The efficacy of postoperative vaginal irradiation in preventing vaginal recurrence in endometrial cancer

Between 1960 and 1985 hysterectomy was performed on 811 FIGO stage I and 116 stage II endometrial cancers which were divided into three groups: low-risk stage Ii (grade 1 and 2 lesions confined to the inner third of the myometrium; high-risk stage Iii (grade 3 and/or invading to the middle third of the myometrium or beyond); and FIGO stage II tumors (also high-risk). Hysterectomy was the only treatment in 492; in 145 the vaginal vault alone was radiated and in 290 the whole vagina, in each instance by an intracavity dose of 60Gy; in 34 of the latter high-risk tumors the pelvis received an additional 46Gy by external beam therapy. Forty isolated vaginal recurrences were detected; 10 in 308 low-risk and 22 in 184 high-risk tumors treated by surgery alone, and two and five in 40 low and 105 high-risk patients, respectively, who received adjuvant vault irradiation. No recurrences followed irradiation of the whole vaginal mucosa in 163 stage Ii low-risk and 40 stage II lesions and one, 9 years later, in 87 high-risk stage Iii tumors. Nearly 45% of patients with vaginal recurrence died from cancer within 1 year, 77% within 5 years and only 10% survived their recurrence 10 years. Total vaginal irradiation eliminated vaginal recurrences in low risk and reduced the incidence to 2.1% at 20 years after high-risk tumors.     

Clinical outcomes following 3D image-guided brachytherapy for vaginal recurrence of endometrial cancer

Purpose

To evaluate clinical outcomes for women with recurrent endometrial cancer treated with 3D image-guided brachytherapy

Methods and materials

44 women, of whom 13 had received prior RT, received salvage RT for vaginal recurrence from 9/03 to 8/11. HDR or LDR interstitial brachytherapy was performed under MR or CT guidance in 35 patients (80%); 9 (20%) had CT-guided HDR cylinder brachytherapy. The median cumulative dose in EQD2 was 75.5 Gy. Actuarial estimates of local failure (LF), disease-free (DFS) and overall survival (OS) were calculated by Kaplan–Meier.

Results

Histologic subtypes were endometrioid (EAC, 33), papillary serous/clear cell (UPSC/CC, 5) and carcinosarcoma (CS, 6). The 2-year DFS/OS rates were 75%/89% for EAC and 11%/24% for UPSC/CC/CS (both p < 0.01). On MVA, high tumor grade was associated with recurrence (HR 3.2 for grade 2, 9.6 for grade 3, p < 0.01). The LF rate at 2 years was 4% for patients without versus 39% for those with prior RT (p = 0.1). Patients who had prior RT received lower cumulative doses at recurrence (66.5 Gy vs. 74.4 Gy, p < 0.01). The 2-year DFS/OS rates with and without prior RT were 26%/55% and 72%/80% (both p = 0.1). Four patients (9%) experienced grade 3 late toxicity, including 3 of 13 (23%) in the re-irradiation setting and 1 of 31 (3%) with no prior radiotherapy.

Discussion

3D image-guided brachytherapy results in excellent local control for women with recurrent endometrial cancer, particularly with cumulative EQD2 doses greater than 70 Gy. Successful salvage of vaginal recurrence is related to tumor grade and histologic subtype.     

A randomized trial of open versus closed vaginal vault in the prevention of postoperative morbidity after abdominal hysterectomy

OBJECTIVE: Our purpose was to evaluate the effects of two surgical techniques, closed vaginal vault with two layers of continuous 3-0 polyglactin suture versus open vaginal vault with a locking 3-0 polyglactin suture, after abdominal hysterectomy.STUDY DESIGN: A prospective, randomized trial was performed. During the hospital stay and 4 to 8 weeks after the operation patients were observed for evidence of morbidity.RESULTS: Of the 273 evaluable subjects, 141 had the vaginal vault left open whereas 132 were closed. Ten (7.1%) and eight patients (6.1%) had infections at the operative site (pelvis or abdominal wound) (p = 0.92). A urinary tract infection was diagnosed in three 2.1%) and in four subjects (3.0%) (p = 0.46). A pelvic hematoma developed in two patients of each group (p = 0.66). Vault granulations were recorded in 11% and 12% of subjects (p = 0.97).CONCLUSION: This study failed to show some benefit in favor of either of the two surgical policies. A careful surgical technique and antibiotic prophylaxis seem to remain the most important factors in the prevention of postoperative morbidity.     

Postoperative vaginal vault brachytherapy for node-negative Stage II (occult) endometrial carcinoma

OBJECTIVE: The aim of this study is to look at the efficacy of extended surgical staging and postoperative vaginal vault brachytherapy in patients with Stage II (occult) endometrial carcinoma. METHODS: Between January 1989 and December 1997, there were 30 patients with Stage II (occult) endometrial carcinoma who received postoperative vaginal vault brachytherapy as the only adjuvant treatment. The study group consisted of 15 of these patients who had extended surgical staging (including lymphadenectomy). RESULTS: At a median follow-up of 36 months (range 17 to 113 months), there has been no recurrence. There were no major complications from surgery. Only 1 patient had mild rectal bleeding following vaginal vault brachytherapy and there were no grade 3 or 4 bowel toxicities. CONCLUSIONS: Extended surgical staging and postoperative vaginal vault brachytherapy for Stage II (occult) endometrial carcinoma is associated with minimal morbidity and excellent survival.     

Surgical pathologic staging in apparent stage I endometrial carcinoma

A multicenter trial on apparent stage I endometrial carcinoma was performed to establish an intensive surgical staging, to formulate a treatment on the basis of the pathological extent of the disease and to determine the effectiveness of adjuvant medroxyprogesterone acetate therapy. The results of the first objective on 1,055 patients are herein reported. All patients had total abdominal hysterectomy, bilateral salpingo-oophorectomy, colpectomy of the superior third, and biopsy of lymph nodes positive or doubtful at radiological imaging or on surgical inspection. On the basis of the pathologic extent of the disease, patients were classified into five categories: disease outside the uterine corpus (RE); disease limited to endometrium (RO); disease with inner myometrial invasion and high or moderate grade (R1); disease with deep myometrial invasion or poor differentiation (R2); disease with positive retroperitoneal nodes (R3). One hundred and forty-six patients were RE, 163 RO, 382 R1, 341 R2 and 23 R3. The results showed a clinical understaging in 16% of the cases. According to the new FIGO classification, the relapse-free survival at 84 months was 96% for patients at stage IA, 92% for patients with stage IB-C, 86% for stage IIA-B, 76% for stage IIIA-B and 74% for patients at stage IIIC. These data confirm the importance of an intensive surgical staging in apparent stage I endometrial carcinoma.     

Salvage of isolated vaginal recurrences in women with surgical stage I endometrial cancer: a multiinstitutional experience

The objective of this study was to evaluate the treatment outcomes and risk factors of women with surgical stage I endometrial adenocarcinoma who were initially treated with surgery alone and subsequently developed isolated vaginal recurrences. Patients with surgical stage I endometrial adenocarcinoma diagnosed from 1975 to 2002 were identified from tumor registry databases at seven institutions. All patients were treated with surgery alone including a total hysterectomy, bilateral salpingo-oophorectomy, pelvic (+/- para-aortic) lymph node dissection, and peritoneal cytology and did not receive postoperative radiation therapy. Vaginal recurrences were documented histologically. Metastatic disease in the chest and abdomen was excluded by radiologic studies. Overall survival was calculated by the Kaplan-Meier method. Sixty-nine women with surgical stage I endometrial cancer with isolated vaginal recurrences were identified. Of the 69 patients, 10 (15%) were diagnosed with stage IA disease, 43 (62%) were diagnosed with stage IB disease, and 16 (23%) were diagnosed with stage IC disease. Patients diagnosed with grade 1 disease were 22 (32%), grade 2 disease were 26 (38%), and grade 3 disease were 21 (30%). Among women, 81% with isolated vaginal recurrences were salvaged with radiation therapy. The mean time to recurrence was 24 months, and the mean follow-up was 63 months. Among women, 18% died from subsequent recurrent disease. The 5-year overall survival was 75%. The majority of isolated vaginal recurrences in women with surgical stage I endometrial cancer can be successfully salvaged with radiation therapy, further questioning the role of adjuvant therapy for patients with uterine-confined endometrial cancer at the time of initial diagnosis.     

Salvage treatment with high-dose-rate brachytherapy for isolated vaginal endometrial cancer recurrence

OBJECTIVE: To evaluate the outcome of patients with recurrent vaginal endometrial cancer treated with high-dose-rate brachytherapy (HDRB) and external beam radiation therapy (EBRT). MATERIALS AND METHODS: The records of all patients diagnosed with endometrial cancer who had presented an isolated vaginal recurrence in our institution between January 1, 1997 and December 30, 2003 were reviewed. Twenty-two patients were identified; 18 (82%) received both EBRT and HDRB, and 4 (18%) received HDRB only. The median EBRT dose prescribed was 45 Gy (range: 44-50.4), and median HDRB was 26 Gy (range: 8-48). Recurrence-free intervals as well as disease-specific survival rates were noted. Complications were assessed in terms of early and late Radiation Therapy Oncology Group toxicity (grade 3 or worse) of the gastrointestinal tract, genitourinary tract and vagina. RESULTS: Median age at recurrence for the 22 patients was 72 years (range: 54-86). Median recurrence time was 20 months (range: 4-135). A complete response was achieved in 100% of patients. After a median follow-up of 32 months (range: 11-78), no patient had locoregional recurrence; 1 developed distant metastasis and died from the disease. Five-year local control, disease-free survival and disease-specific survival were 100%, 96% and 96%, respectively. Four patients (18%) presented grades 3-4 gastrointestinal toxicity, and 11 (50%), grade 3 vaginal toxicity. CONCLUSION: Recurrent vaginal endometrial cancer is amenable to salvage therapy with HDRB and EBRT.     

Laparoscopic-assisted vaginal hysterectomy versus abdominal hysterectomy in patients with stage I and II endometrial cancer

The purpose of this study was to evaluate and compare the outcomes of laparoscopic surgery with those of conventional abdominal surgery in patients with early endometrial cancer. From 1997 to 2003, 79 patients underwent laparoscopic-assisted vaginal hysterectomy with or without lymphadenectomy. Laparoscopy was performed on patients deemed clinical stage I in preoperative studies. Of the 79 patients, 74 found to be surgical stage I or II were enrolled in the comparative study. As a control group, we selected 168 laparotomy cases at the same disease stage as the laparoscopy group. Operation time, amount of blood transfusion, and hemoglobin changes were similar for both groups. In the laparoscopy group, the number of lymph nodes obtained was significantly higher, and the number of postoperative complications was lower compared to the laparotomy group. The hospital stay was significantly shorter for laparoscopy group. Three-year recurrence-free survival rates were similar, being 97.5% for the laparoscopy group and 98.6% for the laparotomy group. We conclude that laparoscopic surgery for treatment of early endometrial cancer is a safe and effective alternative to laparotomy in terms of perioperative complications. Three-year recurrence-free survival did not differ significantly between the groups. However, long-term survival and risk of recurrence have yet to be determined.     

