer who were irradiated between 1983 and 1995 using the following fractionation schedules: group A, 1983-1987, 2.5 Gy 4x/wk to 60 Gy; group B, 1988-1993, 2.5 Gy 4x/wk to 55 Gy, group C, 1994-1995, 2.0 Gy 5x/wk to 55 Gy.

RESULTS

LENT-SOMA Grade 3-4 toxicity was observed as follows: group A (median follow-up 171 months; range 154-222 months), fibrosis 16% (7 of 45), telangiectasia 18% (8 of 45), and atrophy 4% (2 of 45); group B (median follow-up 113 months; range 78-164 months), pain 2% (8 of 345), fibrosis 10% (34 of 345), telangiectasia 10% (33 of 345), arm edema 1% (2 of 345), and atrophy 8% (27 of 345); and group C (median follow-up 75 months, range 51-96 months, n = 200), occurrence of Grade 3-4 late morbidity <or=2%. The cosmetic outcome was very good to acceptable in 78% (35 of 45) of patients in group A, 83% (286 of 345) in group B, and 94% (187 of 200) in group C.

CONCLUSION

In our population, the long-term side effects after breast-conserving therapy were not rare, but were mainly asymptomatic. The LENT-SOMA breast module is a practical tool to assess radiation-induced long-term toxicity.

Early-stage endometrial cancer

For half a century, adjuvant radiation therapy has been an important component in the treatment of patients with early-stage endometrial cancer believed to be at significant risk of local or regional recurrence. The widespread adoption of up-front surgical treatment and staging, including nodal assessment, has raised new questions about the need for and extent of postoperative adjuvant treatment. Furthermore, in some institutions, even in the absence of complete surgical staging, the extent of postoperative adjuvant treatment is being reassessed. These developments have increased interest in the use of intravaginal brachytherapy (IVRT) alone in selected patients whose major risk of recurrence is at the vaginal cuff. The potential advantages of this approach include lower cost and decreased acute and late toxicity. The use of IVRT alone in select patients was examined through a review of the available literature. The authors conclude that there is a subset of patients in whom adjuvant treatment with IVRT alone is adequate. A clinical approach involving patient selection criteria is proposed which suggests separate selection criteria based on whether or not complete surgical staging information is available.

[Role of adjuvant therapy in uterine sarcoma: experience of the Curie Institute]

PURPOSE

Uterine sarcoma is a rare disease and survival is poor. From 1975 to 1995, 73 uterine sarcomas were treated at the Curie Institute, and we analysed prognostics factors of survival.

PATIENTS AND METHODS

Seventy-one patients underwent primary surgery, in most cases a radical non conservative surgery and a lymphadenectomy. Every patient had an irradiation (external beam irradiation and/or brachytherapy), and 24 patients received adjuvant chemotherapy. We observed that youngest patients had more leiomyosarcomas and low histologic grade tumours. Median survival was 42 months, and 5-years survival and local control were 36 and 68% respectively. Pelvic recurrences were most often before 2 years. This series demonstrates the impact of adjuvant irradiation on local control. This impact was stronger if the tumour had a high histologic grade (p < 0.01). However, irradiation, as well as chemotherapy, had no impact on the survival.

CONCLUSION

The study confirmed that irradiation enable a better local control. However modalities of radiation therapy (brachytherapy and/or external beam radiotherapy, dose, volume), are still controversed.