Malignant peritoneal cytology as prognostic indicator in stage I endometrial cancer

The Impact of Positive Peritoneal Cytology on the Survival Rates of Early-Stage-Disease Endometrial Cancer Patients: Systematic Review and Meta-Analysis

Background and Objectives: The impact of positive peritoneal cytology has been a matter of controversy in early-stage endometrial cancer for several years. The latest staging systems do not take into consideration its presence; however, emerging evidence about its potential harmful effect on patient survival outcomes suggests otherwise. In the present systematic review and meta-analysis, we sought to accumulate current evidence. Materials and Methods: Medline, Scopus, the Cochrane Central Register of Controlled Trials CENTRAL, Google Scholar and Clinicaltrials.gov databases were searched for relevant articles. Effect sizes were calculated in Rstudio using the meta function. A sensitivity analysis was carried out to evaluate the possibility of small-study effects and p-hacking. Trial sequential analysis was used to evaluate the adequacy of the sample size. The methodological quality of the included studies was assessed using the Newcastle-Ottawa scale. Results: Fifteen articles were finally included in the present systematic review that involved 19,255 women with early-stage endometrial cancer. The Newcastle-Ottawa scale indicated that the majority of included studies had a moderate risk of bias in their selection of participants, a moderate risk of bias in terms of the comparability of groups (positive peritoneal cytology vs. negative peritoneal cytology) and a low risk of bias concerning the assessment of the outcome. The results of the meta-analysis indicated that women with early-stage endometrial cancer and positive peritoneal cytology had significantly lower 5-year recurrence-free survival (RFS) (hazards ratio (HR) 0.26, 95% CI 0.09, 0.71). As a result of the decreased recurrence-free survival, patients with positive peritoneal cytology also exhibited reduced 5-year overall survival outcomes (HR 0.50, 95% CI 0.27, 0.92). The overall survival of the included patients was considerably higher among those that did not have positive peritoneal cytology (HR 12.76, 95% CI 2.78, 58.51). Conclusions: Positive peritoneal cytology seems to be a negative prognostic indicator of survival outcomes of patients with endometrial cancer. Considering the absence of data related to the molecular profile of patients, further research is needed to evaluate if this factor should be reinstituted in future staging systems.

Diagnostic Cytopathology of Peritoneal Washings

Peritoneal washings used for cytologic evaluation are collected at the outset of surgical exploration of women with gynecologic cancers to assist in determining extent of disease and follow-up therapy.

While there are similarities to ascites, these samples have differences that must be recognized in order to avoid false positive interpretations. Non-neoplastic mesothelial alterations including heterogeneous reactive changes, endosalpingiosis , endometriosis and tumor rupture are typically not seen in ascites samples but can be seen in peritoneal washings from women with malignancies that have not extended to the peritoneal cavity.

Awareness of these potential pitfalls and knowledge of the associated tumor type will facilitate accurate interpretation. When these caveats are recognized, peritoneal washing cytology results are a useful adjunct in helping to determine patient follow-up in women with gynecologic malignancies.

Prognostic value of pre-treatment systemic immune-inflammation index in patients with endometrial cancer

BACKGROUND

The systemic immune-inflammation index (SII), which is calculated using absolute platelet, neutrophil, and lymphocyte counts, has recently attracted attentions as a prognostic indicator in patients with solid malignancies. In the current study, we retrospectively investigated the prognostic significance of pre-treatment SII among patients with endometrial cancer.

METHOD

Endometrial cancer patients treated at Nara medical university hospital between 2008 and 2018 were included in the current study. Receiver operating characteristic (ROC) curve was used to find the optimal SII cut-off values for 3-years progression free survival (PFS) and overall survival (OS). Then, the predictive abilities of SII and its superiority over neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) were investigated. Kaplan-Meier method was used to calculate the OS and PFS rates, and log-rank test was used to compare the survival rate between two groups. Univariate and multivariate Cox regression analysis were performed to identify risk factors for PFS and OS.

RESULT

A total of 442 patients were included in the current study. The cut-off value of SII for predicting PFS and OS were defined by ROC analysis as 931 and 910, respectively. Univariate analyses showed that elevated SII was associated with significantly shorter survival (p <0.001 for both PFS and OS). Cox regression analyses revealed that an advanced FIGO stage (p <0.001 for both PFS and OS) and an elevated SII (p = 0.014 for PFS, p = 0.011 for OS) are the independent prognostic factors for survival. When SII was compared with NLR and PLR, SII showed greater area under curve for predicting survival.

CONCLUSION

The SII is an independent prognostic factor in endometrial cancer patients, allowing more precise survival estimation than PLR or NLR.

Impact of SurePath® liquid-based preparation in cytological analysis of peritoneal washing in practice of gynecologic oncology

Context:

Peritoneal washing is performed for staging of gynecologic tumors to detect subclinical intraperitoneal metastases.

Aim:

The aim of the present study was to assess the impact of SurePath™ liquid-based cytology (LBC) in peritoneal washing in various gynecological malignancies.

Settings and Design:

An audit of peritoneal-fluid/washing (January 2012 to July 2013) was performed with corresponding gynecologic specimens. All peritoneal washings were processed using both conventional and LBC technique. Suspicious cases on cytology were reported along with gynecologic specimens.

Results:

There were a total of 393 peritoneal fluids. Eighty-three (21.1%) were positive for malignancy, and the corresponding histology was available in 352 (89.6%) cases. Sixty-nine positive samples had ovarian malignancies and 5 had uterine causes. There were 9 cases of peritoneal washings in which no histopathology was available. The most common cause of positive peritoneal cytology was ovarian serous carcinoma in 55/84 (65.5%) cases. Other causes included mucinous cystadenocarcinoma, dysgerminoma, squamous cell carcinoma in teratoma, yolk sac tumor, and granulosa cell tumor. Uterine causes included 2/45 (4.4%) cases of endometrioid adenocarcinoma, ¼ (25%) cases of clear cell carcinoma, ½ (50%) cases of carcinosarcoma, and ¼ (25%) cervix carcinoma. On review of positive cases (n = 83), 10 cases were identified, which had nil (n = 4) to low cellularity (<3 tumor clusters/smear; n = 6) on conventional smears, and were confirmed malignant on LBC.

Conclusions:

The most common ovarian malignancy causing positive peritoneal cytology is papillary serous carcinoma. Endometrioid adenocarcinoma rarely leads to positive peritoneal cytology. LBC technique leads to concentration of tumor cells causing reduction in false negative cases, especially in hemorrhagic and low-cellular cases.

The value of peritoneal washing cytology during intra-abdominal surgery for female genital tract neoplasms

BACKGROUND

Peritoneal washing cytology is a technique performed during surgery for genital neoplasms to detect subclinical intraperitoneal metastases from these tumors. The aim of this study was to evaluate PWC utility in presumed benign and malignant female genital tract neoplasms by comparing the results of peritoneal cytology and corresponding histopathological specimens.

PATIENTS AND METHODS

The 305 cases of female genital lesions with available staging (International Federation of Gynecology and Obstetrics) were considered. In cases with positive cytology, without neoplastic involvement of the ovarian and uterine surfaces, the salpinx was accurately examined to reveal primary malignant fallopian tubal neoplasms. For malignant ovarian neoplasms, the correlation rate between cytological and histopathological findings was statistically evaluated using the Fisher exact test. Statistical significance was defined as P < .05.

RESULTS

Histopathological diagnosis revealed that of 32 cases with positive cytology, 21 examples corresponded to primary ovarian serous carcinomas (65.625%). Moreover, the serous carcinoma was the subtype that most frequently revealed neoplastic elements on PWC (21 examples in 22 cases, 95.4%). Only 1 of these malignancies with positive cytology and pT1a stage presented simultaneous invasive and in situ serous carcinoma of contralateral tubal fimbria. Only 1 of serous endometrial carcinomas that involved an endometrial polyp was associated with positive cytology and with simultaneous carcinoma of tubal fimbria.

