Outcome and pattern of failure in pathological stage I-II papillary serous carcinoma of the endometrium: implications for adjuvant radiation therapy

Abstract

Purpose/Objective: Papillary serous (PS) carcinoma of the endometrium is known to have a poor prognosis with a high rate of recurrence. Most patients present with advanced stage (FIGO stage III-IV) tumors and there is little information on outcome and optimal treatment of women with early stage disease. Patients with early stage disease are often grouped with advanced disease patients and treated with whole abdomen radiation therapy (WART) +/- chemotherapy in prior studies. Furthermore, most studies that have analyzed early stage disease have grouped PS with clear cell histology. As a result, the optimal management of these patients remains less defined. The purpose of this study is to evaluate the outcome and patterns of failure in women with pathological stage I-II PS carcinoma and discuss the implications for adjuvant radiation therapy (RT). Materials/Methods: Between 1990 and 2001, 868 endometrial carcinoma patients underwent primary surgery at our institution. Sixty-eight had papillary serous histologies, among which 23 (2.7%) had pathological stage I-II disease. All underwent TAH-BSO and assessment of peritoneal cytology. None received preoperative RT. Pelvic and para-aortic lymph node sampling were preformed in 12 and 8 patients, respectively. FIGO stages were: 3 IA, 8 IB, 6 IC, 5 IIA, and 1 IIB. The depth of myometrial invasion included: 3 none, 10 ≤1/2, and 10 >1/2. Cervical involvement was present in 6 patients. Adjuvant therapies included: 9 none, 10 RT (6 whole pelvic, 1 vaginal brachytherapy, 3 whole pelvic + vaginal brachytherapy), 4 chemotherapy (3 alone and 1 following whole pelvic RT), and 1 hormonal therapy alone. No patient received WART or para-aortic RT. Median follow-up was 38.7 months (range, 3-109 months). Results: The 5-year actuarial disease-free (DFS) and cause-specific (CSS) survivals for the entire group were 44% and 73.6%, respectively. Age, stage, and depth of myometrial invasion were not correlated with disease relapse. The overall failure rate was 35% (8/23). Five patients (22%) failed in the pelvis of which four relapsed in the vagina alone. There were no pelvic failures in patients treated with adjuvant RT. The 5-year actuarial pelvic recurrence rate was 27.5% and was 42.5% among the 13 women who did not receive RT compared with 0% among the 10 who did receive RT (p=0.06). Of note, patients treated with adjuvant RT had higher stage disease (p=0.02). Only 2 patients (8.7%) failed in the abdomen and both had a simultaneous distant recurrence. None had an isolated abdominal failure. The overall distant failure rate was 22% (5/23) and 4 of the failures occurred in patients who did not receive chemotherapy. Conclusions: Pathological stage I-II papillary serous carcinomas comprise a small percentage of patients with endometrial cancer. Although these women have organ-confined disease, recurrence is common particularly in the pelvis and distant sites. However, pelvic failure was effectively reduced by adjuvant pelvic RT. Unlike traditionally thought, abdominal recurrence was rare in our patients despite not delivering WART. The high rate of distant failure supports the use of chemotherapy. Our results suggest that the optimal approach to these patients is pelvic RT plus chemotherapy.