Comparison of hematologic toxicity between 3DCRT and IMRT planning in cervical cancer patients after concurrent chemoradiotherapy: a national multi-center study.

PURPOSE: To compare the incidence and severity of acute and chronic hematologic toxicity (HT) in patients treated with three-dimensional conformal radiotherapy (3DCRT) and intensity modulated radiotherapy (IMRT) for curative treatment of cervical cancer and to ascertain the dosimetric parameters of two techniques associated with acute and chronic HT. MATERIALS AND METHODS: A total of 127 patients with cervical cancer receiving concomitant pelvic radiotherapy (RT) and cisplatin were evaluated. Pelvic bone marrow (BM) was contoured for each patient and divided into five sub-regions: lumbosacrum (LS), ilium (IL), lower pelvis (LP), pelvis (P), and whole pelvis (WP). The volume of each BM region receiving 10, 20, 30, and 40 Gy was calculated (V10, -V20, -V30, and -V40). The lowest level of hemoglobin, leukocyte, neutrophil, and platelet counts were obtained during chemoradiotherapy and six months after RT. The nadir values were graded according to Common Terminology Criteria for Adverse Events (version 3.0). RESULTS: Grade 2 or greater acute anemia, leukopenia, neutropenia, thrombocytopenia was observed in 2%, 41.5%, 12% ,and 0% in 3DCRT group and in 27%, 53%, 24.5%, and 4.5% in IMRT group, respectively. Grade 2 or greater chronic anemia, leukopenia, neutropenia, and thrombocytopenia was observed in 11%, 10%, 6%, and 0% in 3DCRT group and in 11%, 9%, 4.5%, and 0% in IMRT group, respectively. LS-V30, 40; IL-V10, 20, 30, 40; LP-V10, 20 ,40; P-V10, 20, 30, 40, and TP-V10, 20, 30, 40 were significantly reduced with IMRT planning compared to 3DCRT planning. Logistic regression analysis of potential predictors showed that none of the dosimetric parameters were significant for predicting acute and chronic HT. CONCLUSION: The present findings showed that IMRT planning reduced irradiated BM volumes compared to 3DCRT planning. However, no difference between the two techniques was observed in terms of acute and chronic HT. Further studies are needed to confirm these results.

Evaluation of treatment results and prognostic factors in early-stage cervical carcinoma patients treated with postoperative radiotherapy or radiochemotherapy.

PURPOSE: To investigate the clinical features, prognostic factors, and treatment outcome in early-stage cervical carcinoma patients treated with postoperative radiotherapy (RT)/radiochemotherapy (RCT). METHODS: The records of 256 Stage IB and II cervical cancer patients treated with postoperative RT/RCT from 1992-2007 were retrospectively reviewed. Median age of the patients was 47 (range: 25-78). Two hundred one (78.6%) patients had squamous cell carcinoma and 29 (11.3%) had adenocarcinoma. One hundred and eighty-seven (73.0%) had FIGO Stage IB and 69 (27%) had Stage II disease. Concomitant cisplatin-based chemotherapy was administered to 47 (18.4%) patients. Metastatic lymph node ratio (MLNR), defined as number of metastatic lymph nodes divided by the number of dissected lymph nodes, was 0 in 142 (55.5%) patients, from 1% to 10% in 27 (10.5%) and > 10% in 31 (12.1%) patients. RESULTS: Median follow-up duration was 60.5 months (range: 6-202 months). Five-year locoregional control (LRC), disease-free survival (DFS), disease specific survival (DSS) and overall survival (OS) rates were 90.8%, 83.4%, 91.2%, and 85%, respectively. In multivariate analysis; bulky tumor (> 4 cm) was shown as an important prognostic factor for LRC, DFS and DSS. Pretreatment hemoglobin level (< 10 g/dl) was associated with lower OS rate. Endometrial involvement was associated with lower LRC and DFS. Treatment break > 14 days showed significance for DFS and DSS. MLNR was found as a valuable prognostic factor for all endpoints (LRC, DFS, DSS and OS). The rate of grade 3-4 late toxicity was 3.6% and 2%, respectively. CONCLUSION: Postoperative RT/RCT is an effective treatment modality for early-stage cervical cancer patients with unfavorable features and provides satisfactory local control and survival rates with low morbidity.

