Surgery Without Radiotherapy for Endometrial Cancer
ABSTRACT & COMMENTARY
Synopsis: Even high-risk patients with endometrial cancer have an excellent prognosis when treated with surgery, including pelvic and para-aortic lymphadenectomy, without radiotherapy.
Source: Larson DM, Obstet Gynecol 1998;91: 355-359.
Larson and associates report a study in which 225 women with endometrial cancer confined to the uterus were surgically staged by a standard protocol that included pelvic and para-aortic lymphadenectomy in women with high-risk factors. No radiation was administered before or after surgery. The combination of preoperative endometrial biopsy grade and gross depth of myometrial invasion identified 123 (55%) high-risk patients who had lymphadenectomy and 102 (45%) low-risk patients who did not. Eighteen (15%) high-risk patients had lymph node metastases and received postoperative systemic therapy. Three low-risk, eight high-risk-node-negative, and no high-risk-node-positive patients were diagnosed with recurrent cancer, corresponding to five-year recurrence-free proportions of 0.95, 0.89, and 1.00, respectively. Larson et al surmised that, although sample sizes and limited follow-up limited conclusions, the experience to date suggests a high rate of survival in all three groups. Based on their preliminary experience, they conclude that even high-risk patients have an excellent prognosis when treated with surgery, including pelvic and para-aortic lymphadenectomy, without radiotherapy.
COMMENT BY DAVID M. GERSHENSON, MD
The controversy regarding the role of surgical staging in the management of endometrial cancer continues. And the opinions, even among gynecologic oncologists, are all over the place. Who should undergo lymph node sampling? How extensive should it be? What is optimal postoperative treatment for those patients with high-risk features? This study does expand our knowledge base somewhat. Interestingly, Larson et al used histologic grade on preoperative endometrial biopsy and depth of gross myometrial invasion visibly estimated by the surgeon to guide intraoperative management. Although such indicators are not bad, a frozen section, microscopic review of both parameters, in my opinion, would have been preferable. The only patients who did not have pelvic and para-aortic lymphadenectomy were those with grade 1 tumors and less than 50% myometrial invasion. Larson et al are obviously making a case that radiotherapy is probably not indicated in the postoperative treatment of women with endometrial cancer. In fact, they used combination chemotherapy instead of radiotherapy in their high-risk patients with positive lymph nodes. Our group at MD Anderson pioneered the use of chemotherapy in this setting, but I am not certain that it is superior to radiotherapy in all patients. Of course, what we need is a prospective, randomized study comparing radiotherapy to chemotherapy in high-risk patients. As with most, this study is not flawless. Could the authors have been somewhat more liberal in their selection of patients who did not require lymph node sampling? And, I would have liked to see longer follow-up intervals for the study population (they ranged from 39 to 46 months for various subgroups), since such information would have afforded us a better assessment of the efficacy of this approach. Most notably, eight of the 105 high-risk, node-negative patients developed a recurrence-four pulmonary and four vaginal. Although Larson et al state that they salvaged all patients with vaginal recurrence with subsequent radiotherapy, could these recurrences have been prevented by even vaginal brachytherapy? I remain somewhat unconvinced by the authors' approach and believe that further study of this strategy is warranted before we can embrace it.