Patterns of recurrence and outcomes in surgically treated women with endometrial cancer according to ESMO-ESGO-ESTRO Consensus Conference risk groups: Results from the FRANCOGYN study Group

doi:10.1016/j.ygyno.2016.10.025

Gynecologic Oncology

Volume 144, Issue 1, January 2017, Pages 107-112

https://doi.org/10.1016/j.ygyno.2016.10.025 Get rights and content

Highlights

•
Endometrial cancer is associated with a specific pattern of recurrence.
•
High risk group and histological type 2 are associated with a poor prognosis.
•
Patterns of recurrence provide useful information for follow-up recommendations.

Abstract

Objectives

The purpose of this study was to analyse the endometrial cancer (EC) patterns of recurrence based on a large French multicentre database according to ESMO-ESGO-ESTRO classification.

Methods

Data of women with histologically proven EC who received primary surgical treatment between January 2001 and December 2012 were retrospectively abstracted from seven institutions with prospectively maintained databases. The endpoints were recurrence, recurrence free survival (RFS) and overall survival (OS). Time to the first EC recurrence in a specific site was evaluated by using cumulative incidence analysis (Gray's test).

Results

Data from 829 women were analysed in whom recurrences were observed in 176 (21%) with a median and mean time to recurrence of 13 and 19.5 months, respectively. High (35%) and high-intermediate risk groups (16%) were associated with higher recurrence rates compared with low (9%) and intermediate (9%) risk patients (p < 0.0001). Women with high risk EC had a higher 5-year cumulative incidence of distant recurrence (20.7%) than women with high-intermediate, intermediate and low risk EC (5.6%, 3.5%, 3.3%), (p < 0.001), respectively. Women with high risk and high-intermediate risk EC had a higher 5-year cumulative incidence of loco-regional recurrence (24.3% and 16.6%, respectively) than women with intermediate and low risk EC (6.6% and 6.5%, respectively), (p < 0.001).

Conclusions

We report specific time and site patterns of first recurrence according to the ESMO/ESGO/ESTRO classification. Sites and hazard rates for recurrence differ widely between subgroups over time. Defining patterns of EC recurrence may provide useful information for developing follow-up recommendations and designing therapeutic approaches.

Introduction

Endometrial cancer (EC) has been reported to be one of the most common gynaecological tumours in developed countries representing the fifth most common cancer overall and the 14th cancer in terms of mortality (76,000 deaths per year worldwide) [1], [2]. Most ECs (75%) are diagnosed at an early stage (International Federation of Obstetrics & Gynaecology (FIGO) stages I or II) with a 5-year overall survival (OS) ranging from 74% to 91% [1,2]. In comparison, for advanced stages (FIGO stages III and IV), the 5-year OS is 57–66% and 20–26%, respectively [3].

Although EC is characterized by a good prognosis, a great heterogeneity has been reported by several authors, especially for early-stage ECs, exposing women to recurrent disease [3], [4], [5]. EC site-specific recurrence patterns are influenced by classic prognostic factors such as histological type and grade, depth of myometrial invasion, lymphovascular space involvement (LVSI), and nodal status [3], [6], [7], [8], [9]. It is now well established that recurrences after primary surgical treatment are mostly located in the true pelvis with events generally occurring in the regional pelvic lymph nodes or in the vaginal vault [3], [6], [7], [8]. However, other locations including distant metastases or peritoneal carcinomatosis can also be observed underlining the prognostic heterogeneity of the disease [3], [6], [7], [10]. In addition, EC recurrences vary considerably over time and are influenced by adjuvant therapeutic modalities. Nevertheless, despite this recognized variability, more than 70% of recurrences occur within the first 2–3 years after treatment [11], [12], [13].

To take this heterogeneity into account, the European Society for Medical Oncology (ESMO) with the support of the European Society for Radiotherapy & Oncology (ESTRO) and the European Society of Gynaecological Oncology (ESGO) recently proposed a multidisciplinary evidence-based classification for clinical practice [3]. However, in light of the evolving classification of EC, limited information is available for each EC subgroup with regard to patterns of disease recurrence and prognosis. This is of major importance as such information may impact indications for adjuvant therapies and modalities of follow-up for each subgroup. We thus conducted an analysis of EC patterns of recurrence based on a large French multicentre database according to ESMO-ESGO-ESTRO conference consensus classification [3].