Prevention of vaginal recurrence of stage I endometrial adenocarcinoma with postoperative vaginal radiation

From 1975 to 1982 a prospective study was conducted at Roswell Park in 68 patients (group 1) for surgical stage I endometrial cancer, grade 1 or 2, and less than 50% myometrial invasion. These patients were treated by total abdominal hysterectomy, bilateral salpingo-oophorectomy, and postoperative vaginal radium. With median follow-up of 4.8 years, there has not been a single vaginal recurrence. This treatment plan was based on a prospective study at the same institute from 1958 to 1967, which compared patients with stage I endometrial cancer treated by hysterectomy alone, preoperative radium followed by hysterectomy, and hysterectomy followed by postoperative radium. In addition, 19 patients (group 2) were evaluated as to their initial treatment after their referral to Roswell Park with vaginal recurrence after surgical treatment for stage I endometrial cancer. None of these patients were treated initially with postoperative vaginal radium after hysterectomy. Based on the zero incidence of vaginal recurrence in 117 patients with FIGO stage I endometrial cancer, the estimated five-year survival rate of 97.2% for the group 1 patients, and the actuarial five-year survival of 95% in the 1958 to 1967 prospective study, it is concluded that primary surgery should be followed by postoperative vaginal radium (cesium) in those patients with stage I endometrial cancer, grade 1 or 2, with less than 50% myometrial invasion.     

Uterosacral ligament fixation for vaginal vault suspension in uterine and vaginal vault prolapse

OBJECTIVE: The purpose of this study was to determine the simplicity, safety, anatomic, and functional success of using the uterosacral ligaments for correction of significant complex uterine and vaginal vault prolapse by the vaginal route. STUDY DESIGN: Fifty women with uterine or vaginal vault prolapse with descent of the cervix or the vaginal vault to the introitus or greater were treated between 1993 and 1996 by the same surgeon with bilateral uterosacral ligament fixation to the vaginal cuff by the vaginal route. Included were patients with significant enterocele, cystourethrocele, rectocele, and stress urinary incontinence who had concomitant repair of coexisting pelvic support defects. An etiology of vaginal vault prolapse is discussed. RESULTS: Uterosacral ligaments were identified and used for successful vaginal vault suspension by the vaginal route in all 50 consecutive patients without subsequent failure or significant complications with a maximum follow-up of 4 years. One patient had recurrent stress urinary incontinence and two had asymptomatic cystoceles. Three patients had erosion of monofilament sutures at the vaginal apex. CONCLUSIONS: In these 50 patients with significant complex uterine or vaginal vault prolapse, uterosacral ligaments could always be identified and safely used for vaginal vault suspension by the vaginal route with no persistence or recurrence of vaginal vault prolapse 6 to 48 months after surgery. Excessive tension by the surgeon on tagged uterosacral ligaments at the time of hysterectomy may be an etiologic factor in vaginal vault prolapse.(Am J Obstet Gynecol 1997;177:44)     

子宫内膜样腺癌术后辅助放化疗的临床观察

目的评价有高危因素的子宫内膜样腺癌术后辅助放化疗的价值。方法选择宫颈侵犯、G3级、深肌层浸润、淋巴脉管侵犯、腹水细胞学阳性等高危因素的子宫内膜样腺癌268例,140例接受术后放疗,128例接受术后放化疗,比较两组的5年生存率。结果术后辅助放疗和术后辅助放化疗的5年生存率分别为92．14％和92．19％,两者比较,差异无统计学意义（P〉0．05）。而两组的毒性反应比较,术后辅助放化疗组的毒性反应明显增加（P〈0．05）。结论术后辅助盆腔放疗加化疗不能提高具有高危因素的子宫内膜样腺癌的5年生存率,且毒性反应明显增加。     

Postoperative vaginal brachytherapy alone is the treatment of choice for grade 1–2, stage IC endometrial cancer

The aim was to determine outcome and toxicity in grade 1-2, FIGO stage IC endometrial cancer patients treated with external beam radiotherapy plus vaginal cuff brachytherapy or vaginal cuff brachytherapy alone. Between 1986 and 1999, a total of 132 patients were diagnosed with FIGO stage IC endometrial carcinoma. The median age was 67.5 years (range, 36-88). Median follow-up was 54 months (range, 6-157). Grade 1 disease was present in 64 patients, grade 2 in 45 patients, and grade 3 in 23 patients. Patients with grade 3 disease usually received external radiotherapy and were excluded from this analysis. Of the patients with grade 1-2 disease, 31 received brachytherapy alone and 78 received both external radiotherapy and brachytherapy. Ten (8%) patients experienced failure. Isolated pelvic relapse occurred in five patients. Three patients experienced both distant and local relapse. Two patients had isolated distant relapse. Nine failures occurred in patients treated with both external radiotherapy and brachytherapy. Only one failure occurred in those treated with brachytherapy alone. Overall survival and disease-free survival at 5 years were 85% and 92%, respectively. For those treated with both external radiotherapy and brachytherapy, 5-year locoregional control was 95%. For those treated with brachytherapy alone, 5-year locoregional control was 96.4%. There was no significant survival or local control difference between the two groups. Nine patients (9%) treated with both external radiotherapy and brachytherapy developed Radiation Therapy Oncology Group grade 3-4 toxicity. No patient treated with vaginal cuff brachytherapy alone developed grade 3-4 toxicity (P < 0.001). In patients with well-differentiated (grade 1-2) stage IC endometrial cancer, external beam radiotherapy plus brachytherapy versus vaginal cuff brachytherapy alone achieved equivalent local control and survival. However, vaginal cuff brachytherapy alone produced significantly less toxicity.     

Disease-free survival after vaginal vault brachytherapy versus observation for patients with node-negative intermediate-risk endometrial adenocarcinoma

PurposeTo compare the disease-free survival (DFS) of patients with surgical stage 1, intermediate-risk endometrial adenocarcinoma (EAC) treated with primary surgery with or without adjuvant vaginal vault brachytherapy (VVBT).Patients and methodsA retrospective chart review identified 575 patients with stage 1B, 1C or 2A endometrial cancer who had surgery between 1990 and 2004. All patients were surgically staged and 259 patients received postoperative VVBT. The date and site of first recurrence were considered the primary statistical endpoints and were analysed by univariate and multivariate Cox models. Subgroups of patients stratified by substage and grade were created and Log-rank tests using vaginal recurrence as the endpoint were calculated within these groups.ResultsAfter a mean follow-up period of 72 months (95%-confidence interval (CI): 68 to 75 months) a total of 43 (7.5%) patients developed recurrence. Multivariate analysis demonstrated that increasing patient's age at diagnosis and stage 1C or 2A disease were independent risk factors for recurrence whereas the grade of differentiation and the type of treatment (surgery alone vs. surgery followed by postoperative VVBT) were not associated with a change in DFS. Analysis within the subgroups stratified by substage and grade did not even reveal a trend towards improved local control with VVBT.ConclusionPostoperative VVBT was not associated with a measurable reduction in the risk of recurrence in surgical stage 1, intermediate-risk endometrial cancer.     

The clinical significance of malignant peritoneal cytology in stage I endometrial carcinoma

The prevalence of malignant peritoneal cytology in patients with International Federation of Obstetrics and Gynecology (1971) stage I endometrial carcinoma and its predictive value for recurrence of disease following hysterectomy were analyzed by numerically pooling the crude results of independent studies. Malignant cytology occurred in 8.3, 12.1 and 15.9% of patients with grade 1, 2 and 3 histology, respectively, and in 7.6% and 17.2% of patients with superficial and deep myometrial invasion, respectively. Prevalence was heterogeneous in the groups with grade 1 histology, grade 2 histology and superficial invasion, and homogeneous in the groups with grade 3 histology and deep invasion. This, together with a technical false positive rate of approximately 5% in the diagnosis of malignant cytology, suggests that the pooled values of prevalence for the low grade and superficially invasive groups may be overestimated. Malignant cytology was strongly associated with disease recurrence (pooled odds ratio of 4.7 with a 95% confidence interval of 3.5–6.3). Qualitative review of the literature suggests that this is largely due to the association of malignant cytology with other adverse prognostic factors which dominate the clinical course of the disease. In the absence of other adverse prognostic factors, the true prevalence of malignant cytology is low. This limits the clinical utility of cytology as an independent predictor of either overall recurrence or site of recurrence. Routine adjuvant treatment of patients with malignant cytology is therefore not justified.     

Omentectomy, peritoneal biopsy and appendectomy in patients with clinical stage I endometrial carcinoma

Abstract. Saygili U, Kavaz S, Altunyurt S, Uslu T, Koyuncuoglu M, Erten O. Omentectomy, peritoneal biopsy, and appendectomy in patients with clinical stage I endometrial carcinoma.
The aim of this study was to evaluate whether omentectomy, appendectomy, and peritoneal biopsy should be a routine part of staging surgery in endometrial carcinoma. Data of 97 patients who had been diagnosed with clinical stage I endometrial carcinoma were reviewed. Associations in the data obtained, pelvic and para-aortic lymph node status, depth of myometrial invasion, grade, and histology were investigated. The chi-square (χ²) test was used for statistical analysis.
Of 97 patients, six (6%) had omental metastases, which was microscopic in four. There was a statistically significant relationship between omental metastasis and tumor grade ( P < 0.01). Deep myometrial invasion was significantly more common in patients with omental metastases. Tumor was found in one of 55 appendectomy specimens (2%). Omentectomy may be included in surgical staging in patients with deeply invasive or grade 3 endometrial cancer because of the possibility of omental metastasis in spite of what appears to be stage I disease in laparotomy. In other cases, omentectomy and appendectomy and biopsies from peritoneal sites should be performed in the presence of grossly suspicious disease.     

Surgical cytoreduction in stage IV endometrioid endometrial carcinoma

Objective

To evaluate the role of surgical cytoreduction and the amount of residual disease in patients with newly diagnosed stage IV endometrioid endometrial carcinoma (EC).

Methods

Patients with stage IV EC of endometrioid histology who underwent surgery at our institution from 1977 to 2003 were identified. Patients with microscopic stage IV disease were excluded. Progression-free survival (PFS) and overall survival (OS) were estimated using Kaplan Meier method and compared with log-rank test.

Results

A total of 58 patients were identified, of which 9 (15.5%) had no gross residual (NGR) after surgery, 11 (19.0%) had residual disease ≤ 1 cm, 32 (55.1%) had residual disease > 1 cm, and 6 (10.3%) had no cytoreduction attempted. The median PFS was 11.1 months (95% CI, 9.8-12.3) and the median OS was 19.2 months (95% CI, 8.5-29.9) for the cohort. The median PFS was 40.3 months (95% CI, 0-93.9) for patients with NGR disease, 11 months (95% CI, 9.9-12.1) for patients with any residual disease, and 2.2 months (95% CI, 0.1-4.2) for patients who did not have attempted cytoreduction (P < 0.001). The median OS was 42.2 months (95% CI, not estimable) for patients with NGR disease, 19 months (95% CI, 13.9-24.1) for patients with any residual disease, and 2.2 months (95% CI, 0.1-4.2) for patients that did not have attempted cytoreduction (P < 0.001).

Conclusion

Though stage IV endometrioid EC has a poor prognosis, surgical cytoreduction to no gross residual disease in a highly select group of patients is associated with improved survival.     