The management of painful bone metastases with biphosphonates and palliative radiotherapy: a retrospective evaluation of 372 cases.

PURPOSE: The objective of this study was to evaluate the palliation of pain of bone metastases with biphosphonates and different radiotherapy protocols in 372 cancer patients. PATIENTS AND METHODS: Patients were treated with one of the 3 different radiotherapy protocols: 30 Gy in 10 fractions (group A), 20 Gy in 5 fractions (group B) and 8 Gy in a single fraction (group C). Two patient groups were studied: one with radiotherapy alone and the second with biphosphonates plus radiotherapy. The severity of pain was recorded before treatment. According to the pain relief, two different groups were defined: palliation rate<50% (limited palliation) and >50% (partial palliation), including complete pain relief. RESULTS: Overall limited and partial palliation rates were 20.2 and 79.8%, respectively (complete pain palliation 24.2%). In the group treated with both external radiotherapy and biphosphonates, limited and partial palliation rates were 19.5 and 80.4%, respectively (p=0.47). For 244 metastatic lesions treated with palliative radiotherapy alone, limited palliation rate was 20.4% and partial palliation rate 79.5%. No differences were detected between the groups with or without biphosphonates treatment in terms of pain palliation. According to the radiotherapy protocol, limited palliation rates in groups A, B, and C were 17.7, 20.3, and 28.5%, respectively (p=0.19, p=0.38, and p=0.26, respectively). Partial palliation rates were 82.2% in group A, 79.6% in group B and 71.4% in group C (p=0.42, p=0.21, and p=0.11, respectively). Similarly, no statistically significant differences were detected among the 3 radiotherapy schemes in terms of pain palliation. CONCLUSION: When combined with palliative radiotherapy, biphosphonates did not have any additive effects on pain palliation in the management of painful bone metastases. In addition, a single radiotherapy fraction provides equal pain palliation as multiple fractions.

Postoperative radiotherapy in intermediate and high-risk Stage I endometrial cancer: analysis of prognostic factors and survival.

PURPOSE: Patients with Stage IA Grade (G) III, Stage IB GII-III and Stage IC GI-II-III endometrial cancer who received postoperative adjuvant radiotherapy were evaluated in terms of local control, disease-free and overall survival rates and prognostic factors. MATERIALS AND METHODS: Four hundred and three patients with Stage I endometrial cancer treated with radiotherapy from January 1990 to December 2003 at Ege University Faculty of Medicine Department of Radiation Oncology were reviewed retrospectively. According to our radiotherapy protocol patients with Stage IB G2 disease (149 patients) received only external radiotherapy and the remaining (254 patients) received both external radiotherapy and intracavitary brachytherapy. RESULTS: Median age of the patients was 58 (range: 37-83). Nine patients (2.2%) had Stage IA, 196 (48.6%) had Stage IB and 198 (49.1%) had Stage IC disease. Histologic grade was 1 in 52 (12.9%) patients, 2 in 268 (66.5%) patients and 3 in 83 (20.6%) patients. Seventy-one (17.7%) patients had lymphovascular space invasion. Five-year locoregional relapse-free, distant-free, disease-free survival (DFS) and overall survival (OS) were 98.2%, 92.8%, 91.8% and 87.7%, respectively. In multivariate analysis, myometrial invasion and lymphovascular invasion were predictive factors for DFS and for OS prognostic factors were histologic type, myometrial invasion, and histologic grade. During radiotherapy 47.9% of the patients developed acute morbidity and 26.3% developed late morbidity, vaginal stenosis being the most frequent late morbidity. CONCLUSION: Postoperative adjuvant radiotherapy provides high locoregional control rates with acceptable toxicity in selected patients with Stage I endometrial carcinoma.

Evaluation of acute and late radiation morbidity in patients with gynaecologic malignancy using the RTOG criteria and Franco-Italian glossary.

PURPOSE: The purpose of this study was to evaluate acute and late radiation morbidity in patients with gynaecologic malignancy using the RTOG criteria and Franco-Italian glossary, and to compare the usefulness and disadvantages of each system. MATERIALS AND METHODS: Between February 2001 and February 2003, 107 patients with gynaecologic malignancy who received either radical or djuvant external radiotherapy +/- intracavitary brachytherapy or radiochemotherapy were enrolled in this study. The patients were evaluated before radiotherapy and weekly during radiotherapy for acute morbidity using the RTOG grading system and Franco-Italian glossary. Postradiotherapy evaluation was done one month after radiotherapy and at 3-month intervals thereafter. Median follow-up duration was 17 months. Morbidity was graded and recorded according to each scoring system. RESULTS: Median age was 46 years (range 37-82). Sixty-four patients (59.8%) had endometrial cancer. Radical radiotherapy was applied to 26 patients because of inoperability and 81 patients received postoperative radiotherapy. Biologically effective doses for the bladder, rectum and vagina were 98.39, 103.54 and 121.81, respectively, for late morbidity (BED3); 70.88, 72.84 and 80.92, respectively, for acute morbidity (BED10). According to the RTOG grading system acute morbidity rate for the genitourinary and gastrointestinal systems, and skin were 52.3%, 83.2% and 63.5%, respectively. Late morbidity rate for the bladder, colon-rectum, skin and vagina were 16.8%, 20.6%, 47.7% and 51.4%, respectively. The morbidity rate for the bladder, nonspecific abdominal, hematopoietic system, uterus-vulva-vagina, skin and rectum were 35.4%, 29.9%, 5.6%, 60.8%, 40.1% and 32.7%, respectively using the Franco-Italian glossary. In patients with carcinoma of the vulva--whose treatment fields were wider--acute morbidity rate according to RTOG criteria was higher (p = 0.057); photon energy (6 Mv rather than 1.25 MV) (p = 0.01) and treatment interruption of more than eight days (p = 0.019) were correlated with decreased long-term morbidity. According to the Franco-Italian glossary morbidity rates were higher in patients who received chemotherapy (p = 0.047), both external radiotherapy and brachytherapy (p = 0.022) and treatment interruption of less than eight days (p = 0.019). CONCLUSION: There is no common language between the RTOG grading system and Franco-Italian glossary for defining and scoring radiation morbidity. Up to date no standard and well-defined system has been developed for recording and reporting acute and late radiation morbidity in gynaecologic malignancy, but rather it depends on the subjective evaluation and experience of a radiation oncologist and subjective complaints of the patient, and sometimes on clinical findings. A standard and well-defined user friendly objective scoring system is needed to define and predict the morbidity rate more properly.

Results of postoperative radiotherapy in the treatment of uterine sarcomas: a retrospective analysis of 46 patients.

PURPOSE: The aim of this study was to evaluate treatment outcome, survival data and prognostic factors in patients with uterine sarcoma treated by postoperative radiotherapy. MATERIALS AND METHODS: The records of 46 patients treated between 1993 and 2003 were reviewed. Median age was 55 (range 31-75). There were 21 mixed mullerian tumors, 12 leiomyosarcomas, 11 endometrial stromal sarcomas and two adenosarcomas. According to FIGO classification 65.2% were Stage I, 17.4% Stage II, 13% Stage III and 4.3% Stage IV. All patients received external radiotherapy with 1.8 Gy daily fractions up to 50.4-64 Gy (median 50.4 Gy). Intracavitary brachytherapy was applied to 39 patients. Twelve patients received adjuvant chemotherapy. RESULTS: Median follow-up time was 48 months (6-144 months). Seventeen patients (37%) developed distant metastases and one patient had local failure. Five-year overall, disease-free and local recurrence-free survival rates were 57.8%, 60.5% and 97.8%, respectively. Univariate analysis demonstrated that stage (p = 0.011), histologic subtype (p = 0.010), tumor size (p = 0.044), positive peritoneal cytology (p = 0.006) and the use of chemotherapy (p = 0.005) had a significant effect on overall survival. Prognostic factors influencing disease-free survival were stage (p = 0.009), positive peritoneal cytology (p = 0.000) and the use of chemotherapy (p = 0.002). The only prognostic factor affecting local control was stage (p = 0.000). CONCLUSION: Postoperative radiotherapy seems to be an effective adjuvant treatment providing high local control rates in uterine sarcomas. However its efficacy should be clarified by randomized trials. The important prognostic factors influencing the treatment results were stage, histologic subtype, tumor size and positive peritoneal cytology.

Treatment results and prognostic factors for cervical cancer patients treated by radiochemotherapy with weekly cisplatin.

OBJECTIVE: This retrospective trial aims to report the treatment results of patients with locally advanced cervical cancer treated by concomitant radiochemotherapy with weekly cisplatin. METHODS: Between October 1999 and December 2003, 81 patients with FIGO Stages IB-IVA were treated at Ege University Faculty of Medicine Department of Radiation Oncology by radiochemotherapy with weekly cisplatin (40 mg/m2). Intracavitary high-dose rate brachytherapy was applied to 76 patients (93.8%) and five patients (6.2%) were treated with external radiotherapy alone. Early and late side-effects of the treatment were analyzed according to RTOG-EORTC criteria. RESULTS: Median age was 55 years and the most frequent histology was epidermoid carcinoma. Median follow-up time was 42 months. Five-year overall, disease-free and local relapse-free survival rates were 69%, 77%, and 82%, respectively. The presence of low Hgb level (< 12 g/dl), bulky tumor (> 4 cm), poor performance status, pelvic nodal involvement and limited early response to treatment had a significant impact on the local failure rate. Prognostic factors influencing disease-free survival were bulky tumor, performance status, pelvic nodal status, pretreatment Hgb level and limited early response to treatment. A significantly higher 5-year overall survival rate was observed in patients with good performance status, without pelvic nodal involvement, normal pretreatment Hgb level and complete response to treatment. Grade 3-4 side-effects were not observed in any patients. The most frequent acute side-effects were leukopenia, anemia, nausea and vomiting. Long-term side-effects were observed in 54% of patients. CONCLUSION: This series suggests that radiochemotherapy with weekly cisplatin is an effective and a safe treatment in locally advanced cervical cancer.

Evaluation of anxiety levels during intracavitary brachytherapy applications in women with gynecological malignancies.

PURPOSE: To evaluate the anxiety levels of women treated for gynecological malignancies using intracavitary brachytherapy. METHODS: Anxiety levels prior to and after intracavitary brachytherapy application and factors influencing anxiety levels were evaluated. Women were evaluated for quality of life and psychological status before each brachytherapy application using the Hospital Anxiety and Depression Scale (HADS). Scores were grouped as follows: 0-7 = normal, 8-10 = borderline, 11-21 = abnormal. Women were also questioned about other factors which could affect anxiety levels such as marital status, education level, number of pregnancies and prior surgical history. RESULTS: Between January 2003 and August 2004, 146 women with a median age of 56 years were evaluated (range: 27-80). Eighty-six women had cervix uteri carcinoma and 63 had endometrial carcinoma. Sixty-seven women were premenopausal and 85 women were postmenopausal. The median pregnancy number was three (range = 0-10). Eighty-nine women had at least three children. Sixty-seven women had had previous operations. One hundred and twenty-five women were married and 24 women were unmarried or widowed. Before treatment, the anxiety scores were scored as normal in 49 (32%), borderline in 41 (28%), and abnormal in 59 (40%). Anxiety levels were lower in 69 women during the last application as compared with the pretreatment levels (p = 0.00). Marital status and pregnancy number showed a significant correlation with anxiety scores (p = 0.04). Age, level of education or having had a previous operation showed no significant correlation with anxiety level. CONCLUSION: These results indicate that intracavitary brachytherapy is associated with anxiety. Women need to be given detailed information before the brachytherapy application to reduce anxiety. Additional studies are needed to determine it.

Prognostic factors in definitive radiotherapy of uterine cervical cancer.

PURPOSE: To determine the prognostic factors related to local control and survival in 257 patients with uterine cervical cancer treated with definitive radiotherapy (RT). MATERIALS AND METHODS: The medical records of 257 patients treated with definitive RT from January 1987 to December 1998 were reviewed retrospectively. Pretreatment and treatment parameters were analyzed to determine their prognostic value onlocal control and survival. Survival analyses were performed using the Kaplan-Meier method. The log-rank test was used for univariate analyses and the Cox regression model was used for multivariate analyses. RESULTS: Median age was 55 (range 25-82). Squamous cell carcinoma was the most common histologic type (89.1%). The distribution per FIGO Stage was IIA: 13.2%; IIB: 54.9%; IIIA: 3.9%; IIIB: 19.8%; IVA: 8.2%. Ninety-eight patients (38.1%) were treated with external RT alone; 134 (52.1%) received both external RT and intracavitary brachytherapy; 21 (8.2%) received external RT and chemotherapy and four (1.6%) received external RT, intracavitary brachytherapy and chemotherapy. Median follow-up duration was 50 months (range 24-155 months). The failure rate was 51.8% with 26.5% of patients having only local failure, 16.7% only distant failure and 8.6% both local and distant failure. Five-year local progression-free, disease-free and overall survival rates were 58.1%, 44% and 63.7%, respectively. In univariate analysis the prognostic factors identified for local progression-free survival were histology (p = 0.008), FIGO stage (p < 0.001), initial hemoglobin (Hgb) level (p = 0.001), total radiation dose (p = 0.039), use of brachytherapy (p = 0.001) and of chemotherapy (p = 0.037) and enlarged paraaortic nodes (p = 0.016). In multivariate analysis the prognostic factors were FIGO stage (p = 0.014), initial Hgb level (p = 0.040), and use of brachytherapy (p = 0.013). The prognostic factors identified for disease-free survival were histology (p = 0.011), FIGO stage (p < 0.001), initial Hgb level (p < 0.001), use of brachytherapy (p = 0.001) and of chemotherapy (p = 0.014) in univariate analysis; and FIGO stage (p < 0.001), initial Hgb level (p = 0.017), total tumor dose (p = 0.034), use of brachytherapy (p = 0.006) and of chemotherapy (p = 0.021) in multivariate analysis. Factors influencing overall survival were FIGO stage (p < 0.001), initial Hgb level (p = 0.006), overall treatment time (p = 0.028), total tumor dose (p = 0.007), use of brachytherapy (p < 0.001), enlarged paraaortic (p < 0.001) and pelvic nodes (p = 0.004) in univariate analysis; and FIGO stage (p < 0.001), overall treatment time (p = 0.031), enlarged paraaortic (p = 0.007) and pelvic lymph nodes (p = 0.043) in multivariate analysis. CONCLUSION: Definitive RT is an effective treatment for patients with uterine cervical cancer. There are many prognostic factors influencing treatment outcome. Brachytherapy and chemotherapy must be added in appropriate patients to improve the outcome. Future prospective trials should be undertaken to confirm the validity of these factors and to individualize the treatment strategy for every patient.

Radiochemotherapy for patients with locally advanced cervical cancer: early results.

