Adjuvant treatment of intermediate-risk endometrial cancer
- Heidi J Gray, MD
Heidi J Gray, MD
- Associate Professor
- Division of Gynecologic Oncology
- Dept of OB/GYN
- University of Washington
- Section Editors
- Barbara Goff, MD
Barbara Goff, MD
- Section Editor — Gynecologic Oncology
- Professor of Gynecologic Oncology
- University of Washington
- Don S Dizon, MD, FACP
Don S Dizon, MD, FACP
- Section Editor – Gynecologic Oncology
- Clinical Co-Director, Gynecologic Oncology
- Founder and Director, The Oncology Sexual Health Clinic
- Massachusetts General Hospital Cancer Center
- Associate Professor of Medicine
- Harvard Medical School
- Arno J Mundt, MD
Arno J Mundt, MD
- Section Editor — Radiation Therapy
- Chairman of Radiation Oncology
- University of California, San Diego
Cancer of the endometrium is the most common gynecologic malignancy in developed countries and the second most common in developing countries. Endometrioid carcinoma is the most common histologic subtype and typically presents at an early stage with abnormal uterine bleeding. It is associated with a good prognosis. Other histologic types of endometrial carcinoma (eg, serous, clear cell) may not present with uterine bleeding and are typically diagnosed at more advanced stages. As a result, these other types are associated with a poorer prognosis.
The stage at diagnosis (table 1) and histologic subtype of endometrial carcinoma are used to assign risk for recurrent or persistent disease into low-, intermediate-, and high-risk. This review will focus on adjuvant treatment for patients with intermediate-risk endometrial cancer. An overview of endometrial cancer, including clinical features and an approach to diagnosis, an overview on the approach to adjuvant treatment, and treatment of low- and high-risk and advanced endometrial cancer are discussed separately.
- Keys HM, Roberts JA, Brunetto VL, et al. A phase III trial of surgery with or without adjunctive external pelvic radiation therapy in intermediate risk endometrial adenocarcinoma: a Gynecologic Oncology Group study. Gynecol Oncol 2004; 92:744.
- Creutzberg CL, van Putten WL, Koper PC, et al. Surgery and postoperative radiotherapy versus surgery alone for patients with stage-1 endometrial carcinoma: multicentre randomised trial. PORTEC Study Group. Post Operative Radiation Therapy in Endometrial Carcinoma. Lancet 2000; 355:1404.
- Nout RA, Smit VT, Putter H, et al. Vaginal brachytherapy versus pelvic external beam radiotherapy for patients with endometrial cancer of high-intermediate risk (PORTEC-2): an open-label, non-inferiority, randomised trial. Lancet 2010; 375:816.
- Creutzberg CL, van Putten WL, Koper PC, et al. The morbidity of treatment for patients with Stage I endometrial cancer: results from a randomized trial. Int J Radiat Oncol Biol Phys 2001; 51:1246.
- Creutzberg CL, Nout RA, Lybeert ML, et al. Fifteen-year radiotherapy outcomes of the randomized PORTEC-1 trial for endometrial carcinoma. Int J Radiat Oncol Biol Phys 2011; 81:e631.
- ASTEC/EN.5 Study Group, Blake P, Swart AM, et al. Adjuvant external beam radiotherapy in the treatment of endometrial cancer (MRC ASTEC and NCIC CTG EN.5 randomised trials): pooled trial results, systematic review, and meta-analysis. Lancet 2009; 373:137.
- Kong A, Johnson N, Kitchener HC, Lawrie TA. Adjuvant radiotherapy for stage I endometrial cancer. Cochrane Database Syst Rev 2012; :CD003916.
- Alektiar KM, Venkatraman E, Chi DS, Barakat RR. Intravaginal brachytherapy alone for intermediate-risk endometrial cancer. Int J Radiat Oncol Biol Phys 2005; 62:111.
- Jolly S, Vargas C, Kumar T, et al. Vaginal brachytherapy alone: an alternative to adjuvant whole pelvis radiation for early stage endometrial cancer. Gynecol Oncol 2005; 97:887.
- Solhjem MC, Petersen IA, Haddock MG. Vaginal brachytherapy alone is sufficient adjuvant treatment of surgical stage I endometrial cancer. Int J Radiat Oncol Biol Phys 2005; 62:1379.
- McCloskey SA, Tchabo NE, Malhotra HK, et al. Adjuvant vaginal brachytherapy alone for high risk localized endometrial cancer as defined by the three major randomized trials of adjuvant pelvic radiation. Gynecol Oncol 2010; 116:404.
- Becker M, Malafy T, Bossart M, et al. Quality of life and sexual functioning in endometrial cancer survivors. Gynecol Oncol 2011; 121:169.
- Creutzberg CL, van Putten WL, Koper PC, et al. Survival after relapse in patients with endometrial cancer: results from a randomized trial. Gynecol Oncol 2003; 89:201.
- Nout RA, Putter H, Jürgenliemk-Schulz IM, et al. Quality of life after pelvic radiotherapy or vaginal brachytherapy for endometrial cancer: first results of the randomized PORTEC-2 trial. J Clin Oncol 2009; 27:3547.
- Randall ME, Wilder J, Greven K, Raben M. Role of intracavitary cuff boost after adjuvant external irradiation in early endometrial carcinoma. Int J Radiat Oncol Biol Phys 1990; 19:49.
- Beriwal S, Jain SK, Heron DE, et al. Clinical outcome with adjuvant treatment of endometrial carcinoma using intensity-modulated radiation therapy. Gynecol Oncol 2006; 102:195.
- Susumu N, Sagae S, Udagawa Y, et al. Randomized phase III trial of pelvic radiotherapy versus cisplatin-based combined chemotherapy in patients with intermediate- and high-risk endometrial cancer: a Japanese Gynecologic Oncology Group study. Gynecol Oncol 2008; 108:226.
- Klopp AH, Jhingran A, Ramondetta L, et al. Node-positive adenocarcinoma of the endometrium: outcome and patterns of recurrence with and without external beam irradiation. Gynecol Oncol 2009; 115:6.
- Alvarez Secord A, Havrilesky LJ, Bae-Jump V, et al. The role of multi-modality adjuvant chemotherapy and radiation in women with advanced stage endometrial cancer. Gynecol Oncol 2007; 107:285.
- Frigerio L, Mangili G, Aletti G, et al. Concomitant radiotherapy and paclitaxel for high-risk endometrial cancer: first feasibility study. Gynecol Oncol 2001; 81:53.
- Greven K, Winter K, Underhill K, et al. Final analysis of RTOG 9708: adjuvant postoperative irradiation combined with cisplatin/paclitaxel chemotherapy following surgery for patients with high-risk endometrial cancer. Gynecol Oncol 2006; 103:155.
- Lupe K, D'Souza DP, Kwon JS, et al. Adjuvant carboplatin and paclitaxel chemotherapy interposed with involved field radiation for advanced endometrial cancer. Gynecol Oncol 2009; 114:94.
- Onda T, Yoshikawa H, Mizutani K, et al. Treatment of node-positive endometrial cancer with complete node dissection, chemotherapy and radiation therapy. Br J Cancer 1997; 75:1836.
- Lupe K, Kwon J, D'Souza D, et al. Adjuvant paclitaxel and carboplatin chemotherapy with involved field radiation in advanced endometrial cancer: a sequential approach. Int J Radiat Oncol Biol Phys 2007; 67:110.
- Hogberg T, Rosenberg P, Kristensen G, et al. A randomized phase III study on adjuvant treatment with radiation (RT) ± chemotherapy (CT) in early stage high-risk endometrial cancer (NSGO-EC-9501/EORTC 55991) (abstract). J Clin Oncol 2007; 25:274s.
- Johnson N, Bryant A, Miles T, et al. Adjuvant chemotherapy for endometrial cancer after hysterectomy. Cochrane Database Syst Rev 2011; :CD003175.
- Parthasarathy A, Kapp DS, Cheung MK, et al. Adjuvant radiotherapy in incompletely staged IC and II endometrioid uterine cancer. Obstet Gynecol 2007; 110:1237.
- Scholten AN, van Putten WL, Beerman H, et al. Postoperative radiotherapy for Stage 1 endometrial carcinoma: long-term outcome of the randomized PORTEC trial with central pathology review. Int J Radiat Oncol Biol Phys 2005; 63:834.
- DEFINITION OF INTERMEDIATE RISK
- Lower uterine segment involvement
- TREATMENT APPROACH
- Low intermediate risk
- High intermediate-risk disease
- - Radiation therapy
- Vaginal brachytherapy
- Pelvic radiation
- Intensity-modulated radiation therapy
- - Chemotherapy
- - Combined modality treatment
- Unstaged intermediate-risk patients
- POSTTREATMENT SURVEILLANCE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS