Beruflich Dokumente
Kultur Dokumente
EARLY ENDOMETRIAL
CANCER
WHEN TO GO ?
K.S.Reddy
Pondicherry
GLOBOCAN, IARC
INDIA
USA
YEAR
AGE
GROUP
CERVIX
UTERI
CORPUS
UTERI
CERVIX
UTERI
CORPUS
UTERI
2012*
AGE < 65
107287
9178
10545
29041
AGE > 65
15557
3147
2421
20604
AGE < 65
115060
9985
10819
30341
AGE > 65
17254
3492
2676
22859
2015*
Introduction
EC usually diagnosed at early stage (up to 80%
diagnosed as stage I, 13% as stage II)
5-year OS as high as 88% in stage I disease.
Subgroups of patients with early stages have
significantly decreased 5-OS rates, based on
various prognostic factors, such as
Myometrial invasion & grade 3 have a 5-OS of 66%.
FIGO 2010
Low risk:
Grade 12 histology, with invasion through
less than 50% of the myometrium.
Grade 3 without myometrial invasion.
Disease confined to the uterine fundus.
No lympho-vascular space invasion (LVSI)
No evidence of metastases.
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PORTEC-1
PORTEC-1 study group (1990-97) aimed to
Determine the impact of pelvic irradiation without
additional brachytherapy on the outcome in patients with
early stage endometrial cancer
The surgical procedure was a simple
total abdominal hysterectomy and bilateral salpingo
oophorectomy (TAH-BSO) without any lymphadenectomy.
714 patients - IBG2, IBG3, ICG1, ICG2
(ICG3 specifically NOT included)
Randomized to NAT vs 46 Gy pelvic RT
No brachytherapy
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FIFTEEN-YEAR
RADIOTHERAPY
OUTCOMES OF
THE RANDOMIZED
PORTEC-1 TRIAL
CREUTZBERG et al.
IJROBP 81(4), 2011
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Radiation therapy
Pelvic EBRT was administered with a target volume
that included the parametrial tissues, the proximal two
thirds of the vagina, and lymphatic drainage regions
along the internal iliac vessels up to the promontory.
The superior field border was at the L5S1 disc.
The total dose was 46 Gy in 2-Gy daily fractions.
The PORTEC trial was done before three dimensional
conformal treatment planning techniques had been
introduced. Radiation was delivered by
AP-PA opposed fields(30%), three-field (18%) or
four-field techniques (52%)
Calculation of the dose distribution on the central axis
and specification at isocenter or midplane
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GOG # 99 (2004)
Complete surgical staging including pelvic and
para-aortic node sampling
Surgical stage IB, IC, IIA (occult) and IIB (occult)
All histologic types except serous papillary and
clear cell
Randomized to pelvic RT vs. no further therapy
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Vaginal Rec.
Pelvic Rec.
Distant Rec.
EBRT
No RT
EBRT
EBRT
No RT
EBRT
No RT
2(1.1%)
13(6.4%) 1(0.5%)
13(6.4%)
92%
86%
No RT
5(2.5%) 10(5.3%)
Statistically
significant
Statistically not
significant
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21
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Surgery
905 cases
RANDOMIZE
453 cases
No external beam RT
(51% Brachytherapy)
452 cases
External beam RT
(52% Brachytherapy)
Outcomes of ASTEC/EN.5
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Outcomes of ASTEC/EN.5
EBRT: N-452
OBSERVATION: N-453
Vag. Rec.
Pelvic Rec.
Distant Rec.
Over all
survival
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84%
84%
ASTEC/EN.5 CONCLUSION
Overall morbidity (which included documented
postsurgical complications) was greater in the
radiation therapy study arm (60% vs 26%).
No differences in recurrence-free, diseasespecific, or overall survival (hazard ratio 1.01;
P = 0.98)
Although it was not a primary end point of the
study (Not randomized to receive or not)
Vault brachytherapy
Decreased the risk of isolated recurrence in the vagina
(hazard ratio: 0.53; P = .038).
