Intravaginal brachytherapy alone for intermediate-risk endometrial cancer Journal Article


Authors: Alektiar, K. M.; Venkatraman, E.; Chi, D. S.; Barakat, R. R.
Article Title: Intravaginal brachytherapy alone for intermediate-risk endometrial cancer
Abstract: Purpose: Despite the results of the Gynecologic Oncology Group trial No. 99 (GOG#99), some unanswered questions still remain about the role of adjuvant radiotherapy (RT) for intermediate-risk endometrial cancer. First, can intravaginal brachytherapy (IVRT) alone substitute for external beam RT but without added morbidity? Second, is the high-risk (HR) definition from GOG#99 a useful tool to predict pelvic recurrence specifically? The purpose of this study was to try to answer these questions in a group of patients with Stage IB-IIB endometrial carcinoma treated with high-dose-rate (HDR) IVRT alone. Methods and Materials: Between November 1987 and December 2002, 382 patients with Stage IB-IIB endometrial carcinoma were treated with simple hysterectomy followed by HDR-IVRT alone at our institution. Comprehensive surgical staging (CSS), defined as pelvic washings and pelvic/paraaortic lymph node sampling, was performed in 20% of patients. The mean age was 60 years (range, 29-92 years). Lymphovascular invasion (LVI) was present in 14% of patients. The median HDR-IVRT dose was 21 Gy (range, 6-21 Gy), given in three fractions. Complications were assessed in terms of late Radiation Therapy Oncology Group (Grade 3 or worse) toxicity of the GI tract, genitourinary GU tract, and vagina. Results: With a median follow-up of 48 months, the 5-year vaginal/pelvic control rate was 95% (95% confidence interval [CI], 93-98%). On multivariate analysis, a poor vaginal/pelvic control rate correlated with age <60 years old (relative risk [RR], 3, 95% CI, 1-12; p = 0.01), International Federation of Gynecology and Obstetrics (FIGO) Grade 3 (RR, 9, 95% CI, 2-35; p = 0.03), and LVI (RR, 4, 95% CI, 1-13; p = 0.051). The depth of myometrial invasion and CSS, however, were not significant. With regard to pelvic control specifically, the presence of GOG#99 HR features did not affect the pelvic control rate. The 5-year rate for HR patients was 96% (95% CI, 90-100%) vs. 96% (95% CI, 94-