Isolated vaginal recurrences in women with stage I endometrial cancer

Abstract

<h3>Objectives:</h3> To compare clinical and pathologic characteristics of women with surgical stage I endometrial cancer by location of first recurrence; to describe characteristics of isolated vaginal recurrence. <h3>Methods:</h3> All women with surgical stage I endometrial carcinoma treated at two major cancer centers from 2009-2017 were identified. Surveillance was done at standard intervals and consisted of symptom assessment and pelvic exam. Imaging was ordered as clinically indicated. Appropriate statistical analyses were used to compare isolated with extra-vaginal recurrences. Vaginal recurrence in the presence of other sites of disease were included in the extra-vaginal recurrence group. <h3>Results:</h3> 2817 women were analyzed. Median age at diagnosis was 61 years (range 26-92 yrs). At a median follow-up of 36 months (range, 0-139 mos). 280 (10%) recurred: 61 (2%) isolated vaginal, 219 (8%) extra-vaginal (which included 18 cases with a vaginal component). Of the 61 isolated vaginal recurrences, 42 (69%) were located at the cuff, 19 (31%) along the vaginal canal (Figure 1). All isolated recurrences were clinically detected on exam, except for 1 (2%) detected by imaging; endometrioid histology and Grade II were the most common findings (85% and 44%, respectively).Median time to recurrence after initial diagnosis for isolated vaginal recurrence was 11 months (range, 1-68 mos); for extra-vaginal recurrence, 20 months (range, 1-98 mos) (p<0.01). From initial diagnosis to first recurrence, 3-year PFS was 89.8% (SE±0.7) for minimally invasive surgery (MIS), 88.3% (SE±2.0) open approach (p=0.7). 3-year PFS for isolated vaginal recurrence was 97.8% (SE±0.3) MIS, 97.1% (SE±1.0) open (p=0.8). 3-year PFS for extra-vaginal recurrence was 91.9% (SE±0.6) MIS, 90.9% (SE±1.8) open (p=0.8).280 (10%) of the 2817 patients recurred. Those with extra-vaginal recurrences were more likely than those with isolated vaginal recurrences to receive IVRT (64% vs 33%, p<0.01). 153 (5%) patients received non-IVRT-based treatment, of whom 5 (3%) had isolated vaginal recurrences. 1698 (60%) received no adjuvant treatment; 36 (2%) of these had isolated vaginal recurrences.Of the 557 (20%) treated with IVRT alone postoperatively, 73 (13%) recurred with 13 (2%) having isolated vaginal recurrence. The majority recurred at the vaginal apex (77%). Compared with extra-vaginal recurrences, isolated recurrences were more likely to be endometrioid (85% vs 54%, p<0.01), to have <50% myoinvasion (62% vs 48%, p=0.04), to have no LVSI (72% vs 55%, p<0.05), and were less likely to have Grade 3 histology (16% v 62%, p<0.01). <h3>Conclusions:</h3> Isolated vaginal recurrences in stage I endometrial cancer are detected earlier than non-vaginal recurrences, likely due to frequency of clinical exams after initial staging surgery. Surgical approach does not seem to impact overall or isolated recurrence. Adjuvant IVRT alone after primary surgery carries a 2% risk of isolated cuff recurrence.