CONCLUSION

In conclusion, PWC remains a useful procedure for staging malignant genital tract neoplasms and can be necessary to detect occult fallopian tube malignancies.

Positive peritoneal cytology is an independent risk-factor in early stage endometrial cancer

OBJECTIVE

In light of the recent changes in the International Federation of Gynecology and Obstetrics (FIGO) staging system, the objective of this study was to determine the prognostic significance of positive peritoneal cytology (PPC) among patients with early stage endometrial cancer.

METHODS

Data were extracted from the Surveillance, Epidemiology, and End Results database between 1988 and 2005. Only those patients with stage I/II endometrial cancer who had undergone a complete staging procedure (lymph-node removal) were included. Statistical analyses used Chi-square test, Kaplan-Meier log rank, and Cox proportional hazards models.

RESULTS

A total of 14,704 patients were identified: 14,219 with negative peritoneal cytology (NPC) and 485 with positive peritoneal cytology. More patients with PPC compared to those with NPC were diagnosed with high-risk factors such grade III disease (40.2% vs. 23.8%, p<0.0001), and unfavorable histologic types such as clear cell/serous carcinoma (17.5% vs. 7.5%, p=<0.0001) and carcinosarcoma (9.3% vs. 5.6%, p<0.0001). When compared to patients with negative peritoneal cytology, survival was significantly worse among patients with positive peritoneal cytology (p<0.0001): 5-year disease specific survival 95.1% vs. 80.8% in endometrioid adenocarcinoma; 78.0% vs. 50.4% in clear cell/serous cancer; and 64.7% vs. 32.3% in carcinosarcoma. After adjusting for other contributing factors in the multivariable model, PPC remained an independent predictor of poor survival (p<0.0001) in all histologic types examined.

CONCLUSION

PPC is an independent risk factor in patients with early stage endometrial cancer. Although, no longer a part of the current FIGO staging criteria, peritoneal cytology status should still be considered for accurate risk-stratification of these patients.

[Current TNM/FIGO classification for cervical and endometrial cancer as well as malignant mixed müllerian tumors. Facts and background]

Numerous recent studies of endometrial and cervical carcinomas as well as malignant mixed müllerian tumors (MMMT) of the uterus have made a revision of the FIGO/TNM classification necessary, effective as of January 1st, 2010. There will be a new subclassification of carcinoma of the uterine cervix with proximal vaginal infiltration, using the same cut-off for the tumor extension as used for stage FIGOIB/T1b (≤/>4 cm), resulting in stage FIGO IIA1/T2a1 and FIGO IIA2/T2a2. In endometrial carcinoma, the previous FIGO IA/pT1a and FIGO IB/pT1b will be merged to FIGO IA/pT1a. The former category FIGO IC/T1c will be changed into FIGO IB/T1b. The category FIGO IC/pT1c will not longer been used. Additionally, there will be no separate classification for the involvement of the endocervical glands by endometrial carcinoma. This feature will be incorporated in stage FIGO I/T1 disease. The new category FIGO II/T2 will be defined as endocervical stromal involvement. There will be a new category, termed T3c/IIIC, which includes regional lymph node involvement. Stage T3c1/IIIC1 will be defined as pelvic lymph node involvement and stage T3c2/IIIC2 para-aortal lymph node involvement with or without pelvic lymph node disease. In the TNM system, regional lymph node involvement can alternatively be classified as N1. The MMMT will be staged like endometrial carcinoma.

[Changes in the TNM classification of gynecological tumors]

Based on the results of clinical and histomorphological studies in recent years, a revision of the TNM classification of malignant tumours of the female genital organs became necessary. Vulvar cancer saw the most significant changes. In the T1 category the new system recognises tumour size and its relation to the infiltration of adjacent structures by the tumour. The number of positive regional lymph nodes has also been included in the new staging system. For cervical cancer, there is a new subdivision of the category T2a depending on tumour size with a breakpoint of ≤ 4 cm versus > 4 cm and a subdivision into T2a1 und T2a2. In endometrial cancer, the previous pT1a and pT1b were merged to pT1a. The former category T1c has changed into T1b. The category pT1c is no longer used. For the first time, there is a TNM classification system for uterine sarcomas.

Treatment for advanced and recurrent endometrial carcinoma: combined modalities

Women with recurrent or advanced endometrial cancer constitute a heterogeneous group of patients. Depending on previous treatment, women with recurrent endometrial cancer may be appropriate candidates for surgery, radiation therapy, hormonal therapy, or chemotherapy. Women with advanced stage disease at presentation may also be appropriate candidates for systemic and local therapies. We review the treatment options available to treat recurrent and locally advanced endometrial cancer. Treatment choice depends largely on the localization of disease, the patient's performance status and previous treatment history, as well the tumor's hormonal receptor status. Radiation therapy is appropriate for isolated vaginal recurrences in patients with no previous history of radiation therapy. Patients with recurrent low-grade tumors overexpressing estrogen and progesterone receptors may be treated with progestin therapy. Systemic therapy is appropriate for patients with disseminate recurrences or advanced stage disease at presentation, or for those with receptor-negative tumors. We review all these different treatment strategies available to patients with advanced or recurrent endometrial cancer.

FIGO staging of endometrial adenocarcinoma: a critical review and proposal

The optimal staging of tumors would reflect their biology and patterns of spread, permit accurate prognostication, and facilitate therapeutic decision-making. The last revision of the International Federation of Obstetricians and Gynecologists (FIGO) staging of uterine corpus tumors was in 1988, and it represented the transition from a clinical to a surgico-pathologic system. With 20 years of experience, we can now review the accuracy, reproducibility, and utility of this system. Pathologists are in a unique position to study each of these characteristics, comment on their ability to apply the criteria in daily practice, and offer suggestions to further improve the FIGO system. This paper selectively reviews some of the more problematic aspects of the current FIGO system, including the following: the distinction of tumors confined to the endometrium from those which are superficially myoinvasive; the method and utility of histologic grading of endometrial adenocarcinoma; the utility and reproducibility of the diagnosis of cervical epithelial and stromal invasion; the striking heterogeneity within and among stage III A, B, and C tumors and their differing prognostic significance. It concludes with recommendations for changes in a future revision of the FIGO staging of endometrial carcinoma.

Sonohysterography and endometrial cancer: incidence and functional viability of disseminated malignant cells

OBJECTIVE

The purpose of this study was to evaluate sonohysterography in patients with endometrial cancer and to determine whether (1) transtubal fluid spill occurs during routine sonohysterography, (2) a critical infusion volume for spill exists, or (3) disseminated cancer cells demonstrate viability.

STUDY DESIGN

At laparotomy, sonohysterography was performed on 16 patients with endometrial adenocarcinoma. Volumes at which tubal spill occurred were recorded. Collected specimens were processed and incubated. After evaluation for viable cells, cytologic analysis was undertaken.

RESULTS

The median volume that was required for adequate sonohysterography was 8.5 mL. Five patients (31%) had transtubal spill. With an additional saline solution flush, the median total volume for a spill was 20.5 mL. Two patients (12.5%) had viable benign cells that were cultured after routine sonohysterography. One patient (6%) had nonviable carcinoma cells that were identified.

CONCLUSION

Transtubal spill occurs during sonohysterography. No critical spill volume was identified. A highly diagnostic tool when abnormal bleeding is evaluated, sonohysterography has a low probability of cancer cell dissemination.

Is peritoneal cytology a prognostic factor of endometrial cancer confined to the uterus?

OBJECTIVE

The goal of this study was to investigate whether intraoperative peritoneal cytology serves as a prognostic factor in patients with the endometrial cancer limited to the disease confined to the uterus.

