Early-stage Uterine Research Articles

The role of adjuvant treatment for early-stage uterine clear cell carcinomas

BackgroundUterine clear cell carcinoma is a rare and aggressive subtype of endometrial carcinoma. Prospective clinical trials have not been feasible for this rare tumor, and data regarding the optimal adjuvant treatment regimen for early-stage uterine clear cell carcinomas is limited. Our study's objective was to determine if adjuvant chemotherapy or radiation therapy improves patients' outcomes in stage I and II uterine clear cell carcinoma. MethodsPatients with stage I and II uterine clear cell carcinoma were identified at a single institution. All cases were reviewed by a gynecologic pathologist. Both pure and mixed non-serous uterine clear cell carcinomas were included. Primary outcomes were recurrence free survival and overall survival. ResultsA total of 71 patients were identified including 39 (55%) pure and 32 (45%) mixed clear cell carcinoma. Most patients were FIGO stage IA (77.5%). Most patients (n = 58, 82%) received adjuvant therapy, including 43 (61%) receiving chemotherapy, 50 (70%) receiving radiation therapy, and 35 (49%) receiving both. Recurrence free survival was not significantly different among patients receiving no or <6 cycles of chemotherapy versus patients receiving 6 cycles of chemotherapy (p = 0.39). However, median OS was significantly different among patients receiving no or <6 cycles of chemotherapy versus 6 cycles of chemotherapy (p = 0.004). On univariable analysis, 6 cycles of chemotherapy was significantly associated with improved OS (HR 0.1, 95% CI 0.01–0.07). Presence of LVSI, mutated p53, number of pelvic and para-aortic lymph nodes assessed, adjuvant chemotherapy (any number of cycles), and >2 medical co-morbidities were not significant predictors of OS on univariable analysis. On multivariable analysis, 6 cycles of adjuvant chemotherapy remained a significant predictor of improved OS (HR 0.1, 95% CI 0.01–0.8). ConclusionsIn this study, administration of 6 cycles of chemotherapy appears to significantly improve OS. This finding suggests consideration of 6 cycles of adjuvant chemotherapy in patients with early-stage uterine clear cell carcinoma, however clinical trials are needed to confirm these findings.

Impact of Adjuvant Pelvic External Beam Radiotherapy or Vaginal Brachytherapy on Clinical Outcomes for Early-Stage Uterine Carcinosarcoma

<h3>Purpose/Objective(s)</h3> Uterine carcinosarcoma (UCS) is an uncommon but aggressive malignancy with poor prognosis. There is no clear consensus regarding adjuvant radiotherapy (RT) following surgical management for patients (pts) with early stage UCS. We compared outcomes for pts with early stage UCS who underwent adjuvant pelvic external beam RT (EBRT) vs. vaginal brachytherapy (VBT) alone. <h3>Materials/Methods</h3> We conducted an Institutional Review Board-approved single institution retrospective study of 98 pts diagnosed with FIGO stage I-II UCS from 2002 to 2020 and received adjuvant RT, with or without chemotherapy (CT), following definitive surgery. EBRT dose was 45-50.4 Gy alone or followed by VBT boost of 10-18 Gy in 2-4 fractions (fx). Dose for adjuvant VBT alone was 21 Gy in 3 fx or 24 Gy in 6 fx, prescribed to the vaginal surface. We recorded clinical and treatment characteristics and clinical outcomes, including dates and location of progression. Fisher exact tests were used for categorical variables. PFS and OS were analyzed by Kaplan-Meier method and log-rank test. Univariate analyses (UVA) were performed using Cox proportional hazards modeling. <h3>Results</h3> 38 received CT+EBRT, 31 received CT+VBT, and 29 received RT alone (18 EBRT, 11 VBT). Fewer pts in the CT+EBRT and RT-alone groups received nodal sampling compared to pts in the CT+VBT group (<i>P</i>=0.02). Other factors including age, comorbidities, FIGO stage, and pathology were not different between the three groups. Median follow up was 93.5, 50.2, and 143.0 months for CT+EBRT, CT+VBT, and RT-alone groups, respectively. 3-year PFS was 78.7%, 67.6%, and 58.2% for CT+EBRT, CT+VBT, and RT alone, respectively. EBRT+CT significantly improved PFS (P=0.01) compared to RT alone (P=0.01), but not compared to CT+VBT (P=0.22). In terms of locoregional recurrences, 1 pt had a vaginal recurrence and 3 had pelvic nodal recurrences after CT+EBRT. In the CT+VBT cohort, 4 pts had vaginal recurrences, 3 had pelvic nodal recurrences, and 1 had a pelvic soft-tissue recurrence. In the RT-alone group, 1 pt receiving VBT suffered a vaginal recurrence, and 4 pts receiving EBRT had pelvic nodal recurrences. UVA showed that compared to CT+EBRT, RT alone was associated with shorter time to progression (HR 2.50, 95% CI 1.08-5.79, <i>P</i>=0.03) but CT+VBT was not (HR 1.82, 95% CI 0.74-4.50, <i>P=</i>0.20). Other factors including age, stage, nodal sampling, and lymphovascular invasion were not significant on UVA. <h3>Conclusion</h3> In one of the largest retrospective cohorts of early stage UCS, we found adjuvant EBRT+CT improved outcomes compared to RT alone, but not CT+VBT. There were 5 vaginal recurrences in pts undergoing VBT, suggesting that VBT alone at the doses prescribed in this study may not be sufficient. Larger prospective studies and longer follow up are needed to further investigate differences in radiation modalities for the treatment of early-stage UCS. †In Memoriam: LJL, deceased June 23, 2021.

Outcomes and Patterns of Failure in Early-Stage, High-Risk Histology Endometrial Cancer Treated with Vaginal Cuff Brachytherapy

<h3>Purpose/Objective(s)</h3> The majority of patient diagnosed with endometrial cancer have low-risk endometrioid histology with an excellent prognosis. There is a small subset of patients however, who are diagnosed with a histology for which the outcomes are not as good. Serous, clear cell, carcinosarcoma and neuroendocrine carcinomas are more aggressive histological variants with a propensity for early extrauterine spread resulting in higher rates of death. They typically receive upfront chemotherapy but questions remain as to whether the increased risk of spread warrants adjuvant pelvic radiation or whether the risk can be mitigated with vaginal cuff brachytherapy (VCB). We aim to describe the outcomes and patterns of failure in early-stage, high-risk histology patients in which pelvic radiation was omitted, in order to shed light on the risk of pelvic failure. <h3>Materials/Methods</h3> A retrospective chart review was performed on patients treated for high-risk histology, early-stage uterine cancer at our institution. Patients receiving adjuvant VCB +/- chemotherapy were included. Demographic and clinical data was collected. Descriptive statistics were used to summarize variables. Kaplan-Meier analysis was used to estimate the survival probabilities. For all time to event outcomes, univariate cox proportional hazard regression models were built for clinically correlated variables. A two-tailed p<0.05 was considered statistically significant. <h3>Results</h3> 77 patients with early-stage carcinosarcoma (23.4%), clear cell (35.1%), serous (40.3%) and neuroendocrine carcinoma (1.3%) of the uterus were reviewed. Median follow up was 43 months (range 7-117 months). 2yr and 5yr overall survival (OS), metastasis free survival (MFS) and progression free survival (PFS) were 95% and 92%, 95% and 90% and 91% and 82% respectively. Of the 9 patients (11.7%) that recurred, 2 patients (2.6%) had isolated vaginal cuff recurrences, 4 patients (5.2%) had isolated pelvic recurrences and 3 patients (3.9%) had both a local and distant failure. Of the 27 individual sites of recurrence, 21 (77.8%) were below the level of L4. <h3>Conclusion</h3> In patients with early stage, high risk histology endometrial cancer treated with adjuvant VCB +/- chemotherapy, the 2yr and 5yr PFS was 91% and 82% respectively. All patients that recurred had some component of pelvic failure.

