Pelvic insufficiency fractures in patients with cervical and endometrial cancer treated with postoperative pelvic radiation

ObjectiveThere is an increased awareness of pelvic insufficiency fractures (PIF) as a potential morbidity of pelvic radiotherapy (RT). The purpose of this study was to determine the incidence of PIF and assess prognostic factors, including intensity-modulated RT (IMRT), in gynecologic oncology patients treated with postoperative pelvic RT.MethodsWe performed a retrospective review of all patients with endometrial or cervical carcinoma who received postoperative pelvic RT at our institution during 2000–2008. Patients who received definitive or palliative RT were excluded.ResultsA total of 222 patients were identified, of whom 11 (5%) developed PIF at a median time of 11.5 months (range, 5.5–87.3 months) from RT completion. The 5-year actuarial rate was 5.1% (95% CI 3.3–6.9). In patients with osteoporosis, the 5-year rate was 15.6% compared with 2.9% for those without (P = 0.01). Similarly, patients who were on prior hormone-replacement therapy (HRT) had a higher rate (14.8% vs 4.1%, P = 0.009). The median body-mass index (BMI) for patients who developed PIF was significantly lower than those who didn't (25.9 vs 27.2, P = 0.016). The rate of PIF was 4.9% whether patients received IMRT or conventional RT.ConclusionsThe 5-year risk of PIF for postoperative pelvic RT in cervical and endometrial cancer is 5.1%. Women with history of osteoporosis, prior HRT, or low BMI need to be counseled about the risk of PIF. The use of IMRT did not decrease PIF, but further studies are needed to determine if a dose/volume relationship exists between RT and PIF.     

A multi-institutional cohort study of adjuvant therapy in stage I-II uterine carcinosarcoma

ObjectiveTo evaluate the impact of adjuvant post-operative therapy in women with early stage uterine carcinosarcoma.MethodsAfter IRB approval was obtained at all sites, a multi-center retrospective study of women with FIGO stage I–II uterine carcinosarcoma diagnosed from 1997 to 2007 was conducted. Post-operative treatment included observation (OBS), radiation (RT), chemotherapy (CT) alone or with RT (CT + RT). Data analyzed included demographic and pathologic factors, adjuvant therapy outcomes, and time-to-event information. The Kaplan–Meier method was used to estimate time-to-event functions. Cox regression modeling was used to examine the impact of selected covariates on progression free survival (PFS), and overall survival (OS).Results111 women were identified: 94 (85%) had stage I and 17 (15%) had stage II uterine carcinosarcoma. Forty-four women (40%) did not receive adjuvant therapy (OBS), 29 (26%) women had adjuvant CT, 23 (20%) women underwent RT and 15 (14%) women underwent RT + CT. Seventy-three patients were alive without disease and 38 had progressed or died at the close of data collection. In multivariate analysis, CT (p = 0.003), LVSI (p < 0.0001) and a pre-existing cancer (p = 0.004) were most predictive of PFS. LVSI was predictive of shortened OS (p = 0.01).ConclusionsIn women with FIGO stage I–II uterine carcinosarcoma, adjuvant chemotherapy is associated with improved PFS compared to radiation or observation alone. Ongoing clinical trials will clarify the role of chemotherapy in women with this disease.     

Combined chemotherapy and radiation improves survival for node-positive endometrial cancer

ObjectiveTo evaluate the clinical outcomes for women with node-positive endometrioid adenocarcinoma of the uterusMethodsRecords were reviewed for 66 patients with Stage IIIC endometrioid adenocarcinoma diagnosed between 1/1995 and 12/2009. Study inclusion required TAH, BSO and negative chest imaging. Papillary serous and clear cell histologies were excluded. Adjuvant treatment was external beam radiation (RT) alone in 18 patients (27%), combined chemotherapy and RT in 44 (67%), chemotherapy alone in 1 (2%), and no adjuvant therapy in 3 (5%). The median follow-up was 48 months.ResultsOf 66 patients, 56 (85%) had positive pelvic nodes only, 5 (8%) had positive para-aortic nodes only, and 5 (8%) had both. Of the 62 patients who received adjuvant RT, only 4 (6%) had an in-field recurrence, including 2 with residual disease after surgery. Disease-free (DFS) and overall (OS) survival rates at 5 years were 71% and 81%, respectively. By adjuvant treatment modality, 5-year DFS and OS rates were 63% and 67% for RT alone and 79% and 90% for combined modality therapy (p = 0.15 and p < 0.01). On multivariate analysis, combined modality therapy significantly improved DFS (HR 0.12, 95% CI 0.03–0.49, p < 0.01) and OS (HR 0.20, 95% CI 0.05–0.75, p = 0.02) compared to adjuvant RT alone.ConclusionsCompared to RT alone, combined modality therapy decreased recurrence and improved survival in patients with node-positive endometrioid adenocarcinoma of the uterus. In addition, external beam RT resulted in excellent local and regional control. Future studies are needed to define the optimal chemotherapy regimen, sequencing, and radiation fields.     

A retrospective assessment of outcomes of chemotherapy-based versus radiation-only adjuvant treatment for completely resected stage I-IV uterine carcinosarcoma

PurposeTo determine the progression-free survival (PFS) and overall survival (OS) in a cohort of patients who received either platinum-based chemotherapy with or without radiation therapy (pelvic or WAI), or RT alone.MethodsMemorial Sloan-Kettering Cancer Center (MSKCC) electronic medical records from 8/1/1995 to 10/3/2007 were reviewed for patient age, diagnosis date, type of primary surgery, residual disease at the completion of primary surgery, FIGO stage, treatment details, dates of progression and death, and site(s) of first recurrence. PFS and OS by stage (I/II v III/IV) and by treatment type (chemotherapy with or without RT v RT alone) were determined using landmark analyses 8 weeks after surgery. Patients who received chemotherapy with or without RT (pelvic or abdominal) or RT alone (pelvic or abdominal) were included in the analysis. Both groups were allowed to have received intravaginal radiation therapy (IVRT).ResultsForty-nine patients met study criteria. Thirty-eight/49 patients received chemotherapy: 23/38 (60.5%) received paclitaxel-carboplatin; 7/38 (18.4%) received ifosfamide-platinum; 8/38 (21.0%) received other chemotherapy. FIGO stage was: I = 15 (31%); II = 5 (10%); III = 21 (43%); IV = 8 (16%). Three-year PFS for the entire cohort was 24%. Three-year OS for the entire cohort was 60%. Three-year median PFS time for the entire cohort was 15 months (95% CI: 11–25 months). Three-year median OS time for the entire cohort was 67 months (95% CI: 23–89 months). Three-year PFS for stages I–II was 43% v 14% for stages III–IV (HR = 1.98 [0.9–4.33]); P = 0.082. Three-year OS for stages I–II was 68% v 55% for stages III–IV (HR = 1.26 [0.47–3.41]); P = 0.648. Three-year PFS for chemotherapy with or without RT was 35% v 9% for RT alone (HR = 1.74 [0.79–3.85]); P = 0.164. Three-year OS for chemotherapy with or without RT was 66% v 34% for RT alone (HR = 2.02 [0.77–5.33]); P = 0.146.ConclusionsOur study corroborates GOG 150 results, and shows that paclitaxel-carboplatin appears to be an efficacious adjuvant chemotherapy regimen for completely resected uterine carcinosarcoma. The role of adjuvant RT in addition to chemotherapy warrants further investigation.     

Adjuvant radiation for early stage endometrial cancer with lymphovascular invasion

ObjectiveTo determine the impact of the decrease in use of postoperative pelvic external beam radiation (EBRT) in favor of intravaginal RT (IVRT) alone in patients with early stage endometrial cancer who had lymphovascular invasion (LVI).MethodsBetween 11/1988 and 5/2005, 126 patients treated with simple hysterectomy and postoperative RT had a final pathologic diagnosis of stage IB–IIB adenocarcinoma of endometrioid histology with documented LVI. The patients were divided into two groups based on the era of treatment, (early era: 1988–1996, vs. late era: 1997–2005), in order to best capture the shift away from the routine use of EBRT in favor of surgical staging and IVRT.ResultsOf the 126 patients, 35% (n = 44) were treated in the early era and 65% (n = 82) in the late era. The two groups were balanced in regards to age, race, depth of myometrial invasion, histologic grade, and cervical involvement. Significantly more patients had surgical staging and received IVRT alone in the late than early era (p = 0.0001, 0.004, respectively). The rate of pelvic control was 93% for the early era compared to 97% for latter era (p = 0.3). There was no significant impact of the treatment era on vaginal control, disease-free survival, or overall survival.ConclusionsThese data suggest that the mere presence of LVI need not trigger the use of pelvic EBRT. Instead, the decision on whether to omit EBRT in patients with LVI should be made in the context of a patient's competing risk factors and comorbid conditions.     

Robotically assisted laparoscopic hysterectomy versus total abdominal hysterectomy and lymphadenectomy for endometrial cancer

ObjectiveTo compare surgical morbidity and clinical–pathologic factors for patients with endometrial cancer (EC) undergoing robotic-assisted laparoscopic hysterectomy (RALH) versus total abdominal hysterectomy (TAH) with aortic and/or pelvic lymphadenectomy (LA).MethodsDuring the first 14 months of a robotics surgical program, 56 patients with EC were scheduled to undergo RALH with LA. Cases were analyzed for operative (op) time, estimated blood loss (EBL), transfusion, intra- and post-op complications, surgical–pathologic data, patient demographics and length of stay (LOS). Data was compared to 106 serially treated patients with EC who underwent TAH with LA immediately prior to initiation of our robotics program.ResultsThree robotic cases (5.4%) were converted to TAH secondary to intra-op factors. FIGO stages for RALH vs. TAH were: stage I (82 vs. 69%), stage II (7 vs. 7.5%) and stage III (11 vs. 21.5%). Patients' mean age was 59 ± 10 vs. 63 ± 11 years (p = 0.05) and body mass index (BMI) was 29 ± 6.5 vs. 34 ± 9 kg/m² (p = 0.0001) for the robotic and open groups, respectively. Severe medical co-morbidities affected 5.4% of robotic patients compared to 8.5% of open cases (p > 0.05). Comparing RALH and TAH, mean op time was 177 ± 55 vs.79 ± 17 min (p = 0.0001), EBL was 105 ± 77 vs. 241 ± 115 ml (p < 0.0001), transfusion was 0 vs. 8.5% (p = 0.005), and LOS was 1.0 ± 0.5 vs. 3.2 ± 1.0 days (p < 0.0001). Robotic patients incurred a 3.6% major peri-operative complication rate while women undergoing open procedures had an incidence of 20.8% (p = 0.007). Total lymph node count was 19 ± 13 nodes for robotic cases vs. 18 ± 10 nodes obtained from open hysterectomy patients.ConclusionsPatients with EC who underwent RALH with LA during the first year of our robotics program were younger, thinner and had less cardio-pulmonary illness than patients previously treated with TAH and LA. LOS, EBL and peri-op complication rates were significantly lower for the robotic cohort.     