METHODS

From patients with endometrial cancer treated at 2 facilities between 1988 and 2001, 307 patients were selected for retrospective investigation. To be included in this study, patients required (1) full surgical staging including total abdominal hysterectomy/bilateral salpingo-oophorectomy/retroperitoneal lymph node dissection/peritoneal cytology, (2) negative nodes, (3) disease localized to the uterus and (4) endometrioid subtype.

RESULTS

The median duration of the follow-up period was 61 months (25th to 75th percentiles: 45 to 92 months). Peritoneal cytology was positive in 32 patients (10.4%). The 5-year survival rate of peritoneal-cytology-positive patients was 87%, significantly lower than that (97%) of cytology-negative patients (P = 0.011). The relationship between the clinicopathological factors including peritoneal cytology and the prognosis was investigated by univariate analysis, and peritoneal cytology positivity, age of 60 years or older, histologic grade (Grades 2 and 3), myometrial invasion of 1/2 or more and vascular invasion were significant prognostic factors (P < 0.05 in all). On multivariate analysis of these factors, peritoneal cytology positivity and histologic grade (Grade 2 and 3) were independent prognostic factors (P < 0.05 each).

CONCLUSIONS

For the patients with endometrial cancer limited to the disease confined to the uterus in which accurate staging including retroperitoneal lymph node dissection was performed, peritoneal cytology may be an important prognostic factor.

Upstaging based solely on positive peritoneal washing does not affect outcome in endometrial cancer

Surgical staging of endometrial carcinoma includes the collection of peritoneal washings in the abdomen and pelvis. A positive finding upstages patients to International Federation of Gynecology and Obstetrics stage IIIA. However, the prognostic significance of such an upstaging, and thus the justification for the routine performance of this procedure, is unclear. This 5-year retrospective study was conducted to determine the frequency and prognostic significance of upstaging of endometrial carcinoma based solely on positive washings. The cohort for the study was collected by review of pathology reports of all washings that were performed prior to hysterectomies for suspected endometrial carcinomas over a 5-year period (01/1995-12/1999). Cases with positive cytology were selected if there was no grossly apparent intraperitoneal disease, no histologic evidence of extra-uterine tumor and the cases would otherwise have been considered stage I or II (case group). An age-matched control group was selected of stage I and II patients with the same histologic subtypes and negative washings (n=19). Of 220 endometrial carcinomas, peritoneal washing cytology was abnormal in 19 (8.6%) and was solely responsible for upstaging only 10 patients (4.5% of all cases, eight-endometrioid, one-serous, one-mixed; nine stage IA or IB and one stage IIB). Adjuvant therapy was administered in 90% of the case group and 74% of the control group. After a median follow-up of 51 months (case group) and 63 months (control group), we found only a single patient with progression of disease (recurrence, metastases or death) in the control group. It is concluded that abnormal cytology without other evidence of extrauterine disease leads to upstaging of a minority of endometrial carcinoma patients (4.5%), but does not appear to affect their overall outcome. Although this is a small single site study, it raises questions about the value of this procedure in patients with endometrial cancer.

Prospective self-controlled study on prevention of hysteroscopic dissemination in endometrial carcinoma

Patients diagnosed to have endometrial carcinoma without prior hysteroscopic examination were recruited from March 2000 to August 2003. Normal saline was used to distend the uterine cavity during the hysteroscopic examination to look for endocervical spread before the definitive surgical treatment. We performed laparotomy, clamped both fallopian tubes, and collected peritoneal washing before the hysteroscopic examination was performed. Peritoneal washing was collected once more after the hysteroscopic examination. Hysteroscopic assessment was performed in 103 patients. Of them, 10 patients were excluded from the study due to previous history of tubal sterilization or blockage. The final analysis was confined to 93 patients. Positive peritoneal cytology was found in 10 (10.8%) patients and this finding was significantly related to the tumor grading (P = 0.023), adnexal involvement (P = 0.003), cervical invasion (P = 0.01), and the presence of peritoneal seedlings (P = 0.001). In five of the 10 patients with positive peritoneal cytology before the hysteroscopic examination, malignant cells could also be recovered in the peritoneal washing collected after the hysteroscopic examination. For patients with negative peritoneal cytology before hysteroscopy, none exhibited positive peritoneal cytology after the procedure. Our data suggested that complete occlusion of both fallopian tubes can effectively prevent the dissemination of endometrial malignant cells into the peritoneal cavity during hysteroscopy.

Does fluid hysteroscopy increase the stage or worsen the prognosis in patients with endometrial cancer?

OBJECTIVE

To determine whether fluid hysteroscopic directed biopsies, in patients with endometrial cancer upstages the tumor and worsens the prognosis.

STUDY DESIGN

Between January 1996 and September 2001, a total of 62 consecutive patients with endometrial cancer, treated at our institution, were randomized 3:2 to have or not to have a fluid hysteroscopic biopsy just prior to surgery. A total of 38 patients underwent a hysteroscopy after the induction of anesthesia. All patients had pelvic washings performed, followed by a hysterectomy, bilateral salpingooforectomy and pelvic +/- para-aortic lymph node dissections. Only stages I and II endometrioid type tumors or stage IIIa, secondary to positive pelvic washings, were included in the study. Eight patients in the hysteroscopy group and four patients in the control group were excluded for various reasons. Patients received post-operative radiation therapy depending on the surgical-pathological risk factors. The median follow up was 34 months. Fisher's Exact Test was performed to compare differences between the hysteroscopic (n = 30) and the control (n = 20) groups.

RESULTS

We found three patients (10%) with positive washings in the hysteroscopic group compared to one (5%) among the controls (P = 0.64), with a statistical power of <20%. If the differences would persist, we would need 588 patients in each arm to obtain a power of 80%, and reach definitive conclusions. The Odds Ratio (OR) of performing a hysteroscopy and upstaging the tumor in this study was: 2.1 95% CI (0.20-21.09). Prognostic variables were compared between both groups and no differences were observed. All patients but one (dead due to intercurrent disease), were alive and with no evidence of disease at the completion of the study.

CONCLUSIONS

Fluid hysteroscopy and directed biopsies may have a small risk of upstaging early endometrial cancers, but does not seem to influence prognosis.

Peritoneal washing cytology

Peritoneal washing cytology (PWC) is a useful indicator of ovarian surface involvement and peritoneal dissemination by ovarian tumours. It may identify subclinical peritoneal spread and thus provide valuable staging and prognostic information, particularly for non-serous ovarian tumours. The role of PWC as a prognostic indicator for endometrial carcinoma is less clear, due in part to the questionable significance of identifying endometrial tumour cells in the peritoneum. Detection of metastatic carcinoma in PWC is based on the recognition of non-mesothelial cell characteristics. However a number of conditions such as reactive mesothelial cells, endometriosis and endosalpingiosis may mimic this appearance. Cells from these conditions may have a similar presentation in PWC to that of serous borderline tumours and low-grade serous carcinoma. The presence of cilia, lack of single atypical cells, prominent cytoplasmic vacuolation, marked nuclear atypia or two distinct cell populations are features favouring a benign process. Attention to these features along with close correlation with clinical history and the results of surgical pathology should help avoid errors. Additional assistance may be provided by the use of cell blocks and special stains.