Survival after laparoscopy versus laparotomy for apparent early-stage uterine clear cell carcinoma: Results of a large multicenter cohort study.

ObjectiveTo compare the long-term survival between laparoscopic surgery and open surgery in patients with apparent early-stage uterine clear cell carcinoma (UCCC).Patients and methods254 patients with apparent early-stage UCCC were reviewed. Comparisons were made between patients who underwent laparoscopic surgery versus those who underwent open surgery. Baseline data, clinicopathological data, and oncological outcomes were analyzed. 5-year disease-free survival (DFS) rate and 5-year overall survival (OS) rate were estimated and compared using the Kaplan-Meier method and the Log-rank test. The Cox proportional hazard regression model was employed to control the confounding factors.Results147 patients underwent laparoscopic surgery, and 107 patients were managed by open surgery. No differences in terms of recurrence rate (laparoscopy versus laparotomy: 10.9% versus 12.9%, P=0.842) and recurrence pattern were observed. For patients who underwent open surgery and patients who underwent laparoscopic surgery, the 5-year DFS rates and 5-year OS rate were 75.8% (95% CI: 65.8%-83.2%) and 69.1% (95% CI: 58.8%-77.4%), 66.0% (95% CI: 57.1%-73.5%) and 60.8% (95% CI: 52.0%-68.5%), respectively. The Cox proportional hazards regression model shown that for apparent early-stage UCCC, the approach of surgical staging was not an independent predictor for survival (laparoscopy versus laparotomy: for DFS, aHR=1.06, 95% CI=0.64-1.75, P=0.826; for OS, aHR=1.10, 95% CI=0.72-1.68, P=0.671).ConclusionFor apparent early-stage UCCC, in terms of oncological survival, laparoscopic surgery was as safe as open surgery.

The role of adjuvant treatment for early-stage uterine clear cell carcinoma (405)

<b>Objectives:</b> Uterine clear cell carcinoma (UCCC) is a rare histologic subtype of endometrial carcinoma (EC) that is associated with early metastasis, chemoresistance, and poor survival. Due to the aggressive behavior of UCCC and the inability to perform prospective clinical trials for this rare tumor type, adjuvant treatment choices for stage I and II UCCC are often made at the provider's discretion. Our objectives were to determine if adjuvant chemotherapy (CT), radiation therapy (RT), or both were associated with differences in recurrence-free survival (RFS) and overall survival (OS) in stage I and II UCCC confirmed by gynecologic pathology review. <b>Methods:</b> All patients with stage I and II UCCC between 2006 and 2019 were identified via a single institution pathology database. Electronic medical records were used for demographic and clinical- pathologic data. All cases were reviewed by a gynecologic pathologist. Cases of both pure UCCC and mixed non-serous UCCC were included due to prior evidence that mixed UCCC outcomes are driven by the clear cell (CC) component. RFS and OS were analyzed using Kaplan-Meier (KM) failure functions and a Cox proportional hazards (PH) model. <b>Results:</b> A cohort of 71 patients was identified, including 39 (55%) pure UCCC and 32 (45%) mixed UCCC. Most patients were FIGO stage IA (77.5%). Mixed UCCC tumors ranged from 2-90% CC. Among 32 patients with mixed UCCC, 30 (94%) had endometrioid/CC, and two (6%) had endometrioid, CC, and mucinous histology. Of 58 (82%) patients receiving adjuvant therapy, 43 (61%) received CT, 50 (70%) received RT, and 35 (49%) received both. Recurrences were rare, with one local, three regional, and three distant recurrences in the cohort. Deaths were also rare (<i>n</i>=9) and most likely to be cancer-related (<i>n</i>=4). The Median follow-up time was 1078 days. The 5-year RFS was 85% (95% CI: 70-93%) and 5-year OS was 88% (95% CI: 74-94%). 5-year RFS and OS among patients with and without RT were 88% (95% CI: 39-98%) versus 85% (95% CI: 71-93%) and 88% (95% CI: 62-97%) versus 87% (95% CI: 68-95%). 5-year RFS and OS among patients with and without CT were 82% (95% CI: 0.64-0.92) versus 94% (95% CI: 65-99%) and 90% (95% CI: 75-96%) versus 79% (95% CI: 32-95%). There was no difference in RFS among patients receiving no or less than six cycles of CT (<i>n</i>=38) versus patients who received six cycles (<i>n</i>=32) (HR: 0.5, 95% CI: 0.1-2.4). OS was significantly improved for patients who received six cycles of CT versus patients who received no or less than six cycles of CT (HR: 0.1, 95% CI: 0.01-0.7). On univariate analysis, receiving six cycles of CT was predictive of OS. No other variables were statistically significant; however, lymphovascular space invasion and >2 medical comorbid conditions were included in the Cox PH multivariable analysis given their clinical significance. Adjuvant CT remained a significant predictor of improved OS (HR: 0.1, 95% CI: 0.01-0.8) when controlling for these clinically significant factors. <b>Conclusions:</b> In this cohort, OS was significantly improved with six cycles of CT, and CT remained a significant predictor of OS on multivariable analysis. While additional studies are needed, our findings support a full course of adjuvant CT in patients with early-stage UCCC.