PURPOSE: Radiotherapy is the standard treatment for locally advanced cervical cancer. Recent results of the prospective randomized trials have shown an overall survival and local control advantage for cisplatin-based therapy given concurrently with radiation therapy. Thirty-nine patients who received concurrent chemoradiation between October 1999 and December 2000 were evaluated for treatment response, local control and toxicity. MATERIALS AND METHODS: Thirty-nine patients with Stage IB through IVA cervical carcinoma received weekly cisplatin (40 mg/m2) concurrent with radiotherapy. Thirty-two patients received both external and intracavitary radiotherapy and seven patients received only external radiotherapy because of insufficient tumor response for intracavitary application. Total external radiotherapy dose was 64.8 Gy with 1.8 Gy daily fractions in patients who received only external radiotherapy. Midline shielding was performed at 50.4 Gy in patients who were going to receive brachytherapy and the total external radiotherapy dose was 54-59.4 Gy. Brachytherapy was performed with a Rotterdam applicator via the microSelectron HDR machine. A total dose of 8.5-18 Gy was applied to point A. RESULTS: Median age was 55. Distribution by stages were as follows: Stage IB 5.1%, IIA 28.2%, IIB 43.6%, IIIA 7.7%, IIIB 12.8% and IVA 2.6%. Histologically 33 (84.6%) were epidermoid carcinoma, one was adenocarcinoma, two were undifferentiated carcinoma, one was malignant epithelial tumor. In two patients histological type could not be specified. The median duration of follow-up was 20 months. Four patients had local recurrence and three developed distant metastases. Thirty patients (76.9%) had complete response, eight had (20.5%) partial response and one had (2.6%) stable disease. During or after radiochemotherapy 46.2% of the patients developed toxicity due to chemotherapy. Early and late radiation morbidity rates were 66.7% and 71.8%, respectively. No grade III-IV toxicity was observed. CONCLUSION: Concurrent chemoradiation for locally advanced cervical cancer is the treatment of choice in suitable patients providing high response rates with acceptable toxicity.

Evaluation of morbidity after external radiotherapy and intracavitary brachytherapy in 771 patients with carcinoma of the uterine cervix or endometrium.

PURPOSE: The aim of the present study was to evaluate early and late radiation morbidity and to assess the factors influencing morbidity in patients with cervical or endometrial cancer treated by a combination of external radiotherapy (ERT) and intracavitary brachytherapy (IBRT). MATERIALS AND METHODS: Early and late radiation morbidity were evaluated retrospectively using RTOG/EORTC criteria and Franco-Italian glossary in 771 patients treated between November 1992 and December 1999. RESULTS: Four hundred and seven patients (52.8%) had endometrial carcinoma and 364 (47.2%) had carcinoma of the cervix. One hundred and fifty-four patients with cervical carcinoma were inoperable. In patients with endometrial carcinoma total doses at the vagina, bladder and rectum were 60.36 Gy, 56.2 Gy and 55.6 Gy respectively. Biologically equivalent doses (BED) for the same points were 79.35, 68.63 and 67.37, respectively for early effects and 123.67, 97.65 and 94.85, respectively for late effects. One hundred and sixty-nine patients (41.5%) developed acute morbidity, grade I and II bladder morbidity being the most common type and 85 patients (20.9%) developed late morbidity, grade I and II vaginal morbidity being the most common type. No grade IV morbidity was recorded. Total doses at the vagina, bladder and rectum in operated cervix cancer patients were 60.51 Gy, 56.53 Gy and 55.67 Gy, respectively. BED for the same points were 79.77, 69.36 and 67.52, respectively for early effects and 124.74, 99.3 and 95.17, respectively for late effects. Eighty patients (38.1%) developed early morbidity. Grade I and II bladder morbidity was the most common type. Sixty-five patients (30.9%) developed late morbidity, vaginal morbidity being the most common type. Total doses at the vagina, bladder and rectum in inoperable patients were 70.92 Gy, 66.71 Gy and 62.38 Gy, respectively. BED for the same points were 97.43, 89.64 and 81.63, respectively for early effects and 159.3, 143.16 and 126.56, respectively for late effects. Sixty patients (39%) developed acute morbidity which was grade I or II bladder morbidity in 95%. Ninety-five patients (61.7%) developed late morbidity which was grade I-III vaginal morbidity in 94%. CONCLUSION: Patients with cervical or endometrial cancer can be treated safely by a combination of ERT and IBRT. However the patients should be assessed before, during and after treatment and at every period of follow-up using a standard and well-defined system in order to define and predict the morbidity rate.

