Impact of the new FIGO 2009 staging classification for vulvar cancer on prognosis and stage distribution

Objective

In 2009, FIGO modified staging of vulvar cancer — the performance of the new classification relative to the prior system has not been assessed. We sought to investigate the impact of the 2009 FIGO vulvar cancer staging system on stage distribution and prognostic ability of the 2009 sub-stage classifications in a large cohort of uniformly staged cases with long-term followup.

Methods

Patients undergoing surgery for vulvar cancer were identified from 2 institutions (Mayo Clinic and Medical University, Gdansk, Poland) using a similar surgical approach. Inclusion criteria required primary surgery for invasive vulvar cancer for cases with > 1 mm invasion with complete inguinal/femoral lymphadenectomy. The technique of inguinofemoral node dissection used in both institutions was designed to remove both superficial and deep inguinofemoral nodes. A retrospective review was performed and all cases were assigned stage using the 1988 and 2009 FIGO systems after reviewing pathology slides. Cause-specific survival (CSS, death due to cancer) was estimated using the Kaplan-Meier method and compared using the Cox proportional hazards model t for the first 10 years after surgery.

Result

A total of 468 patients met inclusion criteria. Thirty-one percent (n = 155) were down-staged, and 1 case up-staged using 2009 staging. The new system fails to effectively separate 10-yr CSS for stage I and II cases (p = 0.52), while FIGO 1988 failed to separate stages II and III (p = 0.41). We observed a difference in survival for stage I and II cases based on tumor diameter. For smaller stage II lesion (≤ 4 cm vs. > 4 cm) we observed no difference in survival compared to all stage IB cases (p = 0.25) Considering node positive disease, patients with 2009 FIGO stages ΙΙΙA, ΙΙΙB, and ΙΙΙC were not significantly different in terms of CSS (p = 0.17). However, CSS approached significance between patients with extracapsular vs. intracapsular disease (p = 0.072). For stages IIIA and IIIB (excluding extracapsular spread, IIIC), we observed that the number of positive nodes and diameter of lymph node metastasis were not significantly associated with CSS. When comparing bilateral nodal involvement vs. unilateral cases with at least 2 involved nodes, we found no statistical difference in CSS (p = 0.30).

Conclusion

This is the largest cohort study to evaluate the effect and prognostic performance of the new FIGO vulvar cancer staging system. The new staging does not stratify survival between stages I and II and reduces CSS in stage I cases. Our results suggest that lesion size in node negative cases is an important prognostic variable that could be addressed in future staging classifications. Among the node positive cases, the current classification results in slight differences in CSS, primarily between intra- and extra-capsular disease and not according to the number of positive nodes and lymph node metastasis diameter. Finally we observe that bilateral nodal disease does not appear to impact CSS, justifying it being omitted from the 2009 staging system and that separating node positive (2009 stage III) from node negative (2009 stage II) cases is justified.     

A suggested modification to FIGO stage I endometrial cancer

Objective

FIGO stage I endometrial cancers are divided into two substages, regardless of the presence or absence of lymphovascular space invasion (LVSI). The aim of this study was to investigate whether stratification based on the LVSI status would better predict mortality.

Methods

Using a multicentric database, we identified patients who underwent endometrial cancer operations between 2000 and 2010. The staging performance was quantified with respect to discrimination.

Results

The study cohort included 508 patients (198 with LVSI-positive tumors and 310 with LVSI-negative tumors). The survival difference between the stage I patients with LVSI-positive and LVSI-negative tumors was highly significant (81% and 97%, respectively P = .009), whereas the difference between the stage I patients with tumors invading greater or less than half of the myometrium was not (87% and 96%, respectively P = 0.09). The 5-year OS rates for the patients with LVSI-negative tumors invading less than half of the myometrium, with LVSI-negative tumors invading more than half of the myometrium and with LVSI-positive invading more than or less than half of the myometrium were 98%, 95%, and 81%, respectively (P = .03). Separating the LVSI-negative and LVSI-positive tumors would improve discrimination (concordance index, 77% vs. 75%, respectively, using the actual staging system).

Conclusion

A LVSI-positive status has a significantly worse prognosis. In this study, the distinction by LVSI status appears to be more relevant than the distinction between stages IA and IB for predicting survival in stage I endometrial cancer. This difference in prognosis would favor restaging these two entities.     

History of the FIGO cancer staging system

The main objectives of any good staging system - essential to an evidence-based approach to cancer - are: to aid the clinician in planning treatment; to provide indication of prognosis; to assist the physician in evaluating the results of treatment; to facilitate the exchange of information between treatment centers, thus disseminating knowledge; and to contribute to continuing investigations into human malignancies. A good staging system must have 3 basic characteristics: it must be valid, reliable, and practical. The first staging system for gynecological cancers appeared around the turn of the 20th century and applied to the carcinoma of the cervix uteri-the most common cancer affecting women in high income countries at that time. The classification and staging of the other gynecological malignancies was not put forward until the 1950s. Over the years, these staging classifications - with the exception of cervical cancer and gestational trophoblastic neoplasia - have shifted from a clinical to a surgical-pathological basis. This paper reviews the history of the International Federation of Gynecology and Obstetrics (FIGO) cancer staging system, how it was developed, and why.     

Resection of lymph node metastases influences survival in stage IIIC endometrial cancer

OBJECTIVE: Surgical staging of endometrial cancer identifies those patients with microscopic metastatic disease most likely to benefit from adjuvant therapy and may also confer therapeutic benefit. Our objective was to compare survival of patients who underwent resection of grossly positive lymph nodes (LN) to those with microscopically positive LN. METHODS: Patients had stage IIIC endometrial cancer with pelvic and/or aortic LN metastases and underwent surgery between 1973 and 2002. Exclusion criteria included pre-surgical radiation and second primary cancer. Survival was analyzed using Kaplan-Meier method and Cox proportional hazards model. RESULTS: Mean age of 96 patients with stage IIIC endometrial cancer was 64. There were 45 cases with microscopic LN involvement and 51 with grossly enlarged LN. Overall, 41% had disease in aortic LN, which in 18% represented isolated aortic LN metastasis. Adjuvant therapies were given to 92% of patients (85% radiotherapy, 10% chemotherapy, 10% progestins). Among those with grossly involved LN, 86% were completely resected. Five-year disease-specific survival (DSS) was 63% in 45 patients with microscopic metastatic disease compared to 50% in 44 patients with grossly positive LN completely resected and 43% in 7 with residual macroscopic disease. In multivariable analyses, gross nodal disease not debulked (HR=6.85, P=0.009), serosal/adnexal involvement (HR=2.24, P=0.036), diagnosis prior to 1989 (HR=4.33, P<0.001), older age (HR=1.09, P<0.001), and >2 positive lymph nodes (HR=3.12, P=0.007) were associated with lower DSS. CONCLUSION: Grossly involved LN can often be completely resected in patients with stage IIIC endometrial cancer. These retrospective data provide evidence suggestive of a therapeutic benefit for lymphadenectomy in endometrial cancer.     

The significance of surgical staging in intermediate-risk endometrial cancer

Objective

The objective was to evaluate rates of nodal disease in endometrial cancer within risk groups based on uterine factors, and to estimate the rate of potential undertreatment and impact on survival if nodal status was unknown.

Methods

This was a population-based retrospective cohort study of endometrioid-type endometrial cancer in British Columbia from 2005 to 2009. All women with a preoperative grade 2/3 cancer underwent hysterectomy, bilateral salpingo-oophorectomy (HBSO) and lymphadenectomy, and those with intermediate- or high-risk disease based on uterine factors after HBSO alone underwent secondary lymphadenectomy. We compared rates of node-positivity and potential undertreatment in each group if nodal status had been unknown (chi-square test), and estimated the survival benefit from lymphadenectomy.