Oncological Safety of Laparoscopic Surgery for Women with Apparent Early-stage Uterine Clear Cell Carcinoma: A Multicenter Retrospective Cohort Study

To study the effect of different surgical approaches (laparoscopy and laparotomy) on the oncological outcomes of patients with apparent early-stage uterine clear cell carcinoma (UCCC). Retrospective cohort study. Four Chinese teaching hospitals. A total of 273 women with apparent early-stage UCCC. All included patients were surgically staged by laparoscopy or laparotomy. The eligible patients were divided into the laparotomy group and the laparoscopy group. Disease-free survival (DFS) and overall survival (OS) were evaluated by the Kaplan-Meier method and compared by the log-rank test. The Cox proportional hazards regression model was used to estimate the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the effect of surgical approach on DFS and OS. With a median follow-up of 31.0 months, the 3-year DFS rates were 68.82% and 64.27% in the laparotomy group and the laparoscopy group, respectively. The difference in DFS between the 2 groups was not statistically significant (HR, 1.06; 95% CI, 0.72-1.58; p=.758). In addition, the 3-year OS rate (72.76% vs 73.46%; HR, 1.06; 95% CI, 0.65-1.72; p=.823) was not different between the 2 groups. Furthermore, multivariable analysis showed that for patients with apparent early-stage UCCC, the approach of surgical staging was not an independent prognostic factor for OS (adjusted HR, 1.29; 95% CI, 0.78-2.12; p=.321) and DFS (adjusted HR, 1.11; 95% CI, 0.73-1.68; p=.621). For clinical early-stage clear cell carcinoma of the uterus, staging by laparoscopy is oncologically safe. This needs to be justified by further prospective studies.

Distribution of genetic alterations in high-risk early-stage cervical cancer patients treated with postoperative radiation therapy

Somatic genetic alteration analysis was performed for post-hysterectomy high-risk early-stage uterine cervical cancer patients who underwent post-operative radiation therapy. Post-operative radiation therapy was performed for patients with pathological features of pelvic lymph node metastasis, parametrium invasion, or positive vaginal margin, which corresponded to the post-operative high-risk category. DNA was extracted from paraffin-embedded surgical specimens, and 50 somatic hotspot genetic alternations were detected using Ion AmpliSeq Cancer Hotspot Panel. The existence of actionable mutation was assessed based on OncoKB evidence level > 3A. Between January 2008 and November 2019, 89 patients who underwent abdominal radical hysterectomy followed by post-operative radiation therapy were identified. The follow-up period for living patients was 82.3 months (range 9.3–153.9), and the 5-year relapse-free survival and overall survival rates were 72.6% and 85.9%, respectively. The most frequently detected somatic mutation was PIK3CA (26 [29.2%] patients); however, no prognostic somatic genetic alterations were identified. Actionable mutations were detected in 30 (33.7%) patients. Actionable mutations were detected in approximately one-third of patients, suggesting that precision medicine can be offered to patients with post-operative high-risk uterine cervical cancer in the near future.