Prognostic significance of positive peritoneal cytology in endometrial carcinoma confined to the uterus

A retrospective analysis was performed to evaluate the prognostic significance of peritoneal cytology in patients with endometrial carcinoma limited to the uterus. A total of 280 patients with surgically staged endometrial carcinoma that was histologically confined to the uterus were examined clinicopathologically. The median length of follow-up was 62 (range, 12-135) months. All patients underwent hysterectomy and salpingo-oophorectomy with selective lymphadenectomy, and only three patients received adjuvant postoperative therapy. No preoperative adjuvant therapy was employed. In all, 48 patients (17%) had positive peritoneal cytology. The 5-year survival rate among patients with positive or negative peritoneal cytology was 91 or 95%, respectively, showing no significant difference (log-rank, P=0.42). The disease-free survival rate at 36 months was 90% among patients with positive cytology, compared with that of 94% among patients with negative cytology, and the difference was not significant (log-rank, P=0.52). Multivariate proportional hazards model revealed only histologic grade to be an independent prognostic factor of survival (P=0.0003, 95% CI 3.02 - 40.27) among the factors analysed (age, peritoneal cytology, and depth of myometrial invasion). Multivariate analysis revealed that histologic grade (P=0.02, 95% CI 1.21-9.92) was also the only independent prognostic factor of disease-free survival. We concluded that the presence of positive peritoneal cytology is not an independent prognostic factor in patients with endometrial carcinoma confined to the uterus, and adjuvant therapy does not appear to be beneficial in these patients.

Peritoneal lavage cytology: an assessment of its value during prophylactic oophorectomy

OBJECTIVE

Prophylactic oophorectomy (PO) is an accepted treatment strategy for women who are at high risk for the development of ovarian carcinoma, particularly women who are BRCA mutation-positive. This study sought to assess the utility of peritoneal lavage cytology at the time of PO in detecting occult malignancy in this group of patients.

METHODS

Thirty-five high-risk women, who were not suspected of having any malignancy or ovarian mass, underwent peritoneal lavage at the time of PO. Thirty-one of the thirty-five women had undergone BRCA mutation analysis (BRCA1+, 18; BRCA2+, 10; BRCA-, 3). Intensive histopathologic examination was used in all 35 cases to identify occult carcinoma. Lavage specimens were reviewed for the presence of malignant cells and endosalpingiosis. The cytologic review was conducted without knowledge of either the histopathologic or BRCA results.

RESULTS

In 32 of the 35 lavage specimens no malignancy was detected. In the remaining three cases malignant cells were detected; in two of these cases histopathologic examination confirmed an ovarian/tubal occult carcinoma. Two of these women were BRCA1 mutation positive. Endosalpingiosis was detected in the peritoneal lavage specimens of 7 of the 32 cases showing no evidence of malignancy. All of these 7 women were BRCA mutation positive or unknown.

CONCLUSION

Peritoneal lavage cytology can detect occult carcinoma at the time of PO and should be performed at PO. The significance of occult carcinoma detected by either histopathologic or cytopathologic examination is uncertain. Whether the prevalence of endosalpingiosis detectable by lavage cytology is increased in BRCA mutation-positive patients requires further study.

Hysteroscopic dissemination of endometrial carcinoma using carbon dioxide and normal saline: a retrospective study

OBJECTIVE

The aim of this study was to compare the likelihood of disseminating endometrial carcinoma cells into the peritoneal cavity by hysteroscopic examination using carbon dioxide (CO(2)) or normal saline (NS) as the distension medium.

METHODS

A retrospective study of 162 consecutive patients with endometrial carcinoma treated at a university teaching hospital from 1994 to 1999 was undertaken. All patients had a hysteroscopic examination, using either CO(2) or NS as the distension medium, as part of the investigation for abnormal uterine bleeding or in determining whether the uterine cervix was invaded by tumor. Peritoneal fluid for cytology was collected immediately upon entry into the abdominal cavity. Positive peritoneal cytology was considered the primary statistical endpoint.

RESULTS

Among 162 patients, 39 cases were excluded from the study because of macroscopic intraperitoneal diseases (n = 32) or pathology other than endometrioid adenocarcinoma (n = 7). Another 3 cases were excluded because both distension mediums had been used in the hysteroscopy. Analysis was therefore based on the data of 120 patients. There was no statistically significant difference between the two groups of patients undergoing hysteroscopy using either CO(2) (n = 70) or NS (n = 50) with regard to age, pathologic stage, International Federation of Gynecology and Obstetrics grading, myometrial invasion, tumor size, cervical involvement, nodal involvement, and 2-year progression-free survival. However, there was a mean of 13.0 plus minus 5.0 days (range 3-21 days) time gap between laparotomy for definitive surgery and CO(2) hysteroscopy compared to immediate laparotomy after NS hysteroscopy (P < 0.001). Positive peritoneal cytology was noticed in 8 (6.7%) patients of which 7 were in the NS group and 1 was in the CO(2) group. Positive cytology was significantly more common among patients after hysteroscopy using NS than CO(2) (14.0% versus 1.4%, odds ratio = 11.2, 95% confidence interval = 1.3-94.5, P = 0.009). The presence of positive peritoneal cytology was not associated with age, tumor grade, tumor size, myometrial invasion, cervical involvement, or nodal metastasis. All 8 patients with positive cytology received no additional treatment and are disease free at 12 to 34 months of follow-up.

CONCLUSIONS

Our data suggested that endometrial malignant cells were introduced into the peritoneal cavity during hysteroscopy and might be more likely after the use of NS rather than CO(2). This report emphasizes the need for prospective evaluation for further clarification of this hypothesis. The clinical significance of the dissemination awaits the long-term follow-up of these patients.

Endometrial adenocarcinoma: a primer for the generalist

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

Positive peritoneal cytology in endometrial cancer: enhancement of other prognostic indicators

OBJECTIVE

The goal of this study was to investigate the prognostic significance of positive peritoneal cytology in endometrial cancer.

METHODS

A clinicocytopathological study was performed in 534 patients with endometrial cancer to assess the prognostic value of positive peritoneal cytology. The study population was divided into three groups: a low-risk group (disease limited to the uterus, grade 1, and depth of invasion < or =1/2), a moderate-risk group (disease limited to the uterus, grade 2 or 3, and/or depth of invasion >1/2), and a high-risk group (extrauterine disease). In each group, disease-free survival was compared in the patients who were positive or negative for malignant cells.

RESULTS

The overall incidence of positive peritoneal cytology was 22.3% (119/534). The 5-year disease-free survival of patients positive or negative for malignant cells was 98.1% versus 100% in the low-risk group (n = 250), 77.5% versus 91.3% in the moderate-risk group (n = 211), and 42.9% versus 72.1% in the high-risk group (n = 73). A significant difference was noted in the moderate-risk (P = 0.044) and high-risk (P = 0.015) groups, but not in the low-risk group (P = 0.56).

CONCLUSIONS

Positive peritoneal cytology is not a negative prognostic indicator itself, but it potentiates other prognostic indicators for endometrial cancer. Our findings also suggest that patients with positive peritoneal cytology in the absence of other adverse prognostic factors do not need upstaging.

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

PURPOSE

To identify prognostic factors and treatment toxicity in a series of operable endometrial adenocarcinomas.

METHODS AND MATERIALS

Between November 1971 and October 1992, 437 patients (pts) with endometrial carcinoma, staged according to the 1988 FIGO staging system (225 Stage IB, 107 Stage IC, 4 Stage IIA, 35 Stage IIB, 30 Stage IIIA, 6 Stage IIIB, and 30 Stage IIIC), underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy without (n = 140) or with (n = 297) pelvic lymph node dissection. The chronology of adjuvant RT was not randomized and depended on the usual practices of the surgical teams. Seventy-nine pts (Group I) received preoperative low-dose-rate uterovaginal brachytherapy (mean dose [MD]: 57 Gy). Three hundred fifty-eight pts (Group II) received postoperative RT. One hundred ninety-six pts received low-dose-rate vaginal brachytherapy alone (MD: 50 Gy). One hundred fifty-eight pts had external beam pelvic RT (MD: 46 Gy) followed by low-dose-rate vaginal brachytherapy (MD: 17 Gy). Four pts had external beam pelvic RT alone (MD: 47 Gy). The mean follow-up from the beginning of treatment was 128 months.

RESULTS

The 10-year disease-free survival rate was 86%. From 57 recurrences, only 12 were isolated locoregional recurrences. The independent factors decreasing the probability of disease-free survival were as follows: histologic type (clear-cell carcinoma, p = 0.038), largest histologic tumor diameter >3 cm (p = 0.015), histologic grade (p = 0.008), myometrial invasion > 1/2 (p = 0.005), and 1988 FIGO staging system (p = 9.10(-8)). In Group II, the addition of external beam pelvic RT did not seem to independently improve vaginal or pelvic control. The postoperative complication rate was 7%. The independent factors increasing the risk of postoperative complications were stage FIGO (p = 0.02) and pelvic lymph node dissection (p = 0.011). The 10-year rate for Grade 3 and 4 late radiation complications according to the LENT-SOMA scoring system was 3.1%. External beam pelvic RT independently increased the rate for Grade 3 and 4 late complication (RR: 5.6, p = 0.0096).

CONCLUSION

Postoperative external beam pelvic RT increases the risk of late radiation complications. After surgical and histopathologic staging with pelvic lymph node dissection, in subgroup of "intermediate-risk" patients (Stage IA Grade 3, IB-C and II), postoperative vaginal brachytherapy alone is probably sufficient to obtain a good therapeutic index. Results for patients with Stage III tumor are not satisfactory.

A vaginal and extraperitoneal approach to surgically stage patients with endometrial cancer

OBJECTIVE

The purpose of this project was to prospectively evaluate the feasibility of an alternative technique for surgically staging patients with endometrial cancer.

METHODS

Patients with endometrial cancer were enrolled in this protocol from September 1999 until August 2000. The staging procedure included pelvic washings via colpotomy, total vaginal hysterectomy, bilateral salpingo-oophorectomy (TVH/BSO), and extraperitoneal pelvic and paraaortic lymphadenectomy (EP-LND) if indicated. Tumor characteristics, time and feasibility of surgical procedures, length of hospital stays, and complications were prospectively recorded.

RESULTS

Twenty-one patients were enrolled. Grade 1, 2, and 3 tumors were identified in 6 (29%), 10 (48%), and 5 (24%) patients, respectively. Pelvic washings and TVH/BSOs were performed on all patients. A total of 21/21 (100%) uterine specimens were removed vaginally and 41/42 (98%) adnexa were resected vaginally. EP-LNDs were performed on 17 (81%) patients due to pathologic findings of the uterine specimens. The median time to perform a TVH/BSO was 68 (47-149) min. The median time to complete a EP-LND was 77 (59-107) min. The median number of postoperative days was 1 (1-5). Complications were infrequent and mild.

CONCLUSIONS

TVH/BSO, pelvic washings, and EP-LND is a feasible alternative to standard surgical staging of endometrial cancer. The minimal amount of exposure to the intraperitoneal space makes this approach arguably the least invasive for endometrial cancer staging and accounts for the decrease in recovery time and shortened hospital stays. The acceptable length of surgical time, short hospital stays, and minimal requirements for surgical instruments make this approach potentially the most cost-effective option for surgically staging patients with endometrial cancer. A randomized trial comparing this technique to standard surgical staging is warranted.

Prognostic significance of combined conventional and immunocytochemical cytology for peritoneal washings in endometrial carcinoma

BACKGROUND

Noncancerous cells simulating adenocarcinoma cells may interfere with the analysis of peritoneal cytology (PC) in patients with endometrial carcinoma. Immunocytochemistry (ICC) may improve the diagnosis of PC.

METHODS

PC slides from 115 patients with endometrial carcinoma were reviewed. Suspicious or positive cell clusters were recovered with a cell transfer method and were subjected to ICC for MOC-31, cytokeratin 5/6, and p53. Conventional Papanicolaou staining and ICC results were compared directly on the same cells.

RESULTS

By combined conventional and immunocytochemical PC (CONV-ICC-PC), cytodiagnosis was positive in 18 of 115 patients (15.7%) and suspicious in 3 of 115 patients (2.6%). According to a multivariate Cox regression analysis of patients with tumors confined to the uterus that included grade, myometrial invasion, cervical involvement, and CONV-ICC-PC, only CONV-ICC-PC was an independent prognostic factor (P < 0.05). A multivariate analysis for all of the patients studied that compared CONV-ICC-PC with staging variables revealed that only peritoneal metastasis (P < 0.0001) and lymph node metastasis (P < 0.01) were independent prognostic factors. When peritoneal metastases were excluded, CONV-ICC-PC (P < 0.01) and lymph node metastasis (P < 0.0025) were the independent prognostic factors. By cell transfer and p53 immunostaining in samples from 14 patients with malignant cells in their peritoneal washings, no deaths occurred among 5 patients with negative p53, whereas 5 of 9 patients with positive p53 died of disease at the time of data analysis.

CONCLUSIONS

MOC-31 immunostaining improves the diagnosis of PC in endometrial carcinoma. Positive PC is an important prognostic factor for patients with endometrial carcinoma confined to the uterus. The p53 positive cells in PC have possible prognostic significance.

High incidence of positive peritoneal cytology in low-risk endometrial cancer treated by laparoscopically assisted vaginal hysterectomy

OBJECTIVE

Laparoscopically assisted vaginal hysterectomy (LAVH) has evolved into an alternative form of surgical management in the treatment of low-risk endometrial cancer. The purpose of this study was to determine whether low-risk endometrial cancer patients are subject to a higher incidence of positive peritoneal cytology when treated with LAVH compared to total abdominal hysterectomy (TAH).

METHODS

We retrospectively reviewed the medical records of patients with low-risk endometrial cancer (grade 1--2 endometrioid type with no evidence of extrauterine spread or grade 3 with <50% myometrial invasion (MI), no cervical or adnexal involvement, and negative lymph nodes when sampled) treated at Memorial Sloan-Kettering Cancer Center from January 1993 to September 1999. We compared 131 patients treated with LAVH to 246 controls who underwent TAH. The two groups were compared for known prognostic factors including grade, MI, vascular space involvement, and lower uterine segment extension.

RESULTS

The mean age of patients who underwent LAVH (61 years) was similar to that of the controls (62 years). Fourteen (10.3%) of the patients treated with LAVH had positive peritoneal cytology compared to only 7 (2.8%) of the control population. Factors including FIGO grade, myometrial invasion, and preoperative hysteroscopy did not influence the final results. When stratifying for these factors, the odds ratios of having positive peritoneal washings in those patients treated by LAVH were 5.2, 5.2, and 3.7, respectively.

CONCLUSION

Treatment of low-risk endometrial cancer by LAVH is associated with a significantly higher incidence of positive peritoneal cytology. This may be due to the retrograde dissemination of cancer cells into the peritoneal cavity during uterine manipulation. The clinical significance of these findings is yet to be determined.

Treatment of high-risk uterine cancer with whole abdominopelvic radiation therapy

PURPOSE

To evaluate the treatment outcomes in patients with optimally debulked Stage III and IV endometrial adenocarcinoma (ACA) or Stages I-IV uterine papillary serous (UPSC) or clear cell (CCC) carcinoma of the uterus, treated postoperatively with whole abdominopelvic irradiation (WAPI).

METHODS AND MATERIALS

Between 1979 and 1998, 48 patients received postoperative WAPI at our institution. Twenty-two patients had FIGO Stage III or Stage IV ACA and 26 patients had FIGO Stages I-IV UPSC or CCC. The median dose was 30 Gy to the upper abdomen and 49.8 Gy to the pelvis. Mean follow-up was 37 months (2.4-135 months).