Pathologic stage III endometrial cancer treated with adjuvant radiation therapy

Gerszten K, Faul C, Huang Q. Pathologic stage III endometrial cancer treated with adjuvant radiation therapy. Int J Gynecol Cancer 1999; 9: 243–246.
This study was undertaken to evaluate the outcome of pathologic stage III endometrial carcinoma treated with adjuvant radiation therapy (RT). A retrospective review was performed on 32 patients receiving adjuvant RT following abdominal hysterectomy for stage III endometrial carcinoma (19 IIIA, 2 IIIB, 11 IIIC) between 1980 and 1996. Papillary-serous and clear cell adenocarcinomas were excluded. Pathologic nodal sampling was performed on 25 patients (78%). All patients received postoperative external beam RT to the pelvis and 25 of 32 received an additional brachytherapy boost to the vaginal apex. Three patients with involved para-aortic nodes received extended field RT. Mean follow up was 70 mos. Twenty-four patients remain disease-free at mean follow-up of 68 mos. Distant recurrence (DR) occurred in 7 patients at mean of 38 mo. Two local failures were associated with DR. Six patients died of disease after recurrence despite salvage systemic therapy. One patient developed isolated local failure (vaginal apex) and remains disease-free 37 mo after surgical/chemotherapeutic salvage. 5 of 8 (45%) stage IIIC patients developed recurrence vs. only 2 of 19 (10%) stage IIIA cases. 2 of 3 patients treated with extended field RT for positive para-aortic nodal disease remain disease-free at 128 and 56 mo. Long-term survival can be achieved in stage III endometrial carcinoma. Few patients with either adnexal metastases or positive cytology alone develop recurrence. However, patients with stage IIIC disease fare poorly with local therapy alone .     

Predictive factors of recurrence following adjuvant vaginal cuff brachytherapy alone for stage I endometrial cancer

Purpose

The purpose of this study is to identify risk factors for recurrence in a cohort of stage I endometrial cancer patients treated with vaginal cuff brachytherapy at a single academic institution.

Methods and materials

From 1989 to 2011, 424 patients with stage I endometrial cancer underwent total hysterectomy and bilateral salpingo-oophorectomy, with or without lymphadenectomy (LND), followed by high-dose-rate vaginal cuff brachytherapy (VCB) to patients felt to be high or intermediate risk FIGO stage IA and IB disease. Covariates included: 2009 FIGO stage, age, grade, histology, presence of lymphovascular space invasion, LND, and receipt of chemotherapy.

Results

With a median follow-up of 3.7 years, the 5 and 10-year disease free survival were 98.4% and 95.9%, respectively. A total of 30 patients developed recurrence, with the predominant pattern of isolated distant recurrence (57.0%). On multivariate analysis, grade 3 (p = 0.039) and LND (p = 0.048) independently predicted of increased recurrence risk. χ² analysis suggested that higher-risk patients were selected for LND, with significant differences in age, stage, and grade noted between cohorts. Distant metastatic rate was significantly higher for patients who qualified for GOG 0249 at 23.1% (95% CI 10.7–35.5%) compared to those who did not at 6.8% (95% CI 1.8–11.8%, p < 0.001).

Conclusion

Overall disease-free survival for this cohort of patients was > 95% at 10 years. Univariate analysis confirmed previously identified risk factors as predictors for recurrence. Multivariate analysis found that grade 3 and LND correlated with risk for recurrence. Of those that did recur, the initial site of relapse included distant metastasis in most cases.     

The role of vaginal hysterectomy in the treatment of endometrial carcinoma

Between 1964 and 1991, vaginal hysterectomy was performed in 60 patients with clinical stage I endometrial carcinoma, who were not considered candidates for the conventional surgical approach. Of these patients, 66.7% were obese with a median weight of 235 pounds. Other risk factors included hypertension (63%), diabetes mellitus (34%), cardiac disease (28%) and pulmonary disease (12%). Operative mortality was 0%. The complication rate was 14%, with four patients requiring transfusions and four patients developing vaginal cuff cellulitis. Forty per cent of patients received adjuvant pre- or postoperative radiation therapy. Crude survival at 5 and 10 years was 91.1% and 87.1%, respectively. However, only one patient died from disease 6 years after primary treatment. Although we consider surgical staging as the standard of care for the treatment of endometrial cancer, vaginal hysterectomy has a definite place in the management of patients with good prognostic criteria who are at high operative risk for the standard surgical approach.