Primary osteosarcoma of the sphenoid bone with multiple recurrences: a case report and review of the literature.

In this paper a patient with primary osteosarcoma of the sphenoid bone, which recurred twice following surgery and was managed with re-excision, irradiation and chemotherapy is presented due to its extremely rare presentation and atypical course. The relevant literature is also reviewed.

Late radiation effects to the rectum and bladder in gynecologic cancer patients: the comparison of LENT/SOMA and RTOG/EORTC late-effects scoring systems.

PURPOSE: To test the correlation of LENT/SOMA and RTOG/EORTC late-effect scales for rectum and bladder, 116 cases with gynecologic malignancies that were treated with radiotherapy were assessed with both scales. METHODS AND MATERIALS: All cases had been treated at least 6 months before the date of assessment with external beam radiotherapy (50--54 Gy to midline) and 1--2 fractions of HDR brachytherapy (2 x 8.5 Gy to point-A for 32 inoperable cases; 1 x 9.25 Gy to 5--9 mm from the ovoid surface for 84 postoperative cases). The patients were questioned with both scales, and the correlation between the two scales was analyzed by Spearman's rho (rank correlation) test. RESULTS: There were 64 cases with uterine cervix carcinoma and 52 cases with endometrium carcinoma, The overall (external + brachy) doses to ICRU points were 57.8 +/- 3.8 Gy for rectum and 59.3 +/- 4.9 Gy for bladder. The statistical analysis of LENT/SOMA and RTOG/EORTC scales revealed a very good correlation for rectum (r = 0.81; p < 0.01) and a good correlation for bladder (r = 0.72; p < 0.01). CONCLUSION: The LENT/SOMA system is a further step on the reporting of late radiation effects. Some modifications will improve its precision, and multicentric randomized studies are needed to test its validity.

Postoperative radiotherapy in endometrial carcinoma: analysis of prognostic factors in 440 cases.

PURPOSE: The aim of this study was to determine the prognostic factors influencing overall, disease-free and local recurrence-free survival in patients treated postoperatively with adjuvant radiotherapy for endometrial carcinoma. METHODS: The records of 440 patients with endometrial carcinoma treated by postoperative radiotherapy between January 1985 and June 1997 were reviewed retrospectively. All patients received postoperative external radiotherapy with 1.8-2.0 Gy daily fractions up to 36-68 Gy (median 54 Gy). Intracavitary brachytherapy was applied to 61.8% of the cases. Survival analysis was performed using the Kaplan-Meier method. The log-rank test was used for univariate analysis and the Cox regression model for multivariate analysis. RESULTS: Median age of the patients was 57 (range: 35-83). Histologically 80.2% were adenocarcinoma, 5.7% adenosquamous carcinoma, 5.2% clear-cell carcinoma and 4.3% serous papillary carcinoma. The distribution by stages were: 62.2% Stage I, 20.0% Stage II, 14.9% Stage III, 2.8% Stage IV. Median follow-up time was 53 months (7-173 months). Total failure rate was 15.2% with 2.7% of patients having only local failure, 2.0% local and distant failure and 10.5% distant failure only. Five-year overall, disease-free and local recurrence-free survival rates were 81.6%, 80.7% and 94.6%, respectively. According to univariate analysis prognostic factors influencing disease-free survival were histologic type (p=0.0067), histologic grade (p=0.0015), stage (p<0.0001), myometrial invasion (p<0.0001), peritoneal cytology (p=0.0013) and cervical involvement (p=0.0106) while the prognostic factors affecting local recurrence-free survival were stage (p=0.0277), myometrial invasion (p=0.0054), peritoneal cytology (p=0.0427). According to multivariate analysis prognostic factors influencing disease-free survival were histologic type (p=0.0194), myometrial invasion (p=0.0021), and histologic grade (p=0.0303) while the only prognostic factor influencing local recurrence-free survival was myometrial invasion (p=0.0241). CONCLUSION: Radiotherapy is a highly effective adjuvant treatment providing an excellent locoregional control rate and it should be continued for patients with unfavorable prognostic factors.