Impact of adjuvant therapy on oncologic outcomes in early-stage uterine clear cell carcinoma

Impact of adjuvant therapy on oncologic outcomes in early-stage uterine clear cell carcinoma

Outcomes after Adjuvant Therapy in High-Intermediate and High-risk Early-stage Uterine Carcinoma

Outcomes after Adjuvant Therapy in High-Intermediate and High-risk Early-stage Uterine Carcinoma

Comparison of outcomes in early-stage uterine clear cell carcinoma and serous carcinoma

PurposeThe treatment paradigm for uterine clear cell carcinoma is often linked to serous carcinoma. This study compares oncologic outcomes between women with uterine clear cell and serous carcinoma. Methods and MaterialsWe reviewed 114 women with stage I–II uterine clear cell carcinoma (n = 17, 15%) or serous carcinoma (n = 97, 85%) who underwent hysterectomy and salpingo-oophorectomy at our institution from April 1992 to December 2011; 86 (76%) had stage IA, 14 (12%) had stage IB, and 14 (12%) had stage II disease. Median followup was 57 months. ResultsPatients with uterine clear cell and serous carcinoma did not differ significantly by age ≥60 years, stage, or rate of lymphovascular invasion. There was no difference in the number of patients with clear cell or serous histology who received adjuvant radiotherapy (71% vs. 84%, respectively; p = 0.31); however, significantly fewer patients with clear cell histology received adjuvant chemotherapy (35% vs. 67%, respectively; p = 0.02). At 5 years, there were no significant differences in disease-free survival (94% vs. 84%, respectively; p = 0.27), disease-specific survival (100% vs. 92%, respectively; p = 0.20), or overall survival (100% vs. 89%, respectively; p = 0.34). The differences in chemotherapy utilization did not impact pattern of relapse, specifically peritoneal spread (7% vs. 6%, respectively; p = 0.92) or other distant sites (0% vs. 9%, respectively; p = 0.17). ConclusionsOncologic outcomes and recurrence patterns of women with stage I–II uterine clear cell carcinoma compared favorably with those of women with serous carcinoma, despite significantly less adjuvant chemotherapy use. Potential reduction in adjuvant therapy in women with clear cell carcinoma should be studied prospectively.

Uterine Carcinosarcoma in A Postmenopausal Woman: A Rare Case Report

Uterine carcinosarcomas are rare tumors accounting for about 2–4% of all uterine cancer and with a poor prognosis with 5-year survival of only 21–39%. These are highly aggressive tumors and usually diagnosed with distant metastasis at the initial diagnosis. The origin of this tumor has been studied extensively, and these are now believed to be metaplastic carcinomas. The treatment of the early-stage disease is surgery, and in the late stages the role of adjuvant chemotherapy and radiotherapy is debated. We report here a case of the early-stage uterine carcinosarcoma in a postmenopausal woman.

A 16-year experience with early-stage uterine clear cell carcinoma: Are we overtreating?

A 16-year experience with early-stage uterine clear cell carcinoma: Are we overtreating?

Influence of Comorbidity on the Risk of Death: A Single Institution Study of 1132 Women With Early-stage Uterine Cancer.

The impact of competing medical comorbidity on survival endpoints in women with early stage endometrial carcinoma (EC) is not well studied. The study goal was to utilize a validated comorbidity scoring system to determine its impact on all-cause mortality as well as on recurrence-free survival (RFS), disease-specific survival (DSS), and overall survival (OS) in patients with early-stage EC. For this IRB-approved study, we reviewed our prospectively maintained uterine cancer database of 1720 patients. We identified 1132 patients with EC FIGO stages I-II who underwent hysterectomy from 1984 to 2011. Age-adjusted Charlson Comorbidity Index (AACCI) at time of hysterectomy was retrospectively calculated by physician chart review. The cause of death (uterine cancer-related and unrelated) was correlated with AACCI. Univariate and multivariate modeling with Cox regression analysis was used to determine significant predictors of OS, DSS, and RFS. The Kaplan-Meier and the log-rank test methods were used to evaluate survival outcomes. After a median follow-up of 51 months, 262 deaths were recorded (42 from EC [16%], and 220 [84%] from other causes). Median AACCI score for the study cohort was 3 (range, 0 to 15). On the basis of AACCI, patients were grouped as follows: 0 to 2 (group 1, n=379), 3 to 4 (group 2, n=532), and ≥5 (group 3, n=221). By AACCI grouping, the 5-year RFS, DSS, and OS were 95%, 98%, and 97% for group 1, 89%, 95%, and 87% for group 2, and 86%, 95% and 72% for group 3 (P<0.0001). The cause of death in the first 10 years after hysterectomy in our study was mainly non-uterine cancer-related (78% vs. 22% for uterine cancer-related) causes. On multivariate analyses, higher AACCI, lymphovascular space invasion (LVSI), higher tumor grade, age, and involvement of the lower uterine segment were significant predictors of shorter OS. On multivariate analysis for DSS and RFS, only high tumor grade and LVSI were significant predictors. The cause of death for women with early stage EC is mainly nonuterine cancer-related. Comorbidity score is a significant predictor of OS in our study cohort. Comorbidity scores may be useful as a stratification factor in any prospective clinical trial for women with early-stage EC.

The Impact of Adjuvant Therapy on Survival and Recurrence Patterns in Women With Early-Stage Uterine Carcinosarcoma: A Multi-institutional Study.

The aim of the study was to characterize the impact of adjuvant therapy on survival in women with stage I/II uterine carcinosarcoma after primary surgery. We reviewed records of 118 consecutively treated women with 2009 International Federation of Gynecology and Obstetrics stage I/II uterine carcinosarcoma who underwent hysterectomy between 1990 and 2014 at 4 academic institutions. Patients were categorized by adjuvant treatment group into observation, chemotherapy only, radiation only, and combined chemotherapy and radiation. Survival analyses were conducted using Kaplan-Meier and Cox proportional hazards models. Median follow-up was 28 months (range, 1-244 months). Lymphadenectomy was performed in 94 patients (80%). Postoperative management included observation (n = 37 [31%]), chemotherapy alone (n = 19 [16%]), radiation therapy (RT) alone (n = 24 [20%]), and combined RT and chemotherapy (n = 38 [32%]). Radiation therapy modality included vaginal brachytherapy in 22 patients, pelvic external beam RT in 21 patients, and combination in 19 patients. In 58% of women, chemotherapy consisted of carboplatin/paclitaxel. Median overall survival for all women was 97 months. On univariate analysis, adjuvant treatment group was associated with improved overall survival (hazard ratio [HR], 0.74; confidence interval [CI], 0.58-0.96; p = 0.02), freedom from vaginal recurrence (HR, 0.55; CI, 0.37-0.82]; p = 0.004), and freedom from any recurrence (HR, 0.70; CI, 0.54-0.92; p = 0.01). Pairwise comparisons demonstrated a significant benefit to chemoradiation over other adjuvant treatments. Adjuvant treatment group remained a significant covariate for all 3 end points on multivariate analysis as well. In addition, lymphadenectomy improved overall survival on multivariate analysis (HR, 0.24; CI, 0.09-0.61; p = 0.003). Of patients under observation only who had a recurrence, 8 (44%) of 18 had a recurrence in the vagina as the sole site of recurrence. By contrast, of women who received vaginal brachytherapy, significantly fewer had a recurrence in the vagina (1/42 [2.3%]; p < 0.003, log-rank test). In women with early-stage uterine carcinosarcoma, our data suggest superior survival end points with combined RT and chemotherapy. The frequency of vaginal recurrence suggests a role for incorporating vaginal brachytherapy in the adjuvant management of this disease.