RESULTS

The 3-year estimated disease-free survival (DFS) and overall survival (OS) rates for the entire group were 60% and 77%, respectively. Patients with ACA had 3-year DFS and OS of 79% and 89%, respectively, compared with 47% and 68% in the UPSC/CCC group. Early-stage patients (I and II) with UPSC/CCC had 3-year DFS and OS of 87% compared with 32% and 61% in those with advanced (Stage III and IV) disease. The 3-year actuarial major complication rate was 7%, with no treatment-related deaths. All 4 failures in the ACA group were extra-abdominal and 6 of the 11 in the UPSC/CCC group had an extra-abdominal component. Age and UPSC/CCC histology were significant prognostic factors for DFS and OS. In addition, stage and number of extrauterine sites of disease were significant predictors for DFS in UPSC/CCC.

CONCLUSION

WAPI is a safe, effective treatment for patients with optimally debulked advanced-stage uterine ACA or early-stage UPSC/CCC. Survival was significantly worse in advanced-stage UPSC/CCC patients. We recommend future trials of WAPI with concurrent, or subsequent systemic therapy in patients with advanced-stage UPSC or CCC.

Association between initial diagnostic procedure and hysteroscopy and abnormal peritoneal washings in patients with endometrial carcinoma

BACKGROUND

Hysteroscopy has been implicated in the finding of positive peritoneal washings (PW) in patients with endometrial carcinoma in several case reports. The current study was designed to evaluate whether there was an increased incidence rate of positive peritoneal washings in patients after hysteroscopy compared with patients who did not undergo hysteroscopy.

METHODS

Two hundred eighty-four women with endometrial carcinoma were treated by hysterectomy with intraoperative PW at the Memorial Sloan-Kettering Cancer Center between 1995-1998. They were diagnosed by either endometrial biopsy (EMB) or dilatation and curretage (D & C) with or without hysteroscopy during the same period.

RESULTS

Of 173 patients diagnosed by EMB, 16 had abnormal PW (9.2%). Of 111 patients diagnosed by D & C, 11 had abnormal PW (9.9%). There was no significant difference between the two groups (P = 0.85). Of 23 patients who were diagnosed by D & C with hysteroscopy, 3 had abnormal PW (13.0%). Of 177 patients who did not undergo hysteroscopy, 17 had abnormal PW (9.6%). Of 84 patients for whom information regarding hysteroscopy was not available, 7 had abnormal PW (8.3%). The incidence rates among the three groups were not significantly different (P = 0.79).

CONCLUSIONS

The initial diagnostic procedure, including hysteroscopy, does not appear to be associated with a high incidence rate of abnormal PW in patients with endometrial carcinoma.

The significance of peritoneal cytology in uterine cervix and endometrial cancer

OBJECTIVE

The purpose of this study was to determine the incidence of positive peritoneal cytology and to elucidate the prognostic value of peritoneal cytology in patients with uterine cervix and endometrial cancer.

MATERIALS AND METHODS

The incidence of positive peritoneal cytology was investigated in 642 patients including 339 uterine cervix and 303 endometrial cancers. Survival was estimated by the Kaplan-Meier method in a subgroup of 116 stage II cervix and 199 stage I endometrial cancers, and multivariate analysis using Cox's proportional hazards model was used to identify an independent prognostic factor.

RESULTS

The incidence of positive peritoneal cytology was found to be 9% in uterine cervix cancer and 15% in endometrial cancer. The incidence was higher in patients with some clinicopathologic status such as advanced stage, lymph node metastasis, ovarian metastasis, and deeper myometrial invasion. The 5-year survival rate for patients with positive or negative peritoneal cytology was 44 or 80% in stage II cervix cancers and 80 or 92% in clinical stage I endometrial cancers, respectively. Multivariate analysis revealed that independent prognostic determinants were pelvic and paraaortic lymph node metastasis and peritoneal cytology in stage II cervix cancer and peritoneal cytology in stage I endometrial cancer. Proper treatment protocol should be scheduled for patients with positive peritoneal cytology.

Excellent long-term survival and absence of vaginal recurrences in 332 patients with low-risk stage I endometrial adenocarcinoma treated with hysterectomy and vaginal brachytherapy without formal staging lymph node sampling: report of a prospective trial

PURPOSE

The value of adjuvant radiation therapy and staging pelvic lymphadenectomy in patients with low-risk, early-stage endometrial cancer is controversial. The aim of this study was to report the long-term survival, rate of recurrences, and complications in patients with Stage I endometrial cancer, Grade 1-2, with <50% myometrial invasion treated with hysterectomy (without formal staging pelvic and periaortic lymph node sampling or lymphadenectomy) and postoperative vaginal brachytherapy.

METHODS AND MATERIALS

A total of 303 patients with pathologic Stage I endometrial cancer, Grade 1-2, with <50% myometrial invasion and nonmalignant peritoneal cytology, were treated with total abdominal hysterectomy, bilateral salpingo-oophorectomy, and postoperative vaginal brachytherapy (30 Gy to point 0.5 cm depth) in a prospective study extending from 1958 to 1994. In addition, 29 additional Stage I, Grade 1-2 patients with <50% myometrial invasion and malignant peritoneal cytology were treated with 1 year of progesterone therapy. Patients were followed for 1.2-32 years (median 8.1 y).

RESULTS

Six patients had recurrences and died secondary to disease. There were no vaginal recurrences. The 5-, 10-, 20-, and 30-year disease-free survivals of the 303 patients with nonmalignant peritoneal cytology were 98.9%, 97.8%, 96.7%, and 96.7%, respectively. Patients with malignant peritoneal cytology had a 5- and 10-year disease-free survival of 100%. Significant radiation complications occurred in 2.1% of the patients.

CONCLUSION

In patients with low-risk, Stage I endometrial cancer, hysterectomy and adjuvant postoperative vaginal brachytherapy provide excellent long-term survival, eliminate vaginal recurrences, and are not associated with significant complications. The addition of 1 year of progesterone therapy to patients with malignant cytology provides 100% long-term survival. Based on these results, patients with low-risk, Stage I endometrial adenocarcinoma do not need formal staging pelvic and periaortic lymphadenectomy.

Endometrial cancer

Carcinoma of the uterine corpus (endometrial cancer) remains the gynecologic malignant disease with the highest annual prevalence in the United States. The most common histologic type is adenocarcinoma, although more aggressive variants (e.g., papillary serous carcinoma and clear cell carcinoma) have been identified. Risk factors that are strongly associated with the development of endometrial cancer include tamoxifen therapy, obesity, and stimulation from unopposed estrogen (from exogenous sources or endogenously secreting ovarian tumors). The current staging system of the International Federation of Gynecology and Obstetrics is based on surgical-pathologic findings. Survival has been directly correlated with tumor stage in this staging system. The cornerstone of therapy is total abdominal hysterectomy with bilateral salpingo-oophorectomy. Pelvic and para-aortic lymphadenectomy may provide additional prognostic information but probably does not confer a therapeutic advantage. Moreover, such nodal dissections predispose to the development of complications, especially in women who subsequently receive pelvic irradiation. Other than surgical treatment, irradiation is the single most active therapy for endometrial carcinoma. In fact, some women who are not candidates for hysterectomy because of medical contra-indications can be cured with radiation alone. Adjuvant therapy following hysterectomy is based on patient- and tumor-related features that provided prognostic information for incidence and pattern of recurrence. Adjuvant treatment usually includes pelvic irradiation for selected patients. Current investigational strategies are directed at the role of whole-abdomen irradiation, extended-field irradiation, and systemic chemotherapy. The most active systemic agents include cisplatin, doxorubicin, paclitaxel, and progestins.

Endometrial carcinoma. Influence of prognostic factors on radiation management

The earliest intracavitary radium treatment for uterine cancer was reported in 1908. Refinements reported during the next 20 years, using an intrauterine tube and colpostats or radium capsules, established a treatment philosophy of preoperatively irradiating uterine and parauterine tissues. Thus, preoperative intracavitary irradiation became entrenched as therapy for all endometrial cancers for the better part of four decades. In the 1950s and 1960s, the ability of external irradiation to eradicate cancer in regional lymphatic vessels prompted the use of pelvic field irradiation in Stage II and III and recurrent disease. The results of surgical exploratory studies in the 1970s established more refined criteria for preoperative or postoperative external pelvic irradiation in high-grade infiltrating Stage I cancers. In the 1980s, it became apparent that, for tumors with lymphovascular invasion, clear cell, and serous papillary histologic types, the disease spread to the upper abdomen and the paraaortic nodes might benefit from extended field and/or whole abdominal irradiation, with or without systemic bolus or concomitant continuous-infusion chemotherapy. In the 1980s, a subset of patients was identified with high-grade lymphovascular invasion clear cell and papillary serous histologic types or with positive peritoneal cytologic findings who were at high risk of failing in the paraaortic nodes and/or the upper abdomen for whom extended field or whole abdominal irradiation have been advocated. Given the fraction and dose limitation for a large abdominal field, the addition of systemic concomitant bolus or continuous infusion of chemotherapy currently is proposed to improve the control of intraabdominal failure in these high-risk patients.

A prospective trial of progesterone therapy for malignant peritoneal cytology in patients with endometrial carcinoma

From February 1982 to February 1991, 45 patients with endometrial carcinoma confined to the uterus except for malignant peritoneal cytology were treated with 1 year of progesterone therapy. Thirty-six patients have undergone planned second-look laparoscopy with repeat peritoneal washings and the remaining 9 patients either refused second-look laparoscopy or the procedure was medically contraindicated. Of the 36 who underwent second-look laparoscopy, 34 (94.5%) were NED (no evidence of disease) and had negative repeat peritoneal cytology and 2 (5.5%) had persistent malignant cytology. The latter two patients, after an additional year of progesterone therapy, were found to be NED and had negative peritoneal cytology at third-look laparoscopy. Of the 45 women enrolled in this protocol, no patient has developed recurrent endometrial cancer, and the expected 5-year disease-free survival was 88.6%.

Retrograde seeding of endometrial carcinoma during hysteroscopy

Fractional dilatation and curettage remain the most reliable methods in the diagnosis of endometrial carcinoma in the symptomatic patient. In the past few years hysteroscopy has become a helpful method, improving the specificity of the diagnosis of this pathology. We report a case of clinical stage IA grade 2 endometrial adenocarcinoma diagnosed by hysteroscopy and endometrial biopsy. Surgical staging revealed positive cytology. We suggest that irrigation of the endometrial cavity during the hysteroscopic procedure with saline may disseminate the disease to the abdominal cavity and may change the prognosis and the course of treatment.

Multiple peritoneal cytologies collected during laparotomy for gynecologic malignancy

Review of an 18-mo experience with peritoneal cytology specimens showed that 760 peritoneal washings and 177 diaphragmatic smears were collected during 300 laparotomies on patients known to have or suspected of having gynecologic malignancy. One hundred three patients were eventually shown to have benign gynecologic disease. The remaining 197 procedures were done on patients undergoing primary operations for gynecologic malignancy or laparotomies for previously treated gynecologic malignancy. Of the 197 laparotomies for gynecologic malignancies, 168 had washings separately collected from multiple intra-abdominal sites, and these fluids were interpreted as either all positive or all negative in all but seven (4%) patients. The location and extent of the gross or microscopic disease did not correlate with the site of positive washings. Only three of the 177 diaphragmatic smears were positive for malignant cells; these were collected from three patients undergoing primary treatment of ovarian carcinoma, two of whom had extensive peritoneal involvement by carcinoma. Only 35 of the 197 patients with gynecologic malignancy had positive peritoneal cytologies; 32 of these patients had gross or microscopic peritoneal involvement by malignancy, and one additional patient had metastatic carcinoma in pelvic lymph nodes. The analysis of multiple peritoneal washings separately collected from various intra-abdominal sites and the analysis of diaphragmatic smears collected in the absence of gross diaphragmatic disease appear to be of benefit in few cases.

Adjuvant whole abdominopelvic irradiation for high risk endometrial carcinoma

Fifty-six patients with surgical Stage III or IV endometrial carcinoma, or earlier stage disease with two or more risk factors for peritoneal recurrence, were given postoperative whole abdomino-pelvic irradiation (WAPI) with nodal and vaginal boosts between November 1981 and May 1989. Mean age at diagnosis was 63 years. Twenty-seven patients were surgical Stage I-II, 17 Stage III, and 12 Stage IV. Thirty-seven (66%) had deep myometrial involvement, 34 (61%) had positive peritoneal cytology, 31 (55%) had high grade lesions, 20 (36%) had either serous-papillary or adenosquamous histologic variants, and 13 (23%) had up to 2 cm residual disease remaining after surgery. Mean overall follow-up was 45 months. The 7-year actuarial survival was 63.8% with a 7-year disease-free survival (DFS) of 60.9%. By surgical stage, the 7-year DSF was 77.1% for Stage I-II, 57.8% for Stage III, and 25.0% for Stage IV (p = 0.006). The 7-year DSF was 79.8% for those with lesions of Broder's grade 1 or 2, and 46.9% for grades 3 or 4 (p = 0.001). Multivariate analysis demonstrated that of all covariates considered, only surgical stage and histologic grade had prognostic significance for survival and disease-free survival. Acute toxicity has been common but mild; chronic toxicity has been almost entirely subclinical with the exception of three cases of moderate to severe bowel toxicity. These results suggest that post-operative WAPI is a safe and efficacious treatment alternative for patients with surgical Stage I through III high-risk endometrial carcinoma.

Extracorporeal spread and its prognostic impact in stages I and II (FIGO) endometrial carcinoma

Prognostic risk factors were statistically analyzed from the histopathologic data obtained from 90 Japanese women with stages I and II endometrial carcinoma treated surgically, including systemic retroperitoneal lymph node dissection, between June 1979 and June 1989. In stage Ia endometrial carcinoma, pelvic and paraaortic nodes metastasis were seen in 13.8(4/29)% and 0.0(0/19)% of patients, respectively. In stage Ib, the incidence of pelvic and paraaortic node metastasis was 25.6(11/43)% and 9.7(3/31)%, respectively. In stage II, the incidence was 38.9(7/18)% and 13.3(2/15)%, respectively. Prognosis of patients even with deep myometrial invasion (greater than or equal to 2/3) or G3 tumor was fairly good (5-year survival rate: 87.5% and 85.7%, respectively) if the disease was histologically confined to the uterine corpus. Once the tumor spread outside the corpus uteri, the survival rate of patients was strongly affected by the grade of the tumor, moderate to marked lymph-vascular space invasion of tumor cells, or tumor invading middle or outer third of myometrium (P less than 0.05 for each factor). In summary, endometrial cancer frequently metastasize to pelvic and paraaortic lymph nodes even in the early stages, and lymph node metastasis and other extracorporeal spread of disease have a serious impact on patient survival. Prognosis of patients with extracorporeal spread of disease seems to be determined by the high grade of tumor and lymph-vascular space invasion. These results suggest that surgical exploration including paraaortic lymph node dissection to accurately evaluate the extent of the disease is essential to estimate the patient's prognostic risk and to individualize the treatment schedule.

Lymphvascular space involvement--a prognostic indicator in endometrial adenocarcinoma

The present study evaluates the effects of various prognostic indicators on survival of patients with clinical Stage I endometrial carcinoma. Ninety-three patients who were treated for clinical Stage I endometrial adenocarcinoma at Maimonides Medical Center from October 1979 to October 1987 had sufficient surgical-pathological information for retrospective surgical staging according to the new FIGO classification. Histology was reviewed. A new grade and surgical stage was assigned to each patient in accordance with the recent FIGO guidelines for surgical staging of corpus cancer. Poor prognostic indicators, namely, tumor grade, depth of myometrial invasion, peritoneal cytology, lymph node metastases, and lymphvascular space (LVS) involvement, were correlated with 5-year survival rates. Survival rates were calculated by the life table method. Depth of myometrial invasion, lymph node involvement, and peritoneal cytology had significant statistical correlation with poor survival. Positive finding of each of the prognostic indicators, including LVS involvement, was significantly associated with poor survival (all P less than 0.001). The value of these prognostic indicators in early endometrial carcinoma is discussed.

A prospective trial of postoperative vaginal radium/cesium for grade 1-2 less than 50% myometrial invasion and pelvic radiation therapy for grade 3 or deep myometrial invasion in surgical stage I endometrial adenocarcinoma

A prospective trial was performed to evaluate the recurrence rate and 5-year disease-free survival rate in patients with surgical Stage I endometrial adenocarcinoma. Patients with Stage I, Grade 1 or 2 disease, less than 50% myometrial invasion, and no evidence of disease outside the corpus of the uterus were treated by hysterectomy and bilateral salpingo-oophorectomy and postoperative vaginal radium/cesium (Group 1). Patients with surgical Stage I, Grade 3 disease or deep myometrial invasion, and histologically negative paraaortic lymph nodes were treated with postoperative pelvic radiation therapy (5000-5040 cGY) (Group 2). Patients with malignant peritoneal cytologic findings also received progesterone therapy. Of the 92 Group 1 patients, there have been no recurrences and the 5-year estimated disease-free survival rate was 99%. Of the 41 Group 2 patients, there have been four (9.7%) recurrences but only one (2.4%) within the treated field (pelvis), and the 5-year estimated disease-free survival rate was 88%. Of the 133 patients, the 5-year estimated disease-free survival rate was 96%, and only one patient (0.7%) had a local pelvic recurrence. Of the 16 patients with malignant peritoneal cytologic findings who were treated with progesterone therapy, none has had a recurrence.

Prognostic value of peritoneal cytology in endometrial carcinoma

To determine whether positive peritoneal cytology is an independent poor prognostic factor in patients with endometrial carcinoma the records of 381 patients were reviewed. Positive peritoneal cytology was found in 24 of 381 (6.3%) patients. In clinical stage I disease, 16 of 322 (5.0%) patients had positive peritoneal cytology. Patients with positive cytology were more likely to have higher-grade tumors and extrauterine disease at the time of surgery (45% vs 2.3%) than were patients with negative cytology. Five-year survival was significantly less for patients with positive cytology than negative (50% vs 81.2%). For patients with surgical stage I disease (no extrauterine spread at surgery) there was no significant difference in 5-year survival between groups with positive and negative cytology (80% vs 86.3%). The majority (70.8%) of patients with endometrial cancer and positive peritoneal cytology have extrauterine disease at the time of surgery. Although overall 5-year survival is less for patients with positive cytology, when other risk factors are controlled for, there is no difference in survival for patients with no demonstrable extrauterine disease despite positive cytology. We conclude that positive peritoneal cytology is not an independent prognostic indicator for patients with endometrial cancer.

Postoperative whole abdomino-pelvic irradiation for patients with high risk endometrial cancer

Forty-seven patients with endometrial cancer, surgical Stage I through IV, received adjuvant whole abdomino-pelvic irradiation with a nodal and vaginal boost between August 1981 through December 1986. The median age was 66.5 years (range 37-86 years). Twenty-two patients were Stages I-II, 14 Stage III, and eleven patients Stage IV. Thirty-four patients (79%) had positive peritoneal cytology, 29 patients (62%) had deep myometrial involvement, 27 patients (58%) had high grade lesions, 18 patients (40%) had either serous-papillary or adenosquamous histologic variants, and ten patients (22%) had residual disease of up to 2 cm. remaining after operation, mostly in the form of nodal disease. Twenty-four patients (51%) had two or more life time laparotomies. Mean follow-up was 40.5 mo. (range 17-85 mo.). The 5-year actuarial survival was 68% and the 5-year relapse-free survival (RFS) was 77%. The 5 year relapse-free survival for Stages I/II, III, and IV were 85%, 78%, and 53%, respectively. The 5 year relapse-free survival for grades 1/2 was 100% and for grades 3/4 was 60%. (p value of 0.0017). Acute toxicity has been modest, and particularly evident in thinner patients (weight below 115 lbs.). Chronic toxicity of significance has been limited to one patient with a conservatively managed bowel obstruction. These results are very encouraging and suggest benefit to the use of more aggressive adjuvant irradiation.

The predictive value of progesterone receptor levels in endometrial cancer

Recent reports have suggested that the presence of progesterone receptor correlates with other well known predictors of a favorable outcome for endometrial cancer patients. To test this hypothesis, we reviewed the records of 154 patients who had undergone a hysterectomy for adenocarcinoma of the endometrium, and pelvic irradiation if poor prognostic factors were present. The 3 year disease-free survival for all clinical Stage I patients was 80%. Patients with progesterone receptor levels greater than or equal to 100 had a 3 year disease-free survival of 93% compared with only a 36% 3 year disease-free survival for patients with progesterone receptor less than 100 (p less than .0001, log rank test). To determine whether elevated progesterone receptor was an independent prognostic factor for disease-free survival in endometrial cancer, or just correlated with the other well-known predictors, bivariate and multivariate analyses were conducted. Our results indicate the progesterone receptor levels are the single most important prognostic indicator of 3 year disease-free survival in clinical Stage I endometrial cancer, with only cervical involvement and peritoneal cytology being significant prognostic variables after adjusting for progesterone receptor levels.

Features associated with survival and disease-free survival in early endometrial cancer

Age, clinical stage, histologic grade, depth of myometrial penetration, adnexal status, peritoneal cytology, and progesterone and estrogen receptor status were available for 139 patients with clinical stage IA, IB, or II endometrial adenocarcinoma who had therapy at Indiana University Hospital or St. Vincent Hospital in Indianapolis. These features were analyzed for their association with survival and disease-free survival. Patients treated at Indiana University Hospital were similar to those from St. Vincent Hospital when comparisons were made by chi 2 test for age, clinical stage, grade, adnexal metastases, peritoneal cytologic results, progesterone receptor status, or estrogen receptor status. However, patients treated at Indiana University Hospital had lesions that were deeper (p = 0.03) than those treated at St. Vincent Hospital. Survival differences were observed for patients with progesterone receptor-rich versus progesterone receptor-poor tumors (p = 0.004), grades 1 and 2 versus grade 3 lesions (p = 0.013), and malignant versus benign peritoneal cytologic results (p = 0.01). Differences in disease-free survival were observed for those patients with adnexal metastases versus those with no adnexal disease (p = 0.002), those with estrogen receptor-rich versus estrogen receptor-poor tumors, outer third myometrial invasion (p = 0.002), and patients with clinical stage I versus clinical stage II disease (p = 0.03). A stepwise Cox proportional hazards model was constructed to determine correlates of disease-free survival. In the final model, grade (p = 0.0002), peritoneal cytologic results (p = 0.0002), progesterone receptor status (p = 0.004), and age as a continuous variable (p = 0.008) were most closely associated with disease-free survival.

Abdominal radiotherapy for cancer of the uterine cervix and endometrium

From 1973 through 1985, 49 women received postoperative open-field whole abdominal radiotherapy as primary management for peritoneal metastases from uterine cancer. The 5-year relapse-free rate was 63% in women with endometrial carcinoma, and two prognostic subsets were identified. Five-year relapse-free rates fell from 77% in women with spread to the adnexa or peritoneal fluid to 36% in women with macroscopic spread of cancer beyond the adnexa. Any peritoneal spread of cervical carcinoma yielded a 3-year relapse-free rate of 31%. Although abdominal spread of cervical cancer was associated with other poor prognostic factors, peritoneal metastases frequently occurred in otherwise early endometrial cancer. Four percent of patients developed small bowel obstruction requiring surgical intervention. The utility and limitations of whole abdominal radiation are discussed.