Section snippets

Study population

Data of women with histologically proven EC who received primary surgical treatment between January 2001 and December 2012 were retrospectively abstracted from seven institutions with prospectively maintained EC databases in France (Tenon University Hospital, Reims University Hospital, Dijon Cancer Center, Rennes University Hospital, Lille University Hospital, Tours University Hospital, and Creteil University Hospital) and from the Senti-Endo trial. All the women had given written consent to

Characteristics of the study population

During the study period, women with EC were documented as having received primary surgical treatment according to the following distribution: Tenon University Hospital (118/829; 14%), Tours University Hospital (178/829; 21%), Dijon Cancer Centre (77/829; 9%), Creteil Hospital (107/829; 13%), Reims University Hospital (101/829; 12%), Rennes University Hospital (57/829; 7%), Jeanne de Flandre University Hospital (92/829; 11%), and Senti-Endo trial (99/829; 12%).

The median age of the women was 66.0

Discussion

In this large multicentre study, we report specific site and time patterns of first recurrence according both to risk group as defined by the ESMO/ESGO/ESTRO Consensus Conference classification and the histological type. We underline the poor prognosis for women at high and high-intermediate risk as well as for women with histological type 2 ECs for whom a shorter 5-year OS and RFS was observed. It also appears that time to first recurrence, site of first recurrence and the hazard rates for

Conclusion

To the best of our knowledge, this study represents the largest series reporting outcomes and patterns of recurrence of women with EC according to ESMO-ESMO-ESTRO risk groups and pathological subtypes. Our results show that recurrences differ widely in terms of site and timing depending on the risk subgroup, reinforcing the need for appropriate monitoring schemes for which current guidelines are somewhat blurred. In addition, these results could be taken into account to design future

Conflict of interest statement

No authors have conflict of interests.