The Impact of Adjuvant Therapy on Survival Endpoints in Women With Early-Stage Uterine Carcinosarcoma: A Multi-institutional Study

The Impact of Adjuvant Therapy on Survival Endpoints in Women With Early-Stage Uterine Carcinosarcoma: A Multi-institutional Study

The Influence of Adjuvant Radiation Therapy Modality on Outcomes for Early-Stage Uterine Carcinosarcoma in a Large Population-Based Cohort

The Influence of Adjuvant Radiation Therapy Modality on Outcomes for Early-Stage Uterine Carcinosarcoma in a Large Population-Based Cohort

Gynecologic cancer outcomes in the elderly poor: A population-based study.

Adults aged ≥65 years who are dually enrolled in Medicare and Medicaid are an at-risk group in health care. However, to the best of the authors' knowledge, the outcomes of women with gynecologic cancers in this population are unknown. The current study was a population-based cohort study of North Carolina state cancer registry cases of uterine, ovarian, cervical, and vulvar/vaginal cancers (2003-2009), with linked enrollment in Medicare and state Medicaid. Outcomes of all-cause mortality and stage of disease at the time of diagnosis were analyzed as a function of enrollment status using multivariate analysis and survival curves. Of 4522 women aged ≥65 years (3702 of whom were enrolled in Medicare [82%] and 820 of whom were dually enrolled [18%]), there were 2286 cases of uterine (51%), 1587 cases of ovarian (35%), 302 cases of cervical (7%), and 347 cases of vulvar/vaginal (8%) cancers. Dual enrollees had increased all-cause mortality overall (adjusted hazard ratio [aHR], 1.34; 95% confidence interval [95% CI], 1.19-1.49), and within each cancer site (uterine: aHR, 1.22 [95% CI, 1.02-1.47]; ovarian: aHR, 1.25 [95% CI, 1.05-1.49]; cervical: aHR, 1.34 [95% CI, 0.96-1.87]; and vulvar/vaginal: aHR, 1.93 [95% CI, 1.36-2.72]). Increased odds of advanced-stage disease at the time of diagnosis among dual enrollees was only present in patients with uterine cancer (adjusted odds ratio, 1.38; 95% CI, 1.06-1.79). Stratified survival curves demonstrated the strongest disparities among women with early-stage uterine and early-stage vulvar/vaginal cancers. Women aged ≥65 years who were dually enrolled in Medicare and Medicaid were found to have an overall 34% increase in all-cause mortality after diagnosis with a gynecologic cancer compared with the non-dually enrolled Medicare population. Women with early-stage uterine and vulvar/vaginal cancers appeared to have the most disparate outcomes. Because these malignancies are generally curable, they have the most potential for benefit from targeted interventions.

Uterine and Ovary Carcinosarcomas

The aim of this study was to assess the outcome and the prognosis factors of uterine and ovarian carcinosarcomas. From January 1993 to January 2010, data from 68 consecutively treated patients with uterine (n=59) and ovarian (n=9) carcinosarcomas were retrospectively analyzed in a single French comprehensive cancer center. The median follow-up was 24.2 months (interquartile range [IQR]: 13.5 to 54.6). The median age was 69 years (IQR: 63 to 77). Patients were classified as FIGO stage I (n=28; 41%) and FIGO stage II to IV (n=40; 59%), respectively. There were 33 (49%) and 29 (43%) homologous and heterologous type, respectively. The median disease-free survival and overall survival were 21.9 months (IQR: 7.9 to 22.3) and 27.1 months (IQR: 14.5 to 72), respectively. No statistical differences of survival were reported concerning the initial location of the carcinosarcoma (uterine vs. ovarian). Radiation therapy (hazards ratio [HR]=0.3; 95% confidence interval [CI], 0.16-0.67) and FIGO stage I (HR=0.4; 95% CI, 0.17-0.9) were associated with an increased disease-free survival. Homologous type (HR=3; 95% CI, 1.4-6.3) and FIGO stage II to IV (HR=2.64; 95% CI, 1.3-5.4) were associated with a decreased overall survival. There was no survival improvement for the 12% of patients receiving a multimodal adjuvant therapy. Uterine and ovary carcinosarcomas present a worse prognosis. On the basis of the present study data, although it should be prospectively confirmed, a sequential or multimodal adjuvant therapy should be proposed to patients with early-stage uterine and ovary carcinosarcomas.

Quantification of delineation errors of the gross tumor volume on magnetic resonance imaging in uterine cervical cancer using pathology data and deformation correction

Background. To safely optimize target volumes using magnetic resonance imaging (MRI) for uterine cervical cancer radiation therapy, MRI findings need to be validated. The aim of this study was to correlate pre-operatively acquired MRI and surgical specimen imaging for uterine cervical cancer patients using deformable image registration and quantify gross tumor volume (GTV) delineation discrepancies.Material and methods. For 16 retrospectively selected early-stage uterine cervical cancer patients, the cervix-uterus structure, uterine cavity and the GTV were delineated on 2D pathology photos after macroscopic intersection and corresponding pre-operatively acquired T2-weighted 2D sagittal MR images. Segmentations of pathology photos and MR images were simultaneously registered using a three-step multi-image registration strategy. The registration outcome was evaluated by the Dice similarity coefficient (DSC) and the surface distance error (SDE). In addition, GTV expansions within the cervix-uterus structure needed to obtain 95% GTV coverage were determined.Results. After three-step multi-image registration, the median DSC and median SDE were 0.98 and 0.4 mm (cervix-uterus) and 0.90 and 0.4 mm (uterine cavity), respectively. The average SDE around the GTV was 0.7 mm (range, 0.1 mm – 2.6 mm). An underestimation of MRI-based GTV delineations was found when no margin was applied, indicated by a mean GTV coverage of 61%. To obtain 95% GTV coverage for 90% of the patients, a minimum 12.0 mm margin around MRI-based GTVs was needed.Conclusion. The presented three-step multi-image registration strategy was suitable and accurate to correlate MRI and pathology data for uterine cervical cancer patients. To cover the pathology-based GTV, a margin of at least 12.0 mm around GTV delineations on T2-weighted MRI is needed.

Gynecologic cancer outcomes of Medicare's elderly poor: A population-based study of North Carolina.

290 Background: Women ≥ 65 years dually enrolled in Medicare and Medicaid (‘Duals’) represent an at-risk group in cancer care, yet their outcomes across the spectrum of gynecologic cancers have not been studied. Our goal was to compare the association of insurance type to stage at diagnosis and mortality of older women after a gynecologic cancer diagnosis. Methods: Population-based, retrospective cohort study of women ≥ 65 years, diagnosed with gynecologic cancers from 2003 – 2009 in North Carolina Central Cancer Registry files. Medicare, Medicaid, and claims from privately insured health plans were linked with census data. Multiple logistic regression, Cox proportional hazard models, and Kaplan Meier survival curves were constructed comparing Medicare, Medicare HMO, and Medicare/Medicaid populations. Results: Among 4,554 patients in the cohort, 3,403 (74%) Medicare+/- supplemental private, 531(11%) Medicare HMO, and 620 (14%) Medicare + Medicaid (Dual). There were 2,215(49%) cases of early stage disease and 1,447(32%) deaths. Dual enrollees had increased mortality rates vs. Medicare overall (HR 1.61, 95%CI:1.4–1.8), and within each cancer site: uterine HR 1.50 (95%CI:1.2-1.9); ovarian HR 1.46 (95%CI:1.1-1.9); cervical HR 1.54 (95%CI:1.0–2.3); and vulvar/vaginal HR 2.84 (95%CI:1.9–4.2). Duals also had increased odds of advanced stage diagnosis in uterine cancer (OR 1.48, 95%CI:1.1–2.0). Stratified survival curves demonstrate the largest disparities amongst women with early stage uterine, advanced stage ovarian, and early stage vulvar/vaginal cancers. Conclusions: Dually enrolled gynecologic cancer patients have a 60% increased mortality rate compared to non-duals despite equivalent stage distribution at the time of diagnosis. Specific site/stage subgroups drive these results and should be the focus of future studies elucidating mediators of these disparate outcomes, including barriers in access to specialty surgical care.