Results

There were 222 women who underwent primary or secondary lymphadenectomy. Median age was 65 (range 38-86) and median number of lymph nodes was 10 (range 2-39). Of the 66 women with intermediate-risk disease (grade 1 or 2 tumor, deep myometrial invasion), 6 had nodal disease (9.1%) and received adjuvant chemotherapy. They remain disease-free after 24 months (range 8-55). They would not have qualified for chemotherapy based on uterine factors alone, and would have been undertreated compared to other risk groups (chi-square p = 0.071). A 1% survival benefit was estimated from lymphadenectomy.

Conclusion

Women with a grade 1 or 2 tumor and deep myometrial invasion have a 9% risk of nodal disease. Lymphadenectomy is significant for this subgroup as they would have been undertreated based on uterine risk factors alone, although the survival benefit is limited.     

Sentinel lymph node biopsy in endometrial cancer: meta-analysis of 26 studies

Objective

The validity of the sentinel lymph node (SLN) procedure for the assessment of nodal status in patients with endometrial cancer is unclear. We aimed to assess the diagnostic performance of this procedure.

Methods

We searched the PubMed and Embase databases for studies published before June 1, 2011. Eligible studies had a sample size of at least 10 patients, and reported the detection rate and/or sensitivity of the SLN biopsy.

Results

We identified 26 eligible studies, which included 1101 SLN procedures. The overall weighted-mean number of harvested SLNs was 2.6. The detection rate and the sensitivity were 78% (95% confidence interval [CI] = 73%-84%) and 93% (95% CI = 87%-100%), respectively. Significant between-study heterogeneity was observed in the analysis of the detection rate (I-squared statistic, 80%). The use of pericervical injection was correlated with the increase of the detection rate (P = 0.031). The hysteroscopic injection technique was associated with the decrease of the detection rate (P = 0.045) and the subserosal injection technique was associated with the decrease of the sensitivity (P = 0.049), if they were not combined with other injection techniques. For the detection rate, significant small-study effects were noted (P < 0.001).

Conclusions

Although SLN biopsy has shown good diagnostic performance in endometrial cancer, such performance should be interpreted with caution because of significant small study effects. Current evidence is not yet sufficient to establish the true performance of SLN biopsy in endometrial cancer.     

术后化疗对有高危因素的早期子宫内膜癌患者预后的影响

目的 探讨术后化疗对有高危因素的早期(Ⅰ、Ⅱ期)子宫内膜癌患者预后的影响.方法 选择1994年1月-2007年6月间,北京大学第一医院妇产科收治的66例有高危因素的早期子宫内膜癌且术后均辅以化疗的患者(化疗组),40例相同期别及相同高危因素但术后未予化疗者作为对照组,Kaplan-Meier法计算两组患者的5年累积生存率,并进行比较;对有高危因素的早期子宫内膜癌患者的预后影响因素进行单因素及多因素分析.结果化疗组患者的5年累积生存率为94%,对照组为81%,化疗组明显高于对照组(P<0.05).单因素分析显示,化疗组中≥4个疗程患者的5年累积生存率为100%,<4个疗程患者的5年累积生存率为86%,两者比较,差异有统计学意义(P<0.05);而不同年龄、手术病理分期、病理类型、病理分化程度及术后有无放疗、术后化疗后是否联合放疗、有无孕激素治疗患者间比较,差异均无统计学意义(P>0.05).多因素分析显示,术后化疗是影响有高危因素的早期子宫内膜癌患者预后的独立因素(P<0.05).结论术后化疗可改善有高危因素的早期子宫内膜癌患者的预后,且疗程数应≥4个,但因例数较少,需通过前瞻性随机对照研究的进一步证实.     