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To evaluate recurrence rate and pattern in apparently early-stage endometrial cancer (EC) treated with minimally invasive surgery (MIS) and compare it to the “historical” populations treated by laparotomy. Secondary outcomes were to establish if, among MIS recurrent patients, intermediate-high/high-risk patients presented the same recurrence pattern compared to those at low/intermediate-risk and to evaluate time to first recurrence (TTR) of the study population.
Multicenter retrospective observational study.
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Evaluation of recurrence rate and pattern.
Seventy-seven recurrences occurred on the total of 1028 patients treated with MIS for apparently early-stage EC during a median follow-up time of 36 months. The rate of recurrence in our cohort did not differ significantly from the rate of the historical cohort (7.4% vs 7.9%, odds ratio 0.9395, 95% CI 0.6901–1.2792). No significant differences were noticed for local, abdominal, nodal, and multiple site recurrence patterns; distant site recurrence appeared more likely in patients from the historical cohort. Postoperative low/intermediate risk patients had a higher likelihood of local recurrence compared to intermediate-high/high risk patients. Mean TTR was 19 months. No significant difference of TTR was observed for each pattern of recurrence compared to others.
MIS appears to be safe for the treatment of early-stage EC. We did not identify any recurrence pattern specifically associated with MIS in early-stage EC.
Vaginal hysterectomy for the treatment of low-risk endometrial cancer: Surgical technique, costs, and perioperative and oncologic results
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This study aimed to describe an operative technique for vaginal hysterectomy (VH) and assess the costs, perioperative, and oncological outcomes for this procedure when used in the treatment of patients with low-risk endometrial cancer (LREC).
A retrospective analysis of medical records was conducted on patients who underwent VH to treat precursor and invasive endometrial lesions between April 2019 and November 2021 at a single center in São Paulo, Brazil.
Thirty-four patients met the inclusion criteria. The mean patient age was 61.9 years, and the mean body mass index (BMI) was 34. Obese patients (BMI ≥ 30) accounted for 77% of the sample. Preoperative functional capacity measures were Eastern Cooperative Oncology Group (ECOG) 0–1 and ECOG-2 for 91% and 9% of the patients, respectively. The mean operative time and length of hospital stay were 109 min and 1.2 days, respectively. Four patients had a conversion of the surgical route to laparotomy. No major intraoperative complications were observed. Patients who underwent surgical conversion had a greater uterine volume (227 versus 107 mL, p = 0.006) and longer operative time (177 versus 96 min, p = 0.001). The total cost associated with VH was, on average, US$ 2058.77 (R$ 10,925.91), representing 47% of the cost associated with non-vaginal routes. Twenty-eight patients received a definitive diagnosis of endometrial carcinoma; of these, three received adjuvant radiotherapy. The mean follow-up period was 34.6 months for the patients diagnosed with cancer. One case of disease recurrence occurred 16.6 months after surgery, with one death at 28.6 months of follow-up.
These findings suggest that VH could be a feasible and cost-effective alternative for selected patients with LREC in low-resource settings.
National Survey of Current Follow-up Protocols for Patients Treated for Endometrial Cancer in the UK
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The aim of this study was to establish a baseline of national practice for follow-up after treatment for endometrial cancer in the UK.
An online cross-sectional survey was developed and distributed through the Royal College of Radiologists via an email link to the audit leads of radiotherapy centres in the UK. The survey was conducted from November 2021 to 5 January 2022. The main themes assessed in the survey were the form, frequency and duration of follow-up practices.
There were a total of 43/61 (70%) complete responses. 93% of centres had a standard follow-up protocol and 7% who did not have a follow-up protocol discharged patients after the post-operative review. Five centres (13%) used molecular profiling to inform follow-up practices.
Patient-initiated follow-up was mainly used in the cohort of patients who had surgery alone with no adjuvant treatment (68%, (19/28)). In the cohort who had face-to-face follow-up, the majority had pelvic examinations as part of their review and total follow-up for five years.
93% of respondents are interested in a national follow-up protocol.
Our data shows that there is national variation in practise with regard to follow-up of women treated for endometrial cancer. Many of the follow-up practises are based on conventional follow-up regimens and these may fail to address the more holistic needs of cancer survivors. Recent publication of updated guidance from the British Gynaecological Cancer Society may help standardise practise and provide a more relevant approach to follow-up for women treated for endometrial cancer.
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To describe the patterns of recurrence and the prognosis of patients with a recurrent TP53 mutated endometrial carcinoma treated initially by surgery.
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Citation Excerpt :
Moreover, older age, higher stage, positive peritoneal washings and having received adjuvant treatment, although not surgical technique or lymph nodes dissection, were found to be independent predictive factors and associated with a higher risk for recurrence. Endometrioid ECs, especially low grade, display a pattern of recurrence more often localized to vagina than what is the case for non-endometrioid ECs [24–26]. One may consider our finding of 27.2% with only vaginal recurrences low in comparison to others where Gayar et al. [27] found 38.1% isolated vaginal recurrence in endometrioid EC but included only FIGO stage I and II.
The aim of this study was to investigate recurrences and survival in endometrioid endometrial cancer (EC) in a complete population-based cohort.
A regional population-based study including women with endometrioid EC, identified by the Swedish Quality Registry for Gynecological Cancer (SQRGC), where primary surgery was performed between 2010 and 2017. Patient characteristics and outcomes, including recurrences, were retrieved from the SQRGC and completed by records reviews. Overall (OS), net (NS) and disease-free survival (DFS) were calculated using the Kaplan-Meier method. The Fine and Gray proportional subdistribution hazards' regression model was used for risk factors for recurrence.
There were 1630 women included in the study, whereof 136 (8.3%) had a recurrence with a median time to recurrence of 22.5 months (range 3.2–59.3). One site of recurrence was diagnosed in 69.1%, while 27.2% being only vaginal. The total 5-year OS was 88.0%(95% CI:86.4–89.7) and the 5-year NS 98.6%(95% CI:96.5–100.7). If no recurrence occurred, the OS was 91.9%(95% CI:90.4–93.3) and NS 102.8%(95% CI:100.9–104.8). For only vaginal recurrence, 5-year OS was 77.0%(95% CI:64.0–92.6) compared to 36.1%(95% CI:27.5–47.3) for all other recurrences. The total 5-year DFS was 83.9%(95% CI:82.0–85.7). In the multivariable analysis, age, FIGO stage and primary treatment were found independent factors for recurrence with a HR of 1.29(95% CI:1.11–1.51;p = 0.001) for age, 2.78(95% CI:1.80–4.29;p < 0.001) for FIGO stage III and 1.84(95% CI:1.22–2.78;p 0.004) for adjuvant treatment.
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Patterns of recurrence and outcomes in surgically treated women with endometrial cancer according to ESMO-ESGO-ESTRO Consensus Conference risk groups: Results from the FRANCOGYN study Group☆

Highlights

Abstract

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Study population

Characteristics of the study population

Discussion

Conclusion

Conflict of interest statement

Ann. Oncol. Off. J. Eur. Soc. Med. Oncol. ESMO

Gynecol. Oncol.

Gynecol. Oncol.

Lancet

Lancet

Gynecol. Oncol.

Gynecol. Oncol.

Int. J. Gynaecol. Obstet. Off. Organ Int. Fed. Gynaecol. Obstet.

Ann. Oncol. Off. J. Eur. Soc. Med. Oncol. ESMO

Eur. J. Surg. Oncol. J. Eur. Soc. Surg. Oncol. Br. Assoc. Surg. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.