This reduction in local recurrence did not influence survival.
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PORTEC 2 (2008)
Vaginal brachytherapy versus external beam
pelvic radiotherapy for high-intermediate risk
endometrial cancer: Results of the randomized
PORTEC-2 trial
R. A. Nout, H. Putter, I. M. Joergenliemk-Schulz, J. J. Jobsen, L. C. Lutgens,
E. M. van der Steen-Banasik, J. W. Mens, A. Slot, V. T. Smit and C. L.
Creutzberg
Leiden University Medical Center, Leiden, Netherlands; University Medical
Center Utrecht, Utrecht, Netherlands; Medisch Spectrum Twente,
Enschede, Netherlands; MAASTricht Radiation Oncology Clinic, Maastricht,
Netherlands; Radiotherapy Institute Arnhem, Arnhem, Netherlands; Daniel
den Hoed Cancer Center, Rotterdam, Netherlands
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PORTEC 2 Design
TAH / BSO no LND
Eligibility:
High intermediate risk group
-age>60+ IC G1-2 or IB G3
-stage IIa
N=427 pts
EBRT
N=214
Brachytherapy
N=213
EBRT
Vaginal relapse:
1.9%
Loco reg. relapse: 2.5%
Distant relapse:
5.7%
Pelvic relapse:
0.6%
No deaths:
20 pts
DFS:
89%
OS:
90%
BT
0.9%
4%
6.3%
3.5%
20 pts
89%
90%
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P
(p = 0.97)
(p = 0.15)
(p = 0.37)
(p = 0.03)
QOL Diarrhea
Impairment in:
daily activities
Decreased social:
functioning
G1-2 GI toxicity:
G1-2 GU toxicity:
Skin toxicity:
EBRT
~30%
~30%
BT
~10%
~13%
P
(p = 0.001)
(p = 0.03)
~20%
~10%
(p=0.001)
54%
27%
20%
13%
22%
2%
(p = 0.001)
(p=0.1)
(p = 0.001)
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PORTEC 2 Conclusions
VBT as effective as EBRT for intermediate high
risk EC. Despite the slightly but significantly
increased pelvic failure rate in the VBT arm.
OS and RFS were similar.
QOL significantly better with brachytherapy
VBT should be the treatment of choice for
patients with high-intermediate risk EC.
Remaining question:
GOG # 99 vs PORTEC-2
GOG # 99
(2004)
EBRT in early stage
intermediate risk
endometrial carcinoma
decreases the risk of
recurrence, but should be
limited to patients whose
risk factors fit a
high intermediate risk
definition.
PORTEC-2
(2008)
Brachytherapy should be
the treatment of choice
for patients with
high intermediate risk
endometrial carcinoma.
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Cost of therapy
IVBT less costly than external
beam RT
Patient convenience
Ancillary costs
Time to recovery
Time away from home/employment
35
NSGO
EORTC
NSGO EC-9501/EORTC-55991
RT
Randomization
382 cases
Radical surgery
TAH+BSO
TAH+BSO
(+PLA)
(+PLA)
196 cases
RT+CT
(BT:44%)
(BT:44%) 186 cases
OR
44
44 Gy
Gy XRT
XRT
optional
optional
brachytherapy
brachytherapy
(BT:39%)
(BT:39%)
CT+RT
Primary endpoint
Progression-free
Progression-free survival
survival (PFS)
(PFS)
37
NSGO EC-9501/EORTC-55991
Results
Cancer-specific overall survival improved in radiation/
chemotherapy group (10% at 5 y. from 78 % to 88 %).
Combined modality improved progression-free but also
cancer specific overall survival
No difference of overall survival by randomization between
combined modality and radiation alone
RT+CT was better than RT alone.
The next question is if RT+CT better than CT alone
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52
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