Twenty-year review of radiotherapy for vaginal cancer: an institutional experience

ObjectiveTo evaluate clinical outcome, prognostic factors and chronic morbidity with radiotherapy for vaginal cancer treatment.Materials and methods68 patients with vaginal cancer treated by radical or adjuvant radiotherapy (RT) were selected. Five with rare subtypes of histopathology and 8 with adenocarcinoma were excluded from this study. 76.4% of the remainder had early-stage diseases (stage I: 14, II: 28, III: 9, and IV: 4). The patients in the years from which they were treated were almost evenly distributed (1st 5 years: 13, 2nd: 14, 3rd: 16, and 4th: 12). There were four treatment groups: external beam radiotherapy (EBRT) alone (n = 18), brachytherapy (BT) alone (n = 4), EBRT and BT (n = 30), and surgery plus RT (n = 3).ResultsMedian follow-up was 50.3 months ranging from 3 to 213 months. 5-year overall survival (OS) was 55.6%, disease-specific survival (DSS) was 77.3%, disease-free survival was 74.2%, and local control was 87.7%. Independent prognostic factors for DSS and OS were tumor stage, site and size (p < 0.05). Late radiation toxicity was minimal in the bladder (4.6%) and bowel (4.6%). Vaginal morbidity was observed in 35 patients (63.6%). It was lowest in the BT alone (0%), and highest in the EBRT and BT group (82.1%), especially for those received more than 70 Gy (p = 0.05, Odds ratio = 4.64, 95% confidence interval: 1.01–21.65).ConclusionThis retrospective review suggested that tumor stage, site, and size were important prognostic factors in patients with vaginal cancer. Higher radiation dose was associated with more frequent vaginal toxicity.     

REVIEW: Utilization of Pharmacotherapy for Erectile Dysfunction Following Treatment for Prostate Cancer

IntroductionPharmacotherapies improve sexual function following treatments for localized prostate cancer; however, patterns of care remain unknown.AimTo ascertain post-treatment utilization of pharmacotherapies for erectile dysfunction (ED) using a population-based approach.MethodsWe identified 38,958 men who underwent definitive treatment for localized prostate cancer during 2003–2006 from the MarketScan Medstat data.Main Outcome MeasuresWe compared the use of ED pharmacotherapy at baseline (up to 3 months prior) and up to 30 months following radical prostatectomy (RP) or radiotherapy (RT) for localized prostate cancer by utilizing National Drug Classification codes for phosphodiesterase-5 inhibitors (PDE5I), intracavernosal injectable therapies (IT), urethral suppositories and vacuum erection devices (VED). In adjusted analyses, we controlled for the effect of age, comorbidity, type of treatment, health plan and use of adjuvant hormone therapy on the use of pharmacotherapies.ResultsMen undergoing RP vs. RT were younger with less co-morbid conditions. Utilization of PDE5I was up to three times greater for men undergoing RP vs. RT, 25.6% vs. 8.8%, (P < 0.0001) in the first post-treatment year, and usage of these agents was greatest for men undergoing minimally-invasive RP procedures. A higher percentage of men also used IT, suppositories and VED after RP vs. RT (P < 0.001). However, more men in the RT group received adjuvant hormonal therapy (39.53% vs. 5.25% for RP, P < 0.01). In adjusted analyses, men undergoing RP vs. RT were more than two times likely (OR 2.1, 95% CI 1.98, 2.26) to use PDE5I post-treatment while men on adjuvant hormonal therapy were less likely to use PDE5I (OR 0.74, 95% CI 0.70–0.79, P < 0.0001).ConclusionMen undergoing RP vs. RT, particularly minimally-invasive RP, are more likely to employ IT, suppositories, VED, and PDE5I pharmacotherapy post-treatment. Prasad MM, Prasad SM, Hevlone ND, Gu X, Weinberg AC, Lipsitz SR, Palapattu GS, and Hu JC. Utilization of pharmacotherapy for erectile dysfunction following treatment for prostate cancer.     

Significance of abnormal sonographic findings in postmenopausal women with and without bleeding

ObjectiveWe sought to determine the incidence of cancer and to compare pathologic outcomes in bleeding and non-bleeding postmenopausal patients who underwent hysteroscopy.MethodsWe conducted a retrospective chart review of 294 postmenopausal women with abnormal uterine bleeding and 142 postmenopausal women without symptoms who underwent hysteroscopy. An 11 mm cut-off for asymptomatic women was applied to determine whether this endometrial thickness threshold would differentiate women with and without endometrial cancer in the asymptomatic group.ResultsIn symptomatic patients, 14 were found to have endometrial cancer and 10 were found to have endometrial hyperplasia. In the asymptomatic group, two women (1. 4%) were found to have endometrial cancer with average thickness 17 . 5 mm, and one (0 . 71%) was found to have endometrial hyperplasia . Logistic regression models showed the risk of a bleeding patient developing endometrial cancer at an endometrial thickness of 4 mm was the same as the risk in a non-bleeding patient at a thickness of 15 mm.ConclusionAsymptomatic postmenopausal women have a low risk of having significant endometrial pathology . Cancer was approximately four times more prevalent in women with bleeding than in women with no bleeding     

Does postoperative radiotherapy provide any survival advantage over observation in stage IC endometrial cancer after comprehensive surgical staging?

ObjectiveTo compare postoperative radiotherapy and observation for survival and recurrence rates in stage IC endometrial carcinoma patients who underwent comprehensive surgical staging.Study designFifty-seven stage IC endometrial cancer patients who underwent surgical staging were included in this study. Twenty cases (35%) received postoperative radiotherapy and 37 (65%) were observed without additional therapy. The two groups were compared for survival and recurrence rates.ResultsMean follow-up times for the radiotherapy and observation groups were 52.05 and 38.71 months, respectively. Five-year disease-free survival rates for the radiotherapy and observation groups were 91% and 63%, respectively, and 5-year overall survival rates for the radiotherapy and observation groups were 90.0% and 80.8%, respectively. Both the disease-free and overall survival rates were similar between the two groups (p > 0.05). One (5%) of the 20 patients in the radiotherapy group, and four (10.8%) of the 37 patients in the observation group had recurrences and there was no statistical difference for the recurrence rates (p > 0.05). Disease grade had no prognostic significance in terms of survival after surgical staging.ConclusionsComprehensive surgical staging might minimize the unfavorable role of deep myometrial invasion and grade. After surgical staging, postoperative observation without radiotherapy may be an appropriate approach in stage IC, all grades, endometrial carcinoma.     

Adjuvant radiation therapy is associated with improved overall survival in high-intermediate risk stage I endometrial cancer: A national cancer data base analysis

Purpose

Adjuvant radiation therapy (RT) was shown to improve local control in patients with high-intermediate risk (HIR) stage I endometrial cancer (EC) in randomized trials. Overall survival (OS) was not significantly different with adjuvant RT in these trials or subsequent meta-analyses; however, they were underpowered to assess OS. We used the National Cancer Data Base (NCDB) to examine the impact of adjuvant RT on OS in HIR EC patients.

A phase II trial of carboplatin and docetaxel followed by radiotherapy given in a "Sandwich" method for stage III, IV, and recurrent endometrial cancer

ObjectiveTo determine feasibility and efficacy of administering docetaxel and carboplatin chemotherapy followed by pelvic radiotherapy and then consolidation chemotherapy in patients with advanced or recurrent endometrial cancer.MethodsPatients with surgically staged III–IV (excluding IIIA from positive cytology alone) endometrial cancer or biopsy confirmed recurrent disease were eligible. Treatment consisted of 3 cycles of docetaxel (75 mg/m²) and carboplatin (AUC 6) on a q21 day schedule followed by involved field irradiation (45 Gy) ± brachytherapy and three additional cycles of docetaxel and carboplatin. Kaplan–Meier (KM) methods estimated overall survival (OS) and progression free survival (PFS).ResultsForty-two patients enrolled, 7 did not complete therapy. 95% (39/41) had primary disease. Median age = 58 years (range: 21–81 years). 78% (32/41) = endometrioid histology. Stages = 10 IIIA, 21 IIIC, 1 IVA, 7 IVB, (recurrent = 1 IC, 1 IIA). There were 23 non-hematologic and 14 grade 3 and 16 grade 4 hematologic toxicities. Seven patients died following treatment with a median follow-up of 28 months (range: 7–70 months). KM estimates and 95% confidence intervals for OS at 1 year were 95% (82–99%), at 3 years 90% (75–96%), and at 5 years 71% (45–86%). Of the 39 with primary disease, 11 progressed or died within 5 years of study enrollment. KM estimates and 95% confidence intervals for PFS at 1 year were 87% (72–94%), at 3 years 71% (51–83%), and at 5 years 64% (42–80%).Conclusions“Sandwiching” radiation between chemotherapy for advanced or recurrent endometrial cancer merits further development based on the reported PFS and OS.     

