Survival comparison of primary cytoreductive surgery versus interval cytoreductive surgery for the treatment of advanced-stage uterine serous carcinoma

Abstract

Objectives: Uterine serous carcinoma (USC) is a rare but aggressive histologic variant of endometrial cancer that accounts for less than 10% of cases but 80% of endometrial cancer deaths. Initial treatment strategies have remained largely unchanged over the years, with the mainstay of treatment being primary cytoreductive surgery (PCS) followed by adjuvant chemotherapy with or without tailored radiotherapy. More recent strategies have incorporated the use of neoadjuvant chemotherapy (NAC) in certain cases with bulky nodal disease or stage IV disease. This study compares survival outcomes between PCS and neoadjuvant chemotherapy followed by an interval cytoreductive surgery (ICS). Methods: Retrospective data spanning 7 years was collected for patients with stage III or IV USC in a large academic institution. PCS was categorized as initial surgical treatment for stage III or IV disease. This was further stratified into microscopic and bulky disease at the time of surgery. ICS was defined as initial treatment with NAC with interval cytoreductive surgery. Overall survival (OS) and progression free survival (PFS) were calculated for each group with Kaplan-Meier estimation and analyzed using the Chi-Square test. Results: Forty-seven patients were identified to have stage III or IV disease at the time of diagnosis. 35 patients underwent PCS and 12 underwent ICS. The PCS and ICS groups were matched for race, age and BMI. Among the PCS patients, 52% had bulky disease. OS was 82.1 months compared to 40.1 months for PCS and ICS respectively (p=0.23). PFS of PCS patients was 42.9 months compared to 18.1 months of ICS patients (p=0.03). PCS of non-bulky disease, PCS of bulky disease and ICS had OS of 82.1, 40.9, and 31.8 months respectively (p=0.47) while PFS was 42.9, 19.6 and 13.8 months for PCS of non-bulky disease, PCS of bulky disease and ICS respectively (p=0.02). For patients with non-bulky disease and bulky disease, OS was 82.1 vs 40.1 months respectively (p=0.23) while PFS was 42.9 and 18.1 months respectively (p=0.32). Patients with bulky disease who had PCS had an OS of 40.9 months compared to 31.8 months for ICS (p=0.86) and PFS of 19.7 months vs 13.9 months (p=0.13). Conclusions: While no statistical difference in OS was observed between the groups, there was a significant improvement in PFS in the PCS patients compared to ICS patients. PFS was significantly longer after PCS regardless of bulky disease. PFS appears to favor PCS over ICS. This study is limited by the small sample size. Additional studies are needed to better determine optimal treatment strategies for patients with advance stage USC.