Risk factors for early and late postoperative complications of patients with endometrial cancer

OBJECTIVE: We have routinely performed staging with pelvic and/or paraaortic lymphadenectomy in patients with endometrial cancer having moderate to high risk for lymph node metastasis. The aim of this study was to investigate the risk factors for the occurrence of early and late postoperative complications in patients managed primarily by surgery in our institution. STUDY DESIGN: Two-hundred and fifty-nine consecutive cases of endometrial cancer were enrolled in the study. Past history, body mass index, type of surgery, intraoperative findings, and follow-up information were collected from patient charts. Of these, 200, 127, and 30 patients underwent systematic pelvic lymphadenectomy, systematic paraaortic lymphadenectomy, and radical hysterectomy, respectively. The median numbers of dissected pelvic and paraaortic lymph nodes were 32 and 14, respectively. RESULTS: None of the complications resulted in death. Of the study population, 36 early complications and 34 late complications occurred. Overall 65 patients (25.1%) had at least one complication. Multivariate analysis revealed that a longer operative time and paraaortic lymphadenectomy were independent predictors for the occurrence of early and late postoperative complications, respectively. CONCLUSIONS: Since the therapeutic value of lymphadenectomy is still under evaluation, the indications for systematic pelvic and paraaortic lymphadenectomy should be carefully considered.     

Prognostic factors and outcomes in endometrial stromal sarcoma with the 2009 FIGO staging system: A multicenter review of 114 cases

Objective

To assess prognostic factors associated with disease-related survival in endometrial stromal sarcoma (ESS) using the 2009 FIGO staging system.

Methods

From January 1990 to January 2012, 114 patients with ESS were identified at the Samsung and Asan Medical Center and data were retrospectively analyzed.

Results

Ten (8.7%) patients died of the disease and 33 (28.9%) patients relapsed. The 5- and 10-year overall survival (OS) rates for the entire cohort were 92.6% and 87.1%, respectively, and the 5- and 10-year recurrence-free survival (RFS) rates were 71.8% and 52.1%, respectively. The estimated median survival after recurrence for the 33 patients whose tumors relapsed was 133 months (95% CI, 7.7–258.4), and 5-year survival after recurrence was 68.9%. Stage I (P = 0.006), estrogen and/or progesterone receptor (ER/PR) positivity (P = 0.0027), and no nodal metastasis (P = 0.033) were associated with a good prognosis for OS in the univariate analysis. Ovarian preservation was revealed to be an independent predictor for poorer RFS (HR, 6.5; 95% CI, 1.23–34.19; P = 0.027). Positivity for ER/PR (HR, 0.05; 95% CI, 0.006–0.4; P = 0.006) and cytoreductive resection of recurrent lesions (HR, 0.14; 95% CI, 0.02–0.93; P = 0.042) were independent predictors of better survival after recurrence.

Conclusions

Stage, expression of ER/PR, and nodal metastasis are significantly associated with OS in ESS. Bilateral salpingo-oophorectomy (BSO) as the primary treatment and cytoreductive resection of recurrent lesions should be considered for improving survival of patients with ESS.     

Efficacy and prognostic implications of administering adjuvant chemotherapy to patients with endometrial cancer that is confined to the uterus

OBJECTIVE: The purpose of this study was to determine the value of prognostic factors and to assess the efficacy of adjuvant chemotherapy in patients with endometrial cancer confined to the uterus. STUDY DESIGN: Patients surgically stage IB, IC and II endometrial cancer according to the International Federation of Gynecology and Obstetrics were enrolled in this study. Stage IIIA tumors with positive peritoneal cytology, in the absence of other evidence of extra uterine disease, were also included. RESULTS: One hundred and sixty-seven patients fulfilled the eligibility criteria and 58 patients (34.7%) underwent combination chemotherapy. Disease recurrence occurred in 10 patients within a median time of 17 months. Histologic grade 3 was an independent prognostic factor for both disease-free and overall survival rates. Fourteen of 23 patients with histologic grade 3 tumors received adjuvant chemotherapy consisting of cyclophosphamide (or etoposide), epirubicin and cisplatin (in 1989-1999) or paclitaxel, pirarubicin and carboplatin (in 2000-2002). The 5-year disease-free and overall survival rates for these individuals was 92.3%, a value significantly higher than those in patients who had not undergone chemotherapy (50.0%). CONCLUSIONS: Histologic grade of 3 is an independent prognostic marker in patients with endometrial cancer confined to the uterus and adjuvant chemotherapy might improve the survival rates in these patients.     

Comparison between 155 cases of robotic vs. 150 cases of open surgical staging for endometrial cancer

Objective

To compare the outcomes of 155 cases of endometrial cancer who had robot-assisted surgical staging to 150 open cases.

Methods

Retrospective chart review of cases of endometrial cancer that underwent staging two different ways by two surgeons at an academic institution.

Results

Mean age was 62.4 years in the robotic arm and 65 (P = 0.04) in the open arm. Mean body mass index was 34.5 Kg/m² in the robotic arm and 33 Kg/m² in the open arm (P = 0.2). Pelvic and para-aortic lymph node dissection were performed in 94.8% and 67.7% of the robotic cases versus 95.3% and 74% of the open cases, respectively. Mean operative time was 127 min in the robotic arm, and 141 min in the open arm (P = 0.0001). Mean lymph node count was 20.3 in the robotic arm, and 20 in the open arm (P = 0.567). Mean estimated blood loss was 119 ml in the robotic arm and 185 in the open arm (P = 0.015). Mean hospital stay was 1.5 days in the robotic arm, and 4 days in the open arm (P = 0.0001). The incidence of postoperative ileus (0.6% vs. 10.7%, P = 0.0001), infections (5.2% vs. 24%, P = 0.0001), anemia/transfusion (1.3% vs. 7.7%, P = 0.005), and cardiopulmonary complications (3.2% vs.14.7%, P = 0.003) was significantly lower in the robotic arm vs. the open arm. There was one death in the robotic arm attributed to pre-existing cardiac condition.

Conclusion

Robotic-assisted staging reaps the benefits of minimally invasive surgery without compromising the adequacy of the procedure. Dedication to the technique shortens the operative time.     

Quality of life in patients with endometrial cancer treated with or without systematic lymphadenectomy

Objective

To compare the quality of life (QoL) of women affected by endometrial cancer treated with surgery with or without systematic lymphadenectomy.

Study design

Consecutive patients affected by stages I and II endometrial cancer and treated with surgery between 2008 and 2011 were selected. Eligible subjects were divided into two groups: Group A consisted of 36 patients who had hysterectomy plus bilateral salpingo-oophorectomy without lymphadenectomy; Group B consisted of 40 patients who had hysterectomy plus salpingo-oophorectomy plus pelvic and aortic lymphadenectomy. The EORTC Quality of Life Questionnaire-Cancer Module (QLQ-C30) and Quality of Life Questionnaire-Endometrial Cancer Module (QLQ-EN24) were administered to selected patients. All data were recorded and then analyzed using the scoring manual of the EORTC Quality of Life Group.

Results

Among symptom scales, only lymphedema gave a statistically significant difference among two groups, with a score of 10.64 ± 17.43 in Group A and 21.66 ± 24.51 in Group B (p = 0.0285). The p value obtained comparing the “Global Health Status” (items 29 and 30) in Group A and in Group B was not statistically significant.

Conclusion

Lymphadenectomy did not influence negatively global health status, but lymphadenectomy maintained its importance in determining a patient's prognosis and in tailoring adjuvant therapies. We therefore support its practice as part of the surgical procedure in patients affected by high risk endometrial cancer.     

A new prognostic model for FIGO stage 1 epithelial ovarian cancer

BACKGROUND: No consensus exists which patients with surgical stage 1 epithelial ovarian should receive postoperative chemotherapy. The purpose of this study was to evaluate the prognostic impact of preoperative CA-125 and to establish a prognostic index to identify patients in different risk categories. METHODS: Data of 600 surgically staged patients with FIGO stage 1 EOC treated in eleven gynecological cancer centers in Australia, the USA and Europe were analyzed. Eligible patients include those with invasive EOC where a preoperative CA-125 was obtained and standard surgical staging performed. Overall survival (OS) was chosen as study endpoint. Preoperative CA-125 values were compared with other prognostic factors, and univariate and multivariate Cox models were calculated. RESULTS: Two hundred and one patients (33.5%) had preoperative CA-125 < or =30 U/ml and CA-125 levels < or =30 U/ml were associated with lower grade, sub-stage 1A and mucinous histologic cell type. Patients with elevated CA-125 levels were more likely to receive chemotherapy. OS probability was 95% and 85% for patients with pretreatment CA-125 < or =30 U/ml and >30 U/ml, respectively (p 0.003). Multivariate analysis confirmed preoperative serum CA-125 >30 U/ml (OR 2.7) and age at diagnosis >70 years (OR 2.6) as the only independent predictors for overall survival. CONCLUSION: Pretreatment of CA-125 < or =30 U/ml dominates over histologic cell type, sub-stage and grade to identify a subgroup of FIGO stage 1 patients with a genuinely good prognosis with extremely good survival and who could possibly be spared with adjuvant chemotherapy.     

A validation study of a scoring system to estimate the risk of lymph node metastasis for patients with endometrial cancer for tailoring the indication of lymphadenectomy

OBJECTIVE: The aim of this study was to verify whether a preoperative scoring system to estimate the risk of lymph node metastasis (LNM) in endometrial carcinoma is clinically useful for tailoring the indication of lymphadenectomy. STUDY DESIGN: LNM score was set up using volume index, serum CA125 level, and tumor grade/histology, which were found to be independent risk factors for LNM in a pilot study. Based on the LNM score before a validation study was started, the estimated rates of LNM (para-aortic LNM) were 3.4% (0.0%) in a low risk group, 7.7% (5.8%) in an intermediate group, 44.4% (30.6%) in a high risk group and 70.0% (50.0%) in an extremely high risk group. The validation study was carried out using data for 211 patients with endometrial carcinoma for whom three risk factors were preoperatively confirmed. Logistic regression analysis was used to determine whether these factors remain valid. The actual rate of LNM was investigated according to the LNM score. RESULTS: Volume index, serum CA125 level, and tumor grade/histology were found to be independent risk factors for LNM in the cohort of this study. The actual rates of LNM (para-aortic LNM) were 3.2% (1.0%) in the low risk group, 15.3% (11.9%) in the intermediate group, 30.2% (23.8%) in the high risk group and 78.6% (57.1%) in the extremely high risk group. CONCLUSION: The actual rate of LNM for each score was fairly consistent with the estimated rate of LNM. Para-aortic lymphadenectomy may not be necessary in cases of a low risk group. A large prospective multicenter clinical trial needs to be conducted to establish the clinical usefulness of our preoperative scoring system.     

The value of serum albumin as a novel independent marker for prognosis in patients with endometrial cancer

Objective

Hypoalbuminemia, a known marker for malnutrition and increased morbidity and mortality, has been associated with impaired prognosis in different cancer entities. The present study investigates the prognostic value of pre-treatment serum albumin levels for survival in patients with endometrial cancer.

Study design

Within the present cohort study, we evaluated 337 consecutive patients with endometrial cancer and investigated the association of pre-treatment serum albumin levels and clinical-pathological parameters. We performed univariate log-rank tests and multivariable Cox regression models to assess the association between pre-treatment serum albumin levels and survival.

Results

Pre-treatment serum albumin levels were inversely proportionally associated with FIGO tumor stage, histological grade, and patients’ age. In a multivariable analysis pre-treatment serum albumin levels (p = 0.02 and p = 0.001), FIGO tumor stage (p < 0.001 and p < 0.001), and histological grade (p = 0.002 and p < 0.001) were independently associated with disease-free and progression-free survival, respectively.

Conclusion

Pre-treatment serum albumin is a novel and independent prognostic parameter for disease-free and progression-free survival in patients with endometrial cancer.     