Extent of pelvic lymphadenectomy and use of adjuvant vaginal brachytherapy for early-stage endometrial cancer

Objective

To examine trends of adjuvant radiotherapy choice and to examine associations between pelvic lymphadenectomy and radiotherapy choice for women with early-stage endometrial cancer.

Prediction of suboptimal primary cytoreduction in primary ovarian cancer with combined positron emission tomography/computed tomography--a prospective study

ObjectiveThe treatment of FIGO stage IB2 cervical cancer is controversial. Our aim was to assess treatment patterns, outcomes, and complications in patients with stage IB2 cervical cancer.MethodsA retrospective study of patients with stage IB2 cervical carcinoma at a single institution between January 1982 and September 2006 was performed. To adequately control treatment variables, we only included patients who underwent their entire treatment at our institution. Toxicity was assessed using NCI Common Toxicity Criteria (CTC).ResultsWe identified 82 patients, of whom 47 met the strict inclusion criteria. Of these, 27 patients (57%) underwent primary radical hysterectomy (RH) and 20 (43%) were treated with definitive radiation/chemoradiation therapy (RT/CRT). Patients selected for RT/CRT had a higher American Society of Anesthesiologist (ASA) score than those selected for surgery (P = 0.037). The 3-year progression free survival rate was 52% for the RH group and 55% for the RT/CRT group (P = 0.977). The 3-year overall survival rates were 72% and 55%, respectively (P = 0.161). Overall, 52% of patients in the RH group received postoperative radiation therapy as part of their adjuvant treatment. CTC grade 3, 4, and 5 complications affected 5 patients (19%) in the RH group and 3 (15%) in the RT/CRT group.ConclusionBoth RH and definitive RT/CRT are adequate management strategies for patients with FIGO stage IB2 cervical cancer. However, there was a subset of patients in whom RH as monotherapy was appropriate. Further studies are needed to evaluate the role of new preoperative models that will accurately identify these patients.     

Surgical care of young women diagnosed with ovarian cancer: a population-based perspective

ObjectiveTo characterize primary surgical care for women with ovarian cancer aged ≤ 50 years versus > 50 years.MethodsA statewide hospital discharge database was used to identify women undergoing primary surgery for ovarian cancer from 1990 to 2000. Logistic regression models were used to evaluate differences in demographic characteristics and short-term outcomes comparing women ≤ 50 years versus > 50 years.ResultsWomen ≤ 50 years comprised 30.2% (n = 731) of 2417 identified cases. The 30-day mortality rate was 54% lower among women ≤ 50 years (1.2% vs. 2.6%, P = 0.0100). Women ≤ 50 years were less likely to be managed by high-volume surgeons versus women > 50 years (47.1% vs. 59.5%, P < 0.0001). Younger women managed by high-volume surgeons had longer lengths of stay (5.7 days vs. 7.7 days, P < 0.0001), longer ICU stays (0.2 days vs. 0.5 days, P = 0.0020), more billed procedures (4.2 vs. 5.5, P < 0.0001), higher adjusted cost of hospital-related care ($46,590 vs. $97,538, P < 0.0001) and more comorbidities (1.0 vs. 1.6, P < 0.0001) than those treated by lower-volume surgeons. Women ≤ 50 years were as likely to be managed at high volume centers as low volume centers (57.7% vs. 61.3% P = 0.0968). A similar trend in outcomes was observed in younger women treated at high-versus low-volume hospitals as high-versus low-volume surgeons.ConclusionPrimary surgical care for ovarian cancer in women ≤ 50 years is often performed by low-volume providers at low-volume centers. In light of positive volume-outcome data for malignancies treated with complex operative procedures, further efforts to characterize the surgical care of young women with ovarian cancer are warranted.     

Impact de la prise en charge thérapeutique sur la survie chez les femmes très âgées avec cancer de l’endomètre

ObjectivesWe aimed to determine whether patients characteristics, clinicopathologic features and survival rates were worse in elderly women with endometrial cancer.Patients and methodsThe study cohort consisted of consecutive women undergoing surgery for endometrial cancer in our institution from January 2000 to October 2011. Patients were divided by age into two groups: patients aged 65 to 79 and those aged 80 or older. Clinical data included comorbidities, BMI (kg/m²), surgical procedures, surgical International Federation of Gynecology and Obstetrics (FIGO) stage, histological grade, relevant prognostic factors, occurrence of perioperative complications, adjuvant therapies, overall survival and long term disease specific mortality.ResultsAs expected, elderly women had more major comorbidities and were less likely to undergo optimal surgery, FIGO stages, histological grades. The 5-year disease specific survival was significantly poorer for the older group compared to younger women 64.5% 95%CI [54.3–73.8] vs 83.49% 95%CI [74.7–90.2] P = 0.008. Cancer-specific mortality was also higher in the elderly: 100% vs 41.17% (P = 0.005).Discussion and conclusionOldest patients with newly diagnosed endometrial cancer were found to have worse overall survival and higher cancer-specific mortality than younger patients because of less aggressive care. Clinical efforts must be managed toward the oldest patients with an early stage of endometrial cancer to maximize the therapeutic ratio, in particular surgical.     

The effect of maximal surgical cytoreduction on sensitivity to platinum-taxane chemotherapy and subsequent survival in patients with advanced ovarian cancer

ObjectivesLimited information exist about the frequency of micrometastases, their topographic distribution and prognostic impact in patients with cervical carcinoma (CX).MethodsLymph nodes of patients with surgically treated CX, FIGO IB to IIB, with pelvic lymph node involvement, were re-examined regarding the size of metastatic deposits, their topographic distribution within the pelvis. Lymph node status (pN0 vs. pN1mic = metastasis < 0.2 cm vs. pN1 = metastasis > 0.2 cm) was correlated to recurrence free (RFS) and overall survival (OS).Results31.4% of all patients (281/894) represented pelvic lymph node involvement. 22.2.% of the node positive ones showed micrometastases (pN1mic). Most commonly, obturator and internal nodes were affected by pN1mic, without any side differences. Patients with macrometastases (pN1) and micrometastases (pN1mic) represented significant reduced RFS-rate at 5-years (62% [95% CI: 54.2 to 69.8] for pN1 and 68.9% [95% CI: 55.5 to 82.4] for pN1mic) when compared to patients without metastatic disease (91.4% [95% CI: 89.0 to 93.8]; p < 0.001) The 5-years OS-rate was decreased in patients with metastatic disease (pN0: 86.6% [95% CI: 83.7 to 89.5], pN1mic: 63.8% [95% CI: 50.9 to 76.7], pN1: 48.2% [95% CI: 40.4 to 56.0]; p < 0.0001). These differences persisted in detailed analysis within these subgroups. In multivariate analysis, tumor stage, pelvic lymph node involvement and micrometastases were independent prognostic factors.ConclusionsA remarkable number of patients with CX show micrometastases within pelvic nodes. Micrometastatic disease represents an independent prognostic factor. So, all patients with pelvic lymph node involvement, including micrometastatic deposits, might be candidates for adjuvant treatment.     

The unrecognized burden of cardiovascular risk factors in women newly diagnosed with endometrial cancer: A prospective case control study

Background

Cardiovascular disease is a major cause of death in endometrial cancer survivors. The aim of this study was to determine whether women newly diagnosed with endometrial cancer have a higher prevalence of cardiovascular risk factors than the general population.

Is selective lymphadenectomy more cost-effective than routine lymphadenectomy in patients with endometrial cancer?

ObjectiveThe objective of this study is to determine the cost-effectiveness of two strategies in women undergoing surgery for newly diagnosed endometrial cancer.MethodsA decision analysis model compared two surgical strategies: 1) routine lymphadenectomy independent of intraoperative risk factors or 2) selective lymphadenectomy for women with high or intermediate risk tumors based on intraoperative assessment including tumor grade, depth of invasion, and tumor size. Published data were used to estimate the outcomes of stage, adjuvant therapy, and recurrence. Costs of surgery, radiation, and chemotherapy were estimated using Medicare Current Procedural Technology codes and Physician Fee Schedule. Cost-effectiveness ratios were estimated for each strategy. Sensitivity analyses were performed including an estimate for lymphedema for patients that underwent a lymphadenectomy.ResultsFor 40,000 women diagnosed annually with endometrial cancer in the United States, the annual cost of selective lymphadenectomy is $1.14 billion compared to $1.02 billion for routine lymphadenectomy. The selective lymphadenectomy strategy cost an additional $123.3 million. Five-year progression-free survival was 85.9% in the routine strategy compared to 79.3% in the selective strategy. Treatment cost $6349 more per survivor in the selective strategy compared to routine strategy ($36,078 vs. $29,729). These results held up under a variety of sensitivity analyses including costs due to lymphedema which were higher in the routine lymphadenectomy strategy compared to the selective lymphadenectomy strategy ($10 million vs. $7.75 million).ConclusionsA strategy of selective lymphadenectomy based on intraoperative risk factors for patients with endometrial cancer was less cost-effective than routine lymphadenectomy even when the impact of lymphedema was considered.     

The impact of surgery on survival of elderly women with endometrial cancer in the SEER program from 1992-2002

ObjectivesFew population-based studies have evaluated surgical treatment and outcomes in elderly patients with endometrial cancer. The National Cancer Institute's SEER, Surveillance, Epidemiology and End Results, Program provides a database to examine this issue. The objective of this study was to determine the extent to which elderly women with endometrial cancer receive surgical treatment and to evaluate the impact of surgery on survival.MethodsData were obtained from the SEER registries for expanded races from 1992–2002. The inclusion criteria were women ages 50 to 95 with pathologically confirmed endometrial cancer. Cases with multiple primaries were excluded.The data were examined with respect to histology, radiotherapy use, extent of surgery and FIGO stage. The survival data were analyzed using a Cox proportional hazard model. Chi-squared tests were used to examine the extent to which elderly women with endometrial cancer receive surgical treatment, hysterectomy at minimum. Endometrial cancer-specific mortality was analyzed.Results27,517 women were analyzed with 94% of the cohort receiving surgical treatments. There is a significant trend that suggests elderly women, aged 65+ years at time of endometrial cancer diagnosis, received surgical treatment less often than younger women (p < 0.001).The age-adjusted hazard of death was reduced with surgical intervention. After adjustment for stage at diagnosis, histology, and radiotherapy, the hazard ratios for endometrial cancer-specific mortality were decreased when surgery was undertaken.ConclusionsIn this population-based study, the poor prognosis associated with advanced age may be in part associated with the decreased frequency of surgical treatment. The reasons need to be further investigated. Continued efforts should be directed at providing surgical treatment for elderly patients with endometrial cancer.