Tailored Adjuvant Therapy Research Articles

Accuracy of preoperative tests in clinical stage I endometrial cancer: the importance of lymphadenectomy

To evaluate the accuracy of preoperative tests for endometrial cancer in predicting the need for lymphadenectomy. Retrospective study. Tertiary university hospital. One hundred and eighty-two patients diagnosed with clinical stage I endometrial cancer. Review of medical records of the patients preoperatively diagnosed with stage I disease at Yonsei University Health System between April 2000 and December 2007. Preoperative assessment of the tumor grade, depth of myometrial invasion and lymph node metastases were compared with final pathologic results. Survival was analyzed by Cox multivariate regression analysis. In 104 cases with preoperative tumor grade 1, the final pathology was upgraded in 19 cases (18.3%). MRI correctly differentiated among stage Ia, Ib and Ic disease in 58.2% (106/182) of patients. Of the 166 patients undergoing lymphadenectomy, 20 (12.0%) had retroperitoneal lymph node metastases. The sensitivity and specificity of MRI for detection of lymph node metastases was 45% and 80.8%, respectively. Myometrial invasion (hazard ratio = 17.14, p = 0.037) and lymph node metastases (hazard ratio = 8.94, p = 0.042) were independent prognostic factors for overall survival. Incorrect decisions might be made for a substantial number of patients based on preoperative tests. Full systematic lymphadenectomy is necessary to accurately determine the extent of the disease and to guide correct decision making about tailoring adjuvant therapy, even in patients suspected of early stage disease by preoperative tests.

Multidisciplinary treatment of resectable rectal cancer

This review identifies evidence that influences current practices in the multidisciplinary treatment and shapes future directions in the treatment of resectable rectal cancer. Recent advances in surgery, radiotherapy and systemic chemotherapy have provided measurable improvements in disease control, functional outcomes and quality of life for patients with rectal cancer. However, controversies remain regarding the optimum delivery of adjuvant therapies. Preoperative radiation either with or without concurrent chemotherapy demonstrates lower recurrence, with minimal survival benefit. Currently, the use of neoadjuvant standard fractionation chemoradiation versus short-course radiation without chemotherapy is controversial and under investigation. New combinations of chemotherapeutic agents and targeted therapies are also being evaluated. In addition, criteria for patient selection are being re-evaluated to determine the relative benefit of modern treatments, so that we may better tailor adjuvant therapy recommendations to be patient-specific. Recommendations for adjuvant treatments of rectal cancer are continuing to evolve; however, survival has been only marginally affected despite low incidence of local recurrence. Future trials should aim to address the role of adjuvant therapies utilizing new criteria, such as function, quality of life and impact on development of metastatic disease.

0066 Tailored adjuvant therapy for young women with breast cancer

0066 Tailored adjuvant therapy for young women with breast cancer

The role of lymphadenectomy in the management of preoperative grade 1 endometrial carcinoma

Objective We sought to assess the accuracy of a preoperative grade 1 designation and role of lymphadenectomy in women with preoperative grade 1 endometrial cancer. Methods A retrospective analysis of patients diagnosed with preoperative grade 1 endometrial cancer from 1970 to 2006 was conducted. Inclusion criteria were preoperative grade 1 disease and hysterectomy with or without surgical staging. Results 581 patients who underwent surgery for preoperative grade 1 cancer were identified. Lymphadenectomy was performed in 46%. Pelvic and aortic node metastases were identified in 5.4% and 3.2% patients who underwent lymphadenectomy. 9.7% were upgraded intraoperatively and 25% were upgraded on final pathology with 22% having grade 2 and 3% grade 3 disease. 22.5% with grade 1 disease intraoperatively were upgraded on final pathology, with 21.1% having grade 2 and 1.4% grade 3 disease. 9% had advanced stage disease. 20% of patients with disease limited to the uterus had adverse features including high risk histologic variants, grade 3 disease, myometrial invasion > 1/2, and/or cervical involvement. After adjusting for risk factors there was no significant difference in OS (HR 1.00, p = 0.992) or PFS (HR 0.96, p = 0.815) between the patients who did or did not undergo surgical staging. Conclusion A substantial number of patients with grade 1 endometrial cancer based on preoperative and intraoperative assessments have higher grade disease on final pathology. Although lymphadenectomy does not affect survival in this group it may identify patients with advanced disease and assist in tailoring adjuvant therapy for those with adverse risk factors.

Primary surgery versus chemoradiation in the treatment of IB2 cervical carcinoma: A cost effectiveness analysis

Objectives To estimate the relative cost-effectiveness of treatments for patients with FIGO stage IB2 cervical cancer and no evidence of metastasis as determined by combination of positron emission tomography/computed tomography (PET/CT). Methods A Markov state transition model was constructed to compare two strategies: (1) radical hysterectomy and pelvic lymphadenectomy with tailored adjuvant therapy (RH + TA); (2) primary chemoradiation (CR). Five-year survival estimates for FIGO stage IB2 cervical cancer were obtained from literature. Medicare reimbursement rates and Agency for Healthcare Research and Quality database were used to obtain costs of treatment regimens and grades 3–5 adverse events. Strategies were compared using incremental cost per year of life saved (YLS). Extensive sensitivity analyses were performed. Results Overall survival estimates were 78.9% for CR; 79.6% for RH + TA. Mean cost for CR at 5 years was $21,403 compared to $27,840 for RH + TA. RH + TA cost $63,689 per additional year of life saved (YLS) compared to CR. Results were most sensitive to survival estimates and the costs associated with high dose rate (HDR) versus low dose rate (LDR) brachytherapy. If 90% of patients with intermediate pathologic risk factors at surgery were assumed to receive adjuvant CR, the ICER of RH + TA rose to $100,000 per YLS compared to CR. Conclusions RH + TA is potentially cost effective when compared to CR for patients with stage IB2 cervical cancer without metastatic disease by PET/CT imaging. Key factors in the cost-effectiveness of treatments include physician's expected recommendation of adjuvant therapy, brachytherapy modality employed for primary CR and quality of life related to both treatment and its complications.

Radical hysterectomy and pelvic lymphadenectomy for stage IB2 cervical cancer

Objective. We wished to evaluate survival and adverse outcomes of patients with stage IB2 cervical cancer treated primarily with radical hysterectomy and lymphadenectomy. Methods. A review was performed of all patients undergoing primary radical hysterectomy for stage IB2 cervical cancer at two institutions from 1987 to 2002. Patients were stratified into low, intermediate (Gynecologic Oncology Group protocol 92 criteria), and high-risk (positive nodes, margins, or parametria) groups. Survival and progression-free interval were analyzed using the Kaplan-Meier method and multivariate analysis. Results. Seventy-two patients underwent primary type III radical hysterectomy and lymphadenectomy (72 pelvic, 58 pelvic and paraaortic). Patients were classified as low ( n = 6), intermediate ( n = 49), or high ( n = 17) risk for recurrence. Adjuvant therapy was administered to 94%, 12%, and 0% of the high-, intermediate-, and low-risk groups, respectively. Five-year survival was 72%, while 5-year progression-free survival was 63%. Five-year overall and progression-free survival by risk group were 47% and 40% (high-risk), 80% and 66% (intermediate-risk), 100% and 100% (low-risk). Predictors of survival in multivariate analysis were Caucasian race ( P = 0.001), older age ( P = 0.017), inner 2/3 cervical wall invasion ( P = 0.045), and absence of lymph-vascular invasion ( P < 0.001). Major complications were experienced by 10/72 (13.9%) patients. Among 34 patients who received radiation therapy, two (5.9%) experienced complications attributable to radiation. Conclusions. Radical hysterectomy and lymphadenectomy followed by tailored adjuvant therapy is a reasonable alternative to primary radiotherapy for stage IB2 cervical cancer. Patients with low- and intermediate-risk factors have satisfactory results after primary surgical management. A prospective randomized trial will clarify the optimal mode of initial therapy for patients with stage IB2 disease.