A potency of plasminogen activation system in long-term prognosis of endometrial cancer: a pilot study

Objective

Plasminogen activators released from cancer cells lead to degradation of basement membrane proteins and extracellular matrix, and facilitate cancer cell invasion into surrounding tissues and the blood stream. The aim of this study was to evaluate a complex tissue immunohistochemical expression of the plasminogen activation system – urokinase-type plasminogen activator (uPA) and its receptor (uPAR), tissue-type plasminogen activator (tPA) and plasminogen activator inhibitor (PAI)-1 – in endometrial cancer, and to correlate obtained results with disease progression and course.

Study design

The study group was composed of 100 patients classified in three sub-groups according to the FIGO 2010 tumour stratification (G1 = 70, G2 = 19, G3 = 11). Expression of uPA, tPA, uPAR and PAI-1 was examined by means of immunohistochemical staining.

Results

Immunohistochemical expressions of all the studied markers did not differ between G1 and G2 patients. However, G3 subjects were found to have a significantly lower expression of uPA, PAI-1 and tPA. In addition, the patients who survived were found to be PAI-1 negative, while study participants with an unfavourable disease course were PAI-1 positive.

Conclusions

A significantly higher immunohistochemical expression of PAI-1 was found to correlate with shorter relapse-free and overall survival in patients classified as stages IB and II of endometrial cancer.     

Abnormal uterine bleeding and prognosis of endometrial cancer.

OBJECTIVES: The aim of this study was to analyze the relationship between the period of abnormal uterine bleeding (AUB) and the prognosis of endometrial cancer. METHODS: We reviewed 304 endometrial cancer patients who were diagnosed and treated between 1985 and 1998 in our hospital, and whose history of AUB and clinical parameters were clearly available from their charts. Pathological data and overall survival were compared between groups having different periods of AUB. RESULTS: Duration of AUB had no impact on the prognosis of endometrial cancer. Patients diagnosed with endometrial cancer without AUB showed a significantly better 5-year overall survival rate than the patients diagnosed after the onset of AUB. The distribution of clinical stages and histological grades did not differ depending on AUB status. CONCLUSIONS: The prognosis of endometrial cancer was determined by the histopathological character of the tumor. However, the diagnosis and treatment of endometrial cancer with some suspicious signs other than AUB might improve the prognosis.     

Recurrence patterns and surveillance for patients with early stage endometrial cancer

Introduction

To evaluate the recurrence patterns and the clinical and economic role of surveillance with vaginal cytology in women with low risk endometrial cancer.

Methods

Patients undergoing primary surgery with final pathology consistent with a grade 1 endometrial cancer confined to the endometrium (FIGO 1988 stage IA) between 9/1997–12/2007 were retrospectively identified. Follow-up data for at least 2 years was also collected, including diagnosis of a recurrence, symptomatology at that time, and method of detection. Costs for vaginal cytology were estimated using Medicare charge-to-cost ratios adjusted to 2010 costs.

Results

One hundred fifty-four patients met study inclusion criteria. The mean age was 54.4 years and the mean follow-up was 46.9 months. Four recurrences were detected, occurring 16–73 months after the initial diagnosis. During a scheduled visit, one patient was found to have an asymptomatic vaginal cuff recurrence, detected on physical examination. The remaining three cases were diagnosed at an unscheduled visit after the presence of symptoms (vaginal bleeding, abdominal pain, shortness of breath) prompted further evaluation. In all, cytology detected no cases of recurrence and the estimated cost associated with cytology alone for all patients over the study time frame was approximately $7,760 per year.

Conclusions

Patients with grade 1 endometrial cancer confined to the endometrium have a low risk of recurrence (2.6%) and were detected on clinical findings alone. Emphasis should be placed on counseling patients on symptoms of recurrence and performing a thorough physical examination. The elimination of vaginal cytology for this select group of patients may be appropriate and result in a significant reduction in health care costs.