Stage II endometrioid adenocarcinoma of the endometrium: Clinical implications of cervical stromal invasion
Introduction
Endometrial cancer is the most common female gynecologic cancer in the United States, and the second most common among women living in the Western world [1]. The International Federation of Gynecology and Obstetrics (FIGO) introduced a major modification to the staging system in endometrial cancer 20 years ago, changing it from a clinical to a surgical staging system. Parameters included are depth of myometrial invasion, cervical involvement as well as extrauterine extension [2]. Other parameters not related to staging but that have also been proved to have prognostic significance include histologic grade, histologic type, lymphovascular invasion among others [2]. While patients with low-grade endometrial cancers confined to the uterine corpus (Stage I) usually have good prognosis with an estimated 5-year survival rate exceeding 90%, in patients with high grade tumors or with tumors showing deep myometrial and/or lymphovascular invasion the 5-year survival rates may be as low as 40% [3], [4], [5], [6].
In approximately 10% of patients, endometrial carcinoma (6–20% in different series) involves the uterine cervix. These patients have an estimated 70% 5-year survival rate [7]. However, there is a relative lack of consensus as to what represents the most appropriate management strategy for these patients; simple extrafascial vs radical hysterectomy; role and type of radiation therapy (brachytherapy alone, teletherapy alone, teletherapy and brachytherapy combined), and use of pre-operative radiation therapy for occult Stage II disease. The literature is flawed with controversy, largely because: 1) most studies are retrospective and have included patients whose tumors were not comprehensively staged to fulfill FIGO criteria; 2) studies have been often multi-centered; and 3) they have included patients with clinical but not surgical Stage II tumors. The infrequent occurrence of cervical involvement by endometrial carcinoma has made it impossible to accrue enough patients to study these different management strategies prospectively. Finally, no studies have focused on the clinical validity of stage II subdivision, IIA vs IIB, to the best of our knowledge.
The purpose of this study was to investigate the prognostic significance of cervical involvement in patients diagnosed with endometrioid endometrial adenocarcinoma (EEC). Specifically, we aimed to further investigate the potential role of depth of cervical stromal invasion, and to correlate these findings with histologic grade, myometrial invasion and lymphovascular invasion, parameters closely related to survival in patients with EEC. Herein, we present a single institutional series of patients with Stage IIA and IIB EEC, whose tumors were similarly staged and treated by one of six gynecologic oncologists, and whose radiation therapy, if administered, was delivered by one of three radiation oncologists from the assumed institution. We intend to report on surgical, pathologic, and therapeutic factors for both Stage IIA and IIB EECs, as well as other important clinical outcomes, such as complications from single vs dual modality therapies, patterns of recurrence and survival.
Section snippets
Materials and methods
After protocol approval by the Institutional Review Board (IRB) we searched the Cancer Registry for all women diagnosed and treated for FIGO Stage II EEC at the Massachusetts General Hospital between 1993 and 2003.
All pathology reports were reviewed. Patients were stratified into Group 1, if slides were available for re-review or Group 2 if information was obtained from the pathology report. Re-review of archival material was performed by two independent pathologists (EO and SS). In these
Clinical findings
Between 1993 and 2003, a total of 1485 patients with endometrial cancer were diagnosed and treated at our institution. FIGO Stage II tumors represented 10.4% (n = 142) of the overall group and of those, EECs constituted 70% (n = 98). Three patients underwent pre-operative radiation therapy, one patient died before surgical treatment and 13 additional patients had a second gynecologic or non-gynecologic primary malignant tumor and were excluded from the study. The patients' tumors were similarly
Discussion
We report a series of patients with FIGO surgicopathologically designated stage II EEC treated at our institution. In this study, the distinction between stage IIA and IIB or depth of SI does not affect survival in patients with EEC. However, LVI and type of hysterectomy performed had an impact on survival. In this series, the percentage of patients with stage II tumors (10.4%) is in agreement with the findings reported in the literature [4]. However, in contrast to many previous studies, all
Conflict of interest statement
The authors declare that there are no conflicts of interest.
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2018, Diagnostic Gynecologic and Obstetric PathologyPros and cons of vaginal brachytherapy after external beam radiation therapy in endometrial cancer
2016, Gynecologic OncologyCitation Excerpt :Overall, stage II disease is relatively rare, occurring in only 7–10% of endometrial cancer patients, though is notable for resulting in significantly worse outcomes when compared to patients with stage I disease. Specifically, the 5-year OS for stage II disease is 69–75%, as compared to 85–90% for FIGO 2009 stage IB [34,40,56]. Given that patients with stage II disease already have cervical invasion, it seems likely that their risk of recurrence in the vaginal vault is particularly high.
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2015, Gynecologic OncologyCitation Excerpt :While useful, previous studies that evaluated prognostic factors in patients with FIGO stage II endometrial carcinoma were hampered by some limitations. Most of the studies included patients with involvement of endocervical glands without stromal involvement [6–18]. Considering the minimal prognostic impact of endocervical gland involvement, this pathologic factor was not included in the revised FIGO staging system for women with endometrial carcinoma [19].