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Jreij M, El Ahmar A, Finianos P. Applicators used for vaginal high dose rate brachytherapy: Effect of type and shape on dose distribution and toxicity, a literature review. Cancer Radiother 2023; 27:80-85. [PMID: 35973915 DOI: 10.1016/j.canrad.2021.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 10/26/2021] [Indexed: 02/06/2023]
Abstract
The aim of this article is to represent a literature review on the applicators used for vaginal high dose rate brachytherapy for patients with endometrial cancer. The different types and shapes of the clinically used applicator as well as the effects of their characteristics on dose distribution, target coverage and dose received by organs at risk are discussed in detail.
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Affiliation(s)
- Mirna Jreij
- American University of Science and Technology, Beirut, Lebanon.
| | - Ali El Ahmar
- American University of Science and Technology, Beirut, Lebanon
| | - Pascal Finianos
- American University of Science and Technology, Beirut, Lebanon
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2
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Abakay CD, Arslan S, Kurt M, Cetintas S. Improving locoregional outcome in high-intermediate-risk and high-risk stage I endometrial cancer with surgical staging followed by brachytherapy. Radiat Oncol J 2022; 40:103-110. [PMID: 35796113 PMCID: PMC9262699 DOI: 10.3857/roj.2021.00864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/26/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose This study aims to assess the locoregional efficacy of postoperative vaginal brachytherapy (VBT) alone in patients undergoing surgical staging for early-stage high-intermediate-risk (HIR) and high-risk (HR) endometrial cancer. Materials and Methods One hundred and four patients with early-stage HIR and HR endometrial cancer who underwent surgical staging were treated with adjuvant VBT alone. The patients with stage Ib, grade I–III, stage Ia, grade III, lower uterine segment involvement, and lymphovascular invasion (LVI) were included to study. Results The 5- and 10-year overall survival (OS) rates were 87% and 76%, respectively. The 5- and 10-year DFS rates were 86% and 86%, respectively. Among the patients, 92% had endometrioid adenocarcinoma, 2% had undifferentiated carcinoma, 2% had serous papillary carcinoma, and 4% had clear-cell carcinoma. Of the patients, 63% had stage Ib disease, while 37% had stage Ia disease. None of the patients had vaginal or pelvic lymph node recurrence, whereas two had para-aortic lymph node metastasis, one had surgical scar recurrence, one had para-aortic lymph node and brain metastasis, and one had lung metastasis. The presence of lymphatic invasion was found to be a statistically significant prognostic factor for increased distant metastasis rates (p = 0.020). Lymphatic invasion was also regarded as an independent prognostic factor for metastasis-free survival (p = 0.044). Conclusion Our study results suggest that postoperative VBT alone is an effective and safe treatment modality with low complication in patients undergoing surgical staging for HIR and HR endometrial cancer.
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Affiliation(s)
- Candan Demiroz Abakay
- Department of Radiation Oncology, Faculty of Medicine, Uludag University, Bursa, Turkey
- Correspondence: Candan Demiroz Abakay Department of Radiation Oncology, Faculty of Medicine, Uludag University, Nilufer/Bursa 16059, Turkey. Tel: +90-5336663507 E-mail:
| | - Sonay Arslan
- Department of Radiation Oncology, Manisa City Hospital, Manisa, Turkey
| | - Meral Kurt
- Department of Radiation Oncology, Faculty of Medicine, Uludag University, Bursa, Turkey
| | - Sibel Cetintas
- Department of Radiation Oncology, Faculty of Medicine, Uludag University, Bursa, Turkey
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Vaginal toxicity after high-dose-rate endovaginal brachytherapy: 20 years of results. J Contemp Brachytherapy 2018; 10:559-566. [PMID: 30662479 PMCID: PMC6335557 DOI: 10.5114/jcb.2018.79713] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 10/25/2018] [Indexed: 02/07/2023] Open
Abstract
Purpose To evaluate vaginal toxicity (primary endpoint) and local control (secondary endpoint) in patients with endometrial cancer who underwent primary surgery and adjuvant high-dose-rate (HDR) endovaginal brachytherapy (BT). Material and methods In September 2017, the authors conducted a comprehensive literature search of the following electronic databases: PubMed, Web of Science, Scopus, and Cochrane library. In this systematic review, the authors included randomized trials, non-randomized trials, prospective studies, retrospective studies, and cases. The time period of the research included articles published from September 1997 to September 2017. Results Acute endovaginal toxicity occurred in less than 20.6% and all acute toxicities were G1-G2. The most common early side effects due to HDR-BT treatment were vaginal inflammation, vaginal irritation, dryness, discharge, soreness, swelling, and fungal infection. G1-G2 late toxicity occurred in less than 27.7%. Finally, G3-G4 late vaginal occurred in less than 2%. The most common late side effects consisted of vaginal discharge, dryness, itching, bleeding, fibrosis, telangiectasias, stenosis, short or narrow vagina, and dyspareunia. Conclusions The data suggest that HDR endovaginal brachytherapy, with or without chemotherapy, is very well tolerated with low rates of acute and late vaginal toxicities. Further prospective studies with higher numbers of patients and longer follow-up are necessary to evaluate acute and late toxicities after HDR endovaginal brachytherapy.
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Dohopolski MJ, Horne ZD, Gebhardt BJ, Glaser SM, Edwards RP, Kelley JL, Comerci JT, Olawaiye AB, Courtney-Brooks M, Berger JL, Sukumvanich P, Beriwal S. Single-institutional outcomes of adjuvant brachytherapy for Stage I endometrial cancer-Are outcomes consistent with randomized studies? Brachytherapy 2018; 17:564-570. [PMID: 29426745 DOI: 10.1016/j.brachy.2018.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 01/02/2018] [Accepted: 01/08/2018] [Indexed: 01/22/2023]
Abstract
PURPOSE Vaginal brachytherapy (VBT) alone has been shown to be a viable adjuvant treatment strategy for most patients with Stage I endometrioid endometrial cancer. We sought to examine our institutional data following practice pattern changes resulting from the publications of GOG-99 and PORTEC-2. METHODS AND MATERIALS We retrospectively analyzed women who underwent adjuvant VBT after surgical staging for Stage 1 endometrioid endometrial cancer at our institution from 2007 to 2014. RESULTS We identified 297 women. Median time to last followup or death was 52.3 months (interquartile range: 32.3-72.3 months). By International Federation of Gynecology and Obstetrics 2009 staging, 162 patients (54.5%) had Stage IA and 128 (43.1%) had Stage IB disease. Ninety-nine (33.3%) patients had Grade 1, 153 (51.5%) had Grade 2, and 45 (15.2%) had Grade 3 disease. According to GOG-249 and PORTEC-2 criteria, 167 (56.2%) and 127 (42.7%) patients were with high-intermediate-risk disease. Two women had Stage IB Grade 3 disease. The most common high-dose-rate-VBT regimen was 2100 cGy/three fractions to a depth of 5 mm. Four (two acute and two late) (1.3%) Grade 3 genitourinary toxicities were reported: three episodes of vaginal dehiscence (after second course of VBT, 2 months after completion of VBT, and 1 year after completion of VBT) and one episode of radiation necrosis. Twenty-one (7%) women recurred: three recurred in the vagina, two recurred in the pelvic lymph nodes, and 16 recurred distantly. CONCLUSIONS Outcomes appear consistent with published randomized data in women with high-intermediate-risk endometrial cancer who are treated with brachytherapy alone. Recurrence and complication rates were minimal.
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Affiliation(s)
- Michael J Dohopolski
- Department of Radiation Oncology, University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA
| | - Zachary D Horne
- Department of Radiation Oncology, University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA
| | - Brian J Gebhardt
- Department of Radiation Oncology, University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA
| | - Scott M Glaser
- Department of Radiation Oncology, University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA
| | - Robert P Edwards
- Department of Gynecologic Oncology, University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA
| | - Joseph L Kelley
- Department of Gynecologic Oncology, University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA
| | - John T Comerci
- Department of Gynecologic Oncology, University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA
| | - Alexander B Olawaiye
- Department of Gynecologic Oncology, University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA
| | | | - Jessica L Berger
- Department of Gynecologic Oncology, University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA
| | - Paniti Sukumvanich
- Department of Gynecologic Oncology, University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA.
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Topfedaisi Ozkan N, Meydanlı MM, Sarı ME, Demirkiran F, Kahramanoglu I, Bese T, Arvas M, Şahin H, Haberal A, Celik H, Coban G, Oge T, Yalcin OT, Akbayır Ö, Erdem B, Numanoğlu C, Özgül N, Boyraz G, Salman MC, Yüce K, Dede M, Yenen MC, Taşkın S, Altın D, Ortaç UF, Aydın Ayık H, Şimşek T, Güngör T, Güngördük K, Sancı M, Ayhan A. Factors associated with survival after relapse in patients with low-risk endometrial cancer treated with surgery alone. J Gynecol Oncol 2017; 28:e65. [PMID: 28657226 PMCID: PMC5540724 DOI: 10.3802/jgo.2017.28.e65] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 05/11/2017] [Accepted: 05/18/2017] [Indexed: 11/30/2022] Open
Abstract
Objective To determine factors influencing overall survival following recurrence (OSFR) in women with low-risk endometrial cancer (EC) treated with surgery alone. Methods A multicenter, retrospective department database review was performed to identify patients with recurrent “low-risk EC” (patients having less than 50% myometrial invasion [MMI] with grade 1 or 2 endometrioid EC) at 10 gynecologic oncology centers in Turkey. Demographic, clinicopathological, and survival data were collected. Results We identified 67 patients who developed recurrence of their EC after initially being diagnosed and treated for low-risk EC. For the entire study cohort, the median time to recurrence (TTR) was 23 months (95% confidence interval [CI]=11.5–34.5; standard error [SE]=5.8) and the median OSFR was 59 months (95% CI=12.7–105.2; SE=23.5). We observed 32 (47.8%) isolated vaginal recurrences, 6 (9%) nodal failures, 19 (28.4%) peritoneal failures, and 10 (14.9%) hematogenous disseminations. Overall, 45 relapses (67.2%) were loco-regional whereas 22 (32.8%) were extrapelvic. According to the Gynecologic Oncology Group (GOG) Trial-99, 7 (10.4%) out of 67 women with recurrent low-risk EC were qualified as high-intermediate risk (HIR). The 5-year OSFR rate was significantly higher for patients with TTR ≥36 months compared to those with TTR <36 months (74.3% compared to 33%, p=0.001). On multivariate analysis for OSFR, TTR <36 months (hazard ratio [HR]=8.46; 95% CI=1.65–43.36; p=0.010) and presence of HIR criteria (HR=4.62; 95% CI=1.69–12.58; p=0.003) were significant predictors. Conclusion Low-risk EC patients recurring earlier than 36 months and those carrying HIR criteria seem more likely to succumb to their tumors after recurrence.
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Affiliation(s)
- Nazli Topfedaisi Ozkan
- Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Mehmet Mutlu Meydanlı
- Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Mustafa Erkan Sarı
- Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey.
| | - Fuat Demirkiran
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ilker Kahramanoglu
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Tugan Bese
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Macit Arvas
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Hanifi Şahin
- Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Ali Haberal
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Husnu Celik
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Gonca Coban
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Tufan Oge
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Osmangazi University, Eskisehir, Turkey
| | - Omer Tarik Yalcin
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Osmangazi University, Eskisehir, Turkey
| | - Özgür Akbayır
- Department of Gynecologic Oncology, Kanuni Sultan Suleyman Teaching and Research Hospital, Istanbul, Turkey
| | - Baki Erdem
- Department of Gynecologic Oncology, Kanuni Sultan Suleyman Teaching and Research Hospital, Istanbul, Turkey
| | - Ceyhun Numanoğlu
- Department of Gynecologic Oncology, Kanuni Sultan Suleyman Teaching and Research Hospital, Istanbul, Turkey
| | - Nejat Özgül
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Gökhan Boyraz
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Mehmet Coşkun Salman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Kunter Yüce
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Murat Dede
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Gulhane Training and Researh Hospital, Ankara, Turkey
| | - Mufit Cemal Yenen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Gulhane Training and Researh Hospital, Ankara, Turkey
| | - Salih Taşkın
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, School of Medicine, Ankara University, Ankara, Turkey
| | - Duygu Altın
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, School of Medicine, Ankara University, Ankara, Turkey
| | - Uğur Fırat Ortaç
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, School of Medicine, Ankara University, Ankara, Turkey
| | - Hülya Aydın Ayık
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Tayup Şimşek
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Tayfun Güngör
- Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Kemal Güngördük
- Department of Gynecologic Oncology, Tepecik Education and Research Hospital, Faculty of Medicine, University of Health Sciences, Izmir, Turkey
| | - Muzaffer Sancı
- Department of Gynecologic Oncology, Tepecik Education and Research Hospital, Faculty of Medicine, University of Health Sciences, Izmir, Turkey
| | - Ali Ayhan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey
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6
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Harkenrider MM, Block AM, Alektiar KM, Gaffney DK, Jones E, Klopp A, Viswanathan AN, Small W. American Brachytherapy Task Group Report: Adjuvant vaginal brachytherapy for early-stage endometrial cancer: A comprehensive review. Brachytherapy 2017; 16:95-108. [PMID: 27260082 PMCID: PMC5612425 DOI: 10.1016/j.brachy.2016.04.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 03/30/2016] [Accepted: 04/08/2016] [Indexed: 11/29/2022]
Abstract
This article aims to review the risk stratification of endometrial cancer, treatment rationale, outcomes, treatment planning, and treatment recommendations of vaginal brachytherapy (VBT) in the postoperative management of endometrial cancer patients. The authors performed a thorough review of the literature and reference pertinent articles pertaining to the aims of this review. Adjuvant VBT for early-stage endometrial cancer patients results in very low rates of vaginal recurrence (0-3.1%) with low rates of late toxicity which are primarily vaginal in nature. Post-Operative Radiation Therapy in Endometrial Cancer 2 (PORTEC-2) supports that VBT results in noninferior rates of vaginal recurrence compared to external beam radiotherapy for the treatment of high-intermediate risk patients. VBT as a boost after external beam radiotherapy, in combination with chemotherapy, and for high-risk histologies have shown excellent results as well though randomized data do not exist supporting VBT boost. There are many different applicators, dose-fractionation schedules, and treatment planning techniques which all result in favorable clinical outcomes and low rates of toxicity. Recommendations have been published by the American Brachytherapy Society and the American Society of Radiation Oncology to help guide practitioners in the use of VBT. Data support that patients and physicians prefer joint decision making regarding the use of VBT, and patients often desire additional treatment for a marginal benefit in risk of recurrence. Discussions regarding adjuvant therapy for endometrial cancer are best performed in a multidisciplinary setting, and patients should be counseled properly regarding the risks and benefits of adjuvant therapy.
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MESH Headings
- Adenocarcinoma, Clear Cell/pathology
- Adenocarcinoma, Clear Cell/radiotherapy
- Advisory Committees
- Brachytherapy/methods
- Carcinoma, Endometrioid/pathology
- Carcinoma, Endometrioid/radiotherapy
- Carcinosarcoma/pathology
- Carcinosarcoma/radiotherapy
- Combined Modality Therapy
- Endometrial Neoplasms/pathology
- Endometrial Neoplasms/radiotherapy
- Female
- Humans
- Hysterectomy
- Neoplasm Recurrence, Local
- Neoplasm Staging
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Cystic, Mucinous, and Serous/radiotherapy
- Radiotherapy, Adjuvant/methods
- Societies, Medical
- United States
- Vagina
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Affiliation(s)
- Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL.
| | - Alec M Block
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Kaled M Alektiar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Ellen Jones
- Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Ann Klopp
- Department of Radiation Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX
| | - Akila N Viswanathan
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL
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Acute and late vaginal toxicity after adjuvant high-dose-rate vaginal brachytherapy in patients with intermediate risk endometrial cancer: is local therapy with hyaluronic acid of clinical benefit? J Contemp Brachytherapy 2016; 8:512-517. [PMID: 28115957 PMCID: PMC5241378 DOI: 10.5114/jcb.2016.64511] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 11/17/2016] [Indexed: 01/08/2023] Open
Abstract
PURPOSE The aim of the present study was to evaluate the effectiveness of hyaluronic acid (HA) in the prevention of acute and late vaginal toxicities after high-dose-rate (HDR) vaginal brachytherapy (BT). MATERIAL AND METHODS Between January 2011 and January 2015, we retrospectively analyzed 126 patients with endometrial cancer who underwent extrafascial hysterectomy with or without lymphadenectomy and adjuvant HDR-vaginal BT +/- adjuvant chemotherapy. The total dose prescription was 21 Gy in 3 fractions (one fraction for week). Vaginal ovules containing 5 mg of HA were given for whole duration of vaginal BT and for the two following weeks. Acute and late toxicities were evaluated according to CTCAE vs 4.02. RESULTS According to the revised FIGO 2009 classification, most tumors were in stage IA (30.9%) and in stage IB (57.9%). Thirty-three patients (26.2%) received adjuvant chemotherapy before vaginal BT. Five-year disease-free survival (DFS) and five-year overall survival (OS) were 88% and 93%, respectively. The most common grade 1-2 acute toxicities were vaginal inflammation (18 patients, 14.3%) and dyspareunia (7 patients, 5.5%). Two patients (1.6%) had more than one toxicity. Late toxicity occurred in 20 patients (15.9%). Grade 1-2 late toxicities were fibrosis (14 patients, 11.1%) and telangiectasias (7 patients, 5.5%). Six patients (4.8%) had more than one late toxicity. No grade 3 or higher acute or late toxicities were observed. CONCLUSIONS These results appear to suggest that the local therapy with HA is of clinical benefit for intermediate risk endometrial cancer patients who receive adjuvant HDR-vaginal BT after surgery. A randomized trial comparing HA treatment vs. no local treatment in this clinical setting is warranted to further evaluate the efficacy of HA in preventing vaginal BT-related vaginal toxicity.
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8
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Tokar M, Meirovich M, Bobilev D, Mermershtain W. Adjuvant brachytherapy for Stage IB Grade 2 endometrial carcinoma: Multivariate analysis of a single institution experience. Indian J Med Paediatr Oncol 2016; 37:112-5. [PMID: 27168710 PMCID: PMC4854042 DOI: 10.4103/0971-5851.180148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective: The aim was to investigate the value of postoperative brachytherapy for patients with Stage IB, Grade 2 endometrial carcinoma. Patients and Methods: Forty-six patients with Stage IB, Grade 2 endometrial carcinoma, were treated with simple hysterectomy and bilateral oophorectomy in our institution. The mean age was 63 (range, 42-81). Surgical staging, defined as peritoneal washing and pelvic lymph node sampling was performed in 73% of patients. Twenty-two patients (47%) received a postoperative intravaginal brachytherapy (IVRT), and 24 patients (53%) were followed-up without additional treatment. Results: The median follow-up was 60 months. The 5-year overall survival for irradiated and nonirradiated patients, was 83.5 and 94.7%, respectively. Four patients (8.7%) developed relapse, two in the group of postoperative IVRT and 2 in the follow-up only group. Multivariate analysis demonstrated a borderline association (P = 0.06) between lower uterine segment involvement and poor pelvic-vaginal control. The presence of GOG #99 high-risk features did not affect the pelvic control rate. Conclusion: According to our experience and previously published data, most patients with FIGO Stage IB, Grade 2 endometrial carcinoma may be cured with surgery alone.
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Affiliation(s)
- Margarita Tokar
- Department of Oncology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Michael Meirovich
- Division of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Dmitri Bobilev
- Department of Oncology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Wilmosh Mermershtain
- Department of Oncology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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9
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Miyamoto M, Takano M, Aoyama T, Soyama H, Kato M, Yoshikawa T, Shibutani T, Matsuura H, Goto T, Sasa H, Nagaoka I, Furuya K. Is Modified Radical Hysterectomy Needed for Patients with Clinical Stage I/II Endometrial Cancers? A Historical Control Study. Oncology 2016; 90:179-85. [PMID: 26986224 DOI: 10.1159/000444258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 01/22/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of the present study was to assess whether hysterectomy with wider resection could improve survival by preventing local recurrence. METHODS Medical charts of the patients with clinical stage I/II endometrial cancers treated at our hospital between 1990 and 2009 were retrospectively analyzed. The primary endpoint was overall survival (OS), and secondary endpoints were progression-free survival (PFS) and adverse effects according to the type of hysterectomy. RESULTS A total of 247 patients were identified: 46 patients treated with total abdominal hysterectomy (TAH group) and 201 patients with modified radical hysterectomy (mRH group). No significant differences were observed in OS (p = 0.52) and PFS (p = 0.67) between the two groups. Also, there was no significant difference in the distribution of recurrent sites between the two groups. The patients treated with mRH had a longer operation time and more frequently developed severe adverse events, such as blood loss and lymphedema. CONCLUSION In our cohorts, there were no significant differences in both PFS and OS according to surgical procedures, and the mRH group more frequently developed severe adverse events. Overall, clinical benefit was not obtained by mRH in patients with clinical stage I/II endometrial carcinomas.
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Affiliation(s)
- Morikazu Miyamoto
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, Tokorozawa, Japan
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10
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Predictors of vaginal stenosis after intravaginal high-dose-rate brachytherapy for endometrial carcinoma. Brachytherapy 2015; 14:464-70. [PMID: 25887343 DOI: 10.1016/j.brachy.2015.03.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 01/27/2015] [Accepted: 03/03/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE Intravaginal high-dose-rate brachytherapy is an effective adjuvant treatment for localized endometrial carcinoma. However, relatively little is known about risk factors of post-treatment vaginal stenosis (VS). METHODS AND MATERIALS We included patients treated with brachytherapy for endometrial carcinoma from September 2011 to January 2014 with at least 3 months of followup. Patients who received external beam radiation therapy were excluded. VS was prospectively graded at each followup visit per Common Terminology Criteria for Adverse Events, version 4.03. χ(2) and t test analyses were used to assess the association of VS with various patient, tumor, treatment, and post-treatment factors. Multivariable logistic regression analysis was used to identify independent predictors of VS Grade ≥1 and ≥2. RESULTS All 101 patients were disease free at last followup. Mean followup was 12.9 months (range, 3-34). Highest VS grades were zero in 67%, one in 26%, two in 6%, and three in 1%. Borderline significant variables associated with Grade ≥1 VS included vagina length, proportion of vagina treated, and total dose. Dilator use was significantly associated with Grade ≥2. Multivariable analysis revealed that proportion of vagina treated >60% (odds ratio [OR], 3.48; p = 0.009) and total dose >14 Gy (OR, 4.27; p = 0.015) were independent predictors of Grade ≥1 VS, and lack of consistent dilator use was an independent predictor of Grade ≥2 VS (OR, 5.60; p = 0.047). CONCLUSIONS Patients treated with a higher total dose to a larger proportion of the vagina were more likely to develop Grade ≥1 VS. Consistent dilator use may also be protective against Grade ≥2 VS.
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Harkenrider MM, Block AM, Siddiqui ZA, Small W. The role of vaginal cuff brachytherapy in endometrial cancer. Gynecol Oncol 2015; 136:365-72. [DOI: 10.1016/j.ygyno.2014.12.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 12/23/2014] [Accepted: 12/26/2014] [Indexed: 11/15/2022]
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Fiorelli JL, Herzog TJ, Wright JD. Current treatment strategies for endometrial cancer. Expert Rev Anticancer Ther 2014; 8:1149-57. [DOI: 10.1586/14737140.8.7.1149] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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13
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External-beam radiotherapy and/or HDR brachytherapy in postoperative endometrial cancer patients: clinical outcomes and toxicity rates. Radiol Med 2012; 118:311-22. [PMID: 22580814 DOI: 10.1007/s11547-012-0833-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 09/20/2011] [Indexed: 10/28/2022]
Abstract
PURPOSE The objectives of this study were to evaluate local disease control, overall survival (OS), disease-free survival (DFS) and local relapse-free survival (LRFS) in patients with endometrial cancer undergoing adjuvant vaginal brachytherapy (VBT )± external-beam radiotherapy (EBRT). MATERIALS AND METHODS From September 2007 to February 2011, 40 patients with endometrial cancer were retrospectively analysed. Surgery consisted of total hysterectomy and bilateral salpingo-oophorectomy without node dissection (16 patients) or with bilateral pelvic node dissection (24 patients). The stage distribution was as follows: two IA, nine IB, 12 IC, five IIA, eight IIB, two IIIA and two IIIC. Thirty-four patients underwent EBRT and VBT. Six patients received VBT alone. RESULTS Median follow-up was 26 months. The 5-year OS and DFS were 96.4% and 86.9%, respectively. No local recurrence was observed. Four patients presented distant disease (three had lung metastases and one had hepatic node metastases). Acute EBRT-related toxicities were seen in 15 (38%) patients. We recorded late toxicities in 14 patients (35%). There was no evidence of grade 3-4 toxicity. CONCLUSIONS Adjuvant EBRT and/or VBT in patients with endometrial cancer showed good outcomes in terms of local disease control, with an acceptable toxicity profile.
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Diavolitsis V, Rademaker A, Lurain J, Hoekstra A, Strauss J, Small W. Clinical outcomes in international federation of gynecology and obstetrics stage IA endometrial cancer with myometrial invasion treated with or without postoperative vaginal brachytherapy. Int J Radiat Oncol Biol Phys 2012; 84:415-9. [PMID: 22365625 DOI: 10.1016/j.ijrobp.2011.12.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 11/21/2011] [Accepted: 11/29/2011] [Indexed: 10/28/2022]
Abstract
PURPOSE To assess the clinical outcomes of patients with Stage IA endometrial cancer with myometrial invasion treated with postoperative vaginal brachytherapy (VBT) with those who received no adjuvant therapy (NAT). METHODS AND MATERIALS All patients treated with hysterectomy for endometrial cancer at Northwestern Memorial Hospital between 1978 and 2005 were identified. Those patients with Stage IA disease with myometrial invasion who were treated with VBT alone or NAT were identified and included in the present analysis. RESULTS Of 252 patients with Stage IA endometrial cancer with superficial (<50%) myometrial invasion who met the inclusion criteria, 169 underwent VBT and 83 received NAT. The median follow-up in the VBT and NAT groups was 103 and 61 months, respectively. In the VBT group, 56.8% had Grade 1, 37.9% had Grade 2, and 5.3% had Grade 3 tumors. In the NAT group, 75.9%, 20.5%, and 3.6% had Grade 1, 2, and 3 tumors, respectively. Lymphatic or vascular space invasion was noted in 12.4% of the VBT patients and 5.6% of the NAT patients. The 5-year overall survival rate was 95.5%. The 5-year recurrence-free survival rate was 92.4% for all patients, 94.4% for the VBT group, and 87.4% for the NAT group (p = NS). Of the 169 VBT patients and 83 NAT patients, 8 (4.7%) and 6 (7.2%) developed recurrent disease. One vaginal recurrence occurred in the VBT group (0.6%) and three in the NAT group (3.8%). Recurrences developed 2-102 months after surgical treatment. Two of the four vaginal recurrences were salvaged. No Grade 3 or higher acute or late radiation toxicity was noted. CONCLUSIONS The use of postoperative VBT in patients with Stage I endometrial cancer with <50% myometrial invasion yielded excellent vaginal disease control and disease-free survival, with minimal toxicity.
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Affiliation(s)
- V Diavolitsis
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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Bahng AY, Dagan A, Bruner DW, Lin LL. Determination of Prognostic Factors for Vaginal Mucosal Toxicity Associated With Intravaginal High-Dose Rate Brachytherapy in Patients With Endometrial Cancer. Int J Radiat Oncol Biol Phys 2012; 82:667-73. [DOI: 10.1016/j.ijrobp.2010.10.071] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 10/02/2010] [Accepted: 10/29/2010] [Indexed: 10/18/2022]
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Scheithauer HR, Schulz DS, Belka C. Endometrial cancer - reduce to the minimum. A new paradigm for adjuvant treatments? Radiat Oncol 2011; 6:164. [PMID: 22118369 PMCID: PMC3239313 DOI: 10.1186/1748-717x-6-164] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 11/25/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Up to now, the role of adjuvant radiation therapy and the extent of lymph node dissection for early stage endometrial cancer are controversial. In order to clarify the current position of the given adjuvant treatment options, a systematic review was performed. MATERIALS AND METHODS Both, Pubmed and ISI Web of Knowledge database were searched using the following keywords and MESH headings: "Endometrial cancer", "Endometrial Neoplasms", "Endometrial Neoplasms/radiotherapy", "External beam radiation therapy", "Brachytherapy" and adequate combinations. CONCLUSION Recent data from randomized trials indicate that external beam radiation therapy - particularly in combination with extended lymph node dissection - or radical lymph node dissection increases toxicity without any improvement of overall survival rates. Thus, reduced surgical aggressiveness and limitation of radiotherapy to vaginal-vault-brachytherapy only is sufficient for most cases of early stage endometrial cancer.
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Affiliation(s)
- Heike R Scheithauer
- Universitiy of Munich - LMU, Department of Radiation Oncology, Munich, Germany
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Gadducci A, Greco C. The evolving role of adjuvant therapy in endometrial cancer. Crit Rev Oncol Hematol 2011; 78:79-91. [DOI: 10.1016/j.critrevonc.2010.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Revised: 02/23/2010] [Accepted: 03/24/2010] [Indexed: 01/09/2023] Open
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Okuma K, Yamashita H, Kawana K, Nakagawa S, Oda K, Nakagawa K. Advanced age is a significant determinant of poor prognosis in patients treated with surgery plus postoperative radiotherapy for endometrial cancer. J Obstet Gynaecol Res 2010; 36:757-63. [DOI: 10.1111/j.1447-0756.2010.01202.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Postoperative Intensity-Modulated Radiotherapy in Low-Risk Endometrial Cancers: Final Results of a Phase I Study. Int J Radiat Oncol Biol Phys 2010; 76:1390-5. [DOI: 10.1016/j.ijrobp.2009.04.091] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 04/07/2009] [Accepted: 04/07/2009] [Indexed: 11/22/2022]
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Signorelli M, Lissoni AA, Cormio G, Katsaros D, Pellegrino A, Selvaggi L, Ghezzi F, Scambia G, Zola P, Grassi R, Milani R, Giannice R, Caspani G, Mangioni C, Floriani I, Rulli E, Fossati R. Modified Radical Hysterectomy Versus Extrafascial Hysterectomy in the Treatment of Stage I Endometrial Cancer: Results From the ILIADE Randomized Study. Ann Surg Oncol 2009; 16:3431-41. [DOI: 10.1245/s10434-009-0736-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Indexed: 11/18/2022]
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Fakiris AJ, Randall ME. Endometrial carcinoma: The current role of adjuvant radiation. J OBSTET GYNAECOL 2009; 29:81-9. [DOI: 10.1080/01443610802646777] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sorbe B, Nordström B, Mäenpää J, Kuhelj J, Kuhelj D, Okkan S, Delaloye JF, Frankendal B. Intravaginal Brachytherapy in FIGO Stage I Low-Risk Endometrial Cancer. Int J Gynecol Cancer 2009; 19:873-8. [DOI: 10.1111/igc.0b013e3181a6c9df] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Le T, Menard C, Samant R, Choan E, Hopkins L, Faught W, Fung-Kee-Fung M. Longitudinal assessments of quality of life in endometrial cancer patients: effect of surgical approach and adjuvant radiotherapy. Int J Radiat Oncol Biol Phys 2009; 75:795-802. [PMID: 19250764 DOI: 10.1016/j.ijrobp.2008.11.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2008] [Revised: 11/11/2008] [Accepted: 11/14/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE Adjuvant radiotherapy (RT) is often considered for endometrial cancer. We studied the effect of RT and surgical treatment on patients' quality of life (QOL). METHODS AND MATERIALS All patients referred to the gynecologic oncology clinics with biopsy findings showing endometrial cancer were recruited. QOL assessments were performed using the European Organization for Research and Treatment of Cancer QOL questionnaire-C30, version 3. Assessments were obtained at study entry and at regular 3-month intervals for a maximum of 2 years. Open-ended telephone interviews were done every 6 months. Linear mixed regression models were built using QOL domain scores as dependent variables, with the predictors of surgical treatment and adjuvant RT type. RESULTS A total of 40 patients were recruited; 80% of the surgeries were performed by laparotomy. Significant improvements were seen in most QOL domains with increased time from treatment. Adjuvant RT resulted in significantly more severe bowel symptoms and improvement in insomnia compared with conservative follow-up. No significant adverse effect from adjuvant RT was seen on the overall QOL. Bowel symptoms were significantly increased in patients treated with laparotomy compared with laparoscopy in the patients treated with whole pelvic RT. Qualitatively, about one-half of the patients noted improvements in their overall QOL during follow-up, with easy fatigability the most prevalent. CONCLUSION No significant adverse effect was seen on patients' overall QOL with adjuvant pelvic RT after the recovery period. The acute adverse effects on patients' QOL significantly improved with an increasing interval from diagnosis.
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Affiliation(s)
- Tien Le
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Ottawa, 501 Smyth Road, Ottawa, Ontario, Canada.
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Desrosiers L, Fadare O, Xiao ZF, Dresser K, Wang SA. Lymphovascular space invasion does not predict vaginal relapses in stage I endometrioid adenocarcinoma of the endometrium. Ann Diagn Pathol 2008; 12:112-7. [DOI: 10.1016/j.anndiagpath.2007.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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26
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Fleming GF, Montag AC, Mundt AJ, Yamada S. Uterine Malignancies. Oncology 2007. [DOI: 10.1007/0-387-31056-8_53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Johnson N, Cornes P. Survival and recurrent disease after postoperative radiotherapy for early endometrial cancer: systematic review and meta-analysis. BJOG 2007; 114:1313-20. [PMID: 17803718 DOI: 10.1111/j.1471-0528.2007.01332.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To clarify the effect of postoperative (adjuvant) external-beam pelvic radiotherapy (EBRT) for different grades of early endometrial cancer. SEARCH STRATEGY Meta-analysis of data from randomised trials stratified by histological risk factors supported by cohort studies. SELECTION CRITERIA Cochrane methodology. DATA Seven randomised trials were identified. Five were eligible for meta-analysis. Homogeneity was confirmed (I2 < 25%). MAIN OUTCOME MEASURES Survival, site of recurrence and added complications. MAIN RESULTS EBRT after hysterectomy for low-risk disease increases the odds of death (OR for overall survival 0.71; 95% CI 0.52-0.96). EBRT does not appear to alter survival for intermediate-risk cancers (stage ICG1/2 and IBG3) (OR 0.97; 95% CI 0.69-1.35). In contrast, EBRT offers a significant disease-free survival advantage for high-risk cancer (OR 1.76; 95% CI 1.07-2.89). The survival advantage benefits one in ten women. The definition of high risk is variable across studies but focuses on ICG3 (deeply invasive, poorly differentiated) tumours. Pelvic EBRT reduces the risk of pelvic recurrent disease in all types of invasive endometrial cancer (OR 0.27; 95% CI 0.16-0.44), but local recurrence may respond to salvage treatment. The risk of distant metastasis appears to be increased significantly by prophylactic EBRT (OR 1.58; 95% CI 1.07-2.35), but this might be because pelvic relapse in untreated women alters reporting of metastatic disease. AUTHORS' CONCLUSIONS Adjuvant EBRT should not be used for low- (IA, IBG1) or intermediate-risk (IBG2) cancer, but it is associated with a 10% survival advantage for high-risk (stage ICG3) endometrial cancer. This challenges the role of a staging lymphadenectomy.
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Affiliation(s)
- N Johnson
- Department of Gynaecologic Oncology, Royal United Hospital, Bath, UK.
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Tangjitgamol S, Manusirivithaya S, Lertbutsayanukul C. Adjuvant therapy for early-stage endometrial cancer: a review. Int J Gynecol Cancer 2007; 17:949-56. [PMID: 17309664 DOI: 10.1111/j.1525-1438.2007.00860.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Most patients with endometrial cancer (EMC) present their symptoms early in their course, leading to an overall favorable outcome. However, some patients who are in early-stage diseases may carry some risk features that would hamper their prognoses. For these early-stage diseases with high risk of recurrences, radiation therapy certainly plays a major role as an adjuvant treatment. Despite an excellent local diseases control by radiation, systemic failures are still encountered. To improve the prognoses, other types of adjuvant therapy have been attempted. In this review, various options of adjuvant treatment for this early-stage EMC including radiation therapy, chemotherapy, and hormonal therapy are discussed.
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Affiliation(s)
- S Tangjitgamol
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology, Bangkok Metropolitan Administration Medical College and Vajira Hospital, Bangkok, Thailand.
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Li S, Aref I, Walker E, Movsas B. Effects of prescription depth, cylinder size, treatment length, tip space, and curved end on doses in high-dose-rate vaginal brachytherapy. Int J Radiat Oncol Biol Phys 2007; 67:1268-77. [PMID: 17336226 DOI: 10.1016/j.ijrobp.2006.10.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Revised: 10/27/2006] [Accepted: 10/31/2006] [Indexed: 11/21/2022]
Abstract
PURPOSE To determine the effects of the prescription depth, cylinder size, treatment length, tip space, and curved end on high-dose-rate vaginal brachytherapy (HDR-VBT) of endometrial cancer. METHODS AND MATERIALS Treatment plans were prescribed and optimized based on points at the cylinder surface or at 0.5-cm depth. Cylinder sizes ranging from 2 to 4 cm in diameter, and treatment lengths ranging from 3 to 8 cm were used. Dose points in various depths were precisely defined along the cylinder dome. The given dose and dose uniformity to a depth of interest were measured by the mean dose (MD) and standard deviation (SD), respectively, among the dose points belonging to the depth. Dose fall-off beyond the 0.5 cm treatment depth was determined by the ratio of MD at 0.75-cm depth to MD at 0.5-cm depth. RESULTS Dose distribution varies significantly with different prescriptions. The surface prescription provides more uniform doses at all depths in the target volume, whereas the 0.5-cm depth prescription creates larger dose variations at the cylinder surface. Dosimetric uncertainty increases significantly (>30%) with shorter tip space. Extreme hot (>150%) and cold spots (<60%) occur if no optimization points were placed at the curved end. CONCLUSIONS Instead of prescribing to a depth of 0.5 cm, increasing the dose per fraction and prescribing to the surface with the exact surface points around the cylinder dome appears to be the optimal approach.
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Affiliation(s)
- Shidong Li
- Department of Radiation Oncology, Henry Ford Health System, Detroit, Michigan 48202, USA.
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Sorbe B, Straumits A, Karlsson L. Intravaginal high-dose-rate brachytherapy for stage I endometrial cancer: a randomized study of two dose-per-fraction levels. Int J Radiat Oncol Biol Phys 2005; 62:1385-9. [PMID: 16029797 DOI: 10.1016/j.ijrobp.2004.12.079] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2004] [Revised: 12/22/2004] [Accepted: 12/28/2004] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Bengt Sorbe
- Department of Gynecological Oncology, Orebro University Hospital, Orebro, Sweden.
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Abstract
Endometrial cancer is a common female malignancy, affecting approximately 40,000 women per year. Despite the publication of several prospective randomized trials, there continues to be controversy regarding the use of adjuvant radiation therapy in endometrial cancer management. It is clear that most women with early-stage, low-risk disease will do well without adjuvant therapy. Intermediate-risk patients are at risk for local-regional relapse, and radiotherapy has been shown to effectively reduce this risk without significantly impacting overall survival. The absence of a clear impact on survival has resulted in a lack of consensus regarding the use of radiotherapy in intermediate-risk patients. At the same time, the patterns of failure in intermediate-risk patients have resulted in differing recommendations regarding appropriate radiotherapy targets. High-risk patients are at risk for both local and distant failure, and chemotherapy has been shown to improve outcome in these patients. High-risk patients are also at risk for local failure, and targeted radiotherapy may be appropriate. In this article, we discuss the controversies surrounding the use of adjuvant radiotherapy in endometrial cancer using an evidence-based approach.
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Mariani A, Dowdy SC, Keeney GL, Haddock MG, Lesnick TG, Podratz KC. Predictors of vaginal relapse in stage I endometrial cancer. Gynecol Oncol 2005; 97:820-7. [PMID: 15894363 DOI: 10.1016/j.ygyno.2005.03.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2004] [Revised: 03/02/2005] [Accepted: 03/09/2005] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To identify factors predictive of vaginal relapse in stage I endometrial cancer, thereby potentially facilitating the selection of patients who may benefit from vaginal brachytherapy. METHODS The study population included 632 patients with stage I endometrial cancer managed with hysterectomy at our institution between 1984 and 1996. Median follow-up was 73 months; 122 patients (19%) received adjuvant radiotherapy. RESULTS Overall, 2.9% of the stage I cohort developed vaginal relapse at 5 years. Vaginal relapse was observed in 1.7% of patients who received radiotherapy and in 3.0% of those whose treatment did not include radiotherapy (P = 0.36). Cox regression analysis (including radiotherapy) identified only grade 3 differentiation (hazard ratio = 3.83, P = 0.007) as an independent predictor of vaginal relapse. Patients with a low-grade tumor had a 5-year vaginal relapse rate of 2%, compared with 7% for those with a grade 3 tumor. When only patients who did not receive adjuvant radiotherapy were considered, both grade 3 tumor and lymphovascular invasion were significant predictors of vaginal relapse (P < 0.05). When neither variable was present, 2% of patients experienced vaginal relapse at 5 years, compared with 11% when either 1 was present (P < 0.001). Depth of myometrial invasion was not a significant predictor of vaginal recurrence. CONCLUSION Histologic grade 3 tumor and lymphovascular invasion were the cogent predictors of vaginal relapse in our population. The cost and morbidity of vaginal brachytherapy should be balanced against the potential risk of vaginal relapse in this group of patients.
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Affiliation(s)
- Andrea Mariani
- Section of Gynecologic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Jolly S, Vargas C, Kumar T, Weiner S, Brabbins D, Chen P, Floyd W, Martinez AA. Vaginal brachytherapy alone: An alternative to adjuvant whole pelvis radiation for early stage endometrial cancer. Gynecol Oncol 2005; 97:887-92. [PMID: 15943991 DOI: 10.1016/j.ygyno.2005.02.021] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2004] [Revised: 02/10/2005] [Accepted: 02/18/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Postoperative management of early stage adenocarcinoma of the endometrium remains controversial. The use of pelvic radiation therapy as shown by the Gynecologic Oncology Group (GOG)-99 trial improves the event free interval at the cost of increased toxicity. We reviewed and compared our results treating early stage endometrial adenocarcinoma using hypofractionated high dose rate (HDR) vaginal brachytherapy (VB) alone with the results of the GOG-99. METHODS From 1992 to 2002, 243 endometrial cancer patients were treated with TAH/BSO and selective lymph node dissection followed by adjuvant radiotherapy (RT). Of these, 50 FIGO stage I-II (occult) adenocarcinoma (no clear cell or serous papillary) of the endometrium were managed with HDR hypofractionated VB as monotherapy using Iridium-192 to a dose of 30 Gy in 6 fractions twice weekly prescribed to a depth of 5 mm and median length of 4 cm. The characteristics, toxicity rates, and outcomes of our patients were compared with the results of the GOG-99. The median follow up of our patients and the GOG-99 were 3.2 years and 5.8 years, respectively. RESULTS Patient characteristics including age, stage, and grade were similar in our study and the GOG-99. The local recurrence rate in our study, the pelvic RT arm of the GOG-99, and the no RT arm of the GOG-99 were 4% (n = 2), 2% (n = 3), and 9% (n = 18), respectively. In our study, one patient failed in the vagina alone and a second patient failed in the vagina and pelvis. In the GOG-99, the vagina as a component of locoregional failure was also the most common failure site in the no RT arm 77.8% (n = 14) and in the RT arm 100% (n = 3). The 2-year cumulative recurrence rate in our study was 2%, which compares favorably with the GOG-99 pelvic RT arm (3%) and observation arm (12%). Four-year survival rates of the no RT arm of the GOG-99, the RT arm of the GOG-99, and our study with HDR VB were 86%, 92%, and 97%, respectively. Chronic grade 2 toxicity rates were reduced by the use of VB compared to pelvic RT, especially GI toxicity 0% vs. 34% (P value < 0.001), and GI obstruction 0% vs. 7% (P value = 0.08). CONCLUSION Stage I-II (occult) endometrial adenocarcinoma treated with postoperative HDR vaginal brachytherapy has similar overall survival, locoregional failure rates, and cumulative recurrence rates to standard fractionation external beam pelvic RT with the benefit of much lower toxicity rates and shorter overall treatment time.
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Affiliation(s)
- Shruti Jolly
- Department of Radiation Oncology, William Beaumont Hospital, 3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA
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Chen Y, Wang XL, Yan ZP, Cheng JM, Wang JH, Gong GQ, Qian S, Luo JJ, Liu QX. HDR- 192Ir intraluminal brachytherapy in treatment of malignant obstructive jaundice. World J Gastroenterol 2004; 10:3506-10. [PMID: 15526374 PMCID: PMC4576236 DOI: 10.3748/wjg.v10.i23.3506] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM: To determine the feasibility and safety of intraluminal brachytherapy in treatment of malignant obstructive jaundice (MOJ) and to evaluate the clinical effect of intraluminal brachytherapy on stent patency and patient survival.
METHODS: Thirty-four patients with MOJ were included in this study. Having biliary stent placed, all patients were classified into intraluminal brachytherapy group (group A, n = 14) and control group (group B, n = 20) according to their own choice. Intraluminal brachytherapy regimen included: HDR-192Ir was used in the therapy, fractional doses of 4-7 Gy were given every 3-6 d for 3-4 times, and standard points were established at 0.5-1.0 cm. Some patients of both groups received transcatheter arterial chemoembolization (TACE) after stent placement.
RESULTS: In group A, the success rate of intraluminal brachytherapy was 98.0%, RTOG grade 1 acute radiation morbidity occurred in 3 patients, RTOG/EORTC grade 1 late radiation morbidity occurred in 1 patient. Mean stent patency of group A (12.6 mo) was significantly longer than that of group B (8.3 mo) (P < 0.05). There was no significant difference in the mean survival (9.4 mo vs 6.0 mo) between the two groups.
CONCLUSION: HDR-192Ir intraluminal brachytherapy is a safe palliative therapy in treating MOJ, and it may prolong stent patency and has the potentiality of extending survival of patients with MOJ.
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Affiliation(s)
- Yi Chen
- Department of Radiology, Affiliated Zhongshan Hospital, Medical Center of Fudan University, Shanghai 200032, China
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DuBeshter B, Estler K, Altobelli K, McDonald S, Glantz C, Angel C. High-dose rate brachytherapy for Stage I/II papillary serous or clear cell endometrial cancer. Gynecol Oncol 2004; 94:383-6. [PMID: 15297176 DOI: 10.1016/j.ygyno.2004.05.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2003] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the efficacy of high-dose rate brachytherapy as adjuvant treatment for Stage I/II papillary serous or clear cell endometrial cancer. METHODS A retrospective study of all patients with Stage I/II papillary serous or clear cell endometrial cancer treated with high-dose rate brachytherapy between 1995 and 2001 was performed. Following surgical staging, which included hysterectomy with pelvic and aortic lymphadenectomy, all patients without extrauterine disease were treated with high-dose rate brachytherapy and followed for recurrence. The locations of recurrences were noted and were classified as local or distant. RESULTS Three (13%) recurrences occurred among 24 patients with Stage I/II papillary serous or clear cell carcinoma. The risk of recurrence was similar for papillary serous and clear cell cancer (12% vs. 12%). Local control was achieved in 96%. The risk of recurrence for those with no myometrial invasion, less than 1/2, or more than 1/2 myometrial invasion was 0%, 10%, and 50%, respectively (P < 0.04). Two of the three recurrences were distant and all patients with recurrence died despite additional treatment. CONCLUSIONS High-dose rate brachytherapy (HDR) as the sole adjuvant treatment of Stage I/II papillary serous or clear cell carcinoma is associated with a 13% risk of recurrence. Although local control with HDR is excellent, the risk of distant recurrence is increased with deep myometrial invasion. High-dose rate brachytherapy is adequate for Stage IA cases, but more aggressive treatment combining chemotherapy with HDR should be evaluated for more advanced Stage I/II cases.
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Affiliation(s)
- Brent DuBeshter
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Wilmot Cancer Center, University of Rochester School of Medicine, 125 Lattimore Road, Rochester, NY 14620, USA.
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Aoki Y, Watanabe M, Amikura T, Obata H, Sekine M, Yahata T, Fujita K, Tanaka K. Adjuvant chemotherapy as treatment of high-risk stage I and II endometrial cancer. Gynecol Oncol 2004; 94:333-9. [PMID: 15297170 DOI: 10.1016/j.ygyno.2004.05.040] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2003] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This study was performed to define the subgroups of patients who benefit from postoperative adjuvant chemotherapy in stage I and II endometrial carcinoma. METHODS A retrospective review of 170 International Federation of Gynecology and Obstetrics (FIGO) stage I and II endometrial carcinoma patients treated between 1988 and 2000 at Niigata University Hospital was performed. All patients underwent surgery, of which 41 patients underwent adjuvant chemotherapy, consisting of intravenous cisplatin, doxorubicin, and cyclophosphamide. Multivariate analysis was performed for the prognostic factors and actuarial techniques were used for the survival and recurrence rates. RESULTS The patients were divided into low-risk and high-risk groups based on the number of prognostic factors (tumor grade G3, outer half myometrial invasion, lymph-vascular space involvement (LVSI), and cervical invasion). The 5-year disease-free survival and the 5-year overall survival for the low-risk group were 97.4%, and 100%, respectively, which were significantly better than 77.4% and 88.1% for the high-risk group (P < 0.0001, P < 0.0001), respectively. Among high-risk group patients, the 5-year disease-free survival and the 5-year overall survival were 88.5% and 95.2% in 26 patients treated with adjuvant chemotherapy, and 50.0% and 62.5% in eight cases who underwent only surgery (P = 0.0150, P = 0.0226). Disease recurrence occurred in 7 (20.6%) of 34 high-risk group patients. Four of seven recurrences occurred in patients who did not receive postoperative chemotherapy, in which all four were distant failure. In the remaining three patients who were in the CAP group, two had vaginal wall recurrence and only one had pulmonary recurrence. Three recurrences were also observed in the 133 low-risk group patients. Only isolated vaginal wall recurrence occurred in three patients without adjuvant chemotherapy after the initial surgery. CONCLUSIONS There is possibility that postoperative adjuvant CAP may be omitted in surgical stage I or II endometrial cancer patients with 0 or 1 prognostic factor. The high-risk group of patients should be treated with postoperative adjuvant CAP to decrease distant failure and improve prognosis.
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Affiliation(s)
- Yoichi Aoki
- Department of Obstetrics and Gynecology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Niigata 951-8510, Japan.
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Citron JR, Sutton H, Yamada SD, Mehta N, Mundt AJ. Pathologic stage I-II endometrial carcinoma in the elderly: Radiotherapy indications and outcome. Int J Radiat Oncol Biol Phys 2004; 59:1432-8. [PMID: 15275729 DOI: 10.1016/j.ijrobp.2004.01.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2003] [Revised: 12/30/2003] [Accepted: 01/16/2004] [Indexed: 11/30/2022]
Abstract
PURPOSE To assess the indications for, and the outcome of, adjuvant radiotherapy (RT) in elderly patients with pathologic Stage I-II endometrial carcinoma. METHODS AND MATERIALS Between 1980 and 2001, 79 elderly (age > or =75 years) patients with pathologic Stage I-II endometrial carcinoma were seen at our institution. All underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy with assessment of peritoneal cytology. Pelvic and paraaortic lymph node sampling was performed in 39 and 29 women, respectively. Patients with Stage IA and IB Grade 1-2 were designated as low risk; those with Stage IB Grade 3 and IC-IIB were designated as high risk. Thirty-four received adjuvant RT consisting of whole pelvic (n = 23) or vaginal brachytherapy (n = 3), or both (n = 8). Actuarial disease-free survival, cause-specific survival, and pelvic recurrence-free survival analyses were performed by the Kaplan-Meier method. RESULTS Adverse factors were common, including deep (>50%) myometrial invasion (47%), Grade 3 disease (28%), cervical involvement (15%), and unfavorable histologic features (15%). Overall, 46 patients (58%) had high-risk disease. Primarily because of concerns over toxicity, RT was administered in only 73%, 55%, and 67% of patients with deep myometrial invasion, Grade 3 disease, and cervical involvement, respectively. Thirty-one high-risk patients (67%) received adjuvant RT. At a median follow-up of 33.5 months, 19 patients had relapsed, for a 5-year actuarial disease-free survival rate of 67.7%. Ten patients (12%) had recurrence in the pelvis, 9 of whom had been patients treated with surgery alone. The 5-year pelvic recurrence-free survival rate of patients treated with and without RT was 97% and 73.1%, respectively (p = 0.02). The corresponding rates in the high-risk patients were 97% and 47% (p = 0.0001). High-risk patients treated with RT also had better 5-year actuarial disease-free survival (p = 0.0001) and cause-specific survival (p = 0.003) than those treated with surgery alone. RT was well tolerated, with all patients receiving their treatment as planned. Only 1 patient developed significant late toxicity. CONCLUSIONS Adverse features are common in pathologic Stage I-II elderly endometrial carcinoma patients, and pelvic recurrence is high after surgery alone. Given the improvement in outcome and low incidence of toxicity, our results support the use of adjuvant RT in elderly pathologic Stage I-II patients with high-risk disease.
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Affiliation(s)
- Jason R Citron
- Department of Obstetrics and Gynecology, Section of Gynecologic Oncology, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
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Alektiar KM, Venkatraman E, Abu-Rustum N, Barakat RR. Is endometrial carcinoma intrinsically more aggressive in elderly patients? Cancer 2003; 98:2368-77. [PMID: 14635071 DOI: 10.1002/cncr.11830] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND The current study was conducted to determine the influence of old age (age >/= 70 years) on outcome in a group of patients with endometrial carcinoma who were treated with simple hysterectomy followed by adjuvant radiation therapy (RT). METHODS Between November 1987 and May 2000, 405 patients with International Federation of Gynecology and Obstetrics (FIGO) Stage IB-II endometrial carcinoma were treated with postoperative RT. Intravaginal RT alone was given to 77% of patients (median dose, 21grays [Gy] given in 3 fractions). Additional postoperative external beam radiation therapy (EBRT) was given to 23% of patients (median dose, 45 Gy). Eighty-four patients were age >/= 70 years and 321 patients were age < 70 years. The two groups were well balanced with regard to race, comprehensive surgical staging, aggressive histology, lymphovascular invasion, lower uterine segment involvement, cervical involvement, and the use of postoperative EBRT. Significantly more patients in the age >/= 70 years group had other comorbidities such as obesity, diabetes mellitus, or hypertension (P = 0.02) and were found to have deep (> 50%) myometrial invasion (P = 0.008). RESULTS With a median follow-up time of 48 months, the 5-year locoregional control (LRC), disease-free survival (DFS), and overall survival (OS) rates were 95%, 91%, and 90% respectively. On multivariate analysis, poor LRC was found to be correlated with age >/= 70 years (P = 0.019) and lymphovascular invasion (P = 0.001). Poor DFS was found to be correlated with age >/= 70 years (P = 0.03), lymphovascular invasion (P = 0.01), and aggressive histology (P = 0.001). Similarly, poor OS was found to correlate with age >/= 70 years (P = 0.001), lymphovascular invasion (P = 0.01), aggressive histology (P = 0.01), and cervical involvement (P = 0.02). The same factors that were found to correlate with OS (age >/= 70 years, lymphovascular involvement, aggressive histology, and cervical involvement) also appeared to correlate with disease-specific survival (P = 0.03, P = 0.008, P = 0.001, and P = 0.04, respectively). The 5-year actuarial rates of Radiation Therapy Oncology Group late complications that were >/= Grade 3 (gastrointestinal tract, genitourinary tract, or vagina) were 3% in both groups. CONCLUSIONS Even when treated in a similar fashion, endometrial carcinoma patients age >/= 70 years appear to fare worse than younger patients independent of other poor prognostic factors. The rate of complications from adjuvant RT, despite a higher rate of comorbidity in elderly patients, was found to be similar in both age groups. Endometrial carcinoma appears to be intrinsically more aggressive in older patients, thus mandating further improvement in their treatment strategies.
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Affiliation(s)
- Kaled M Alektiar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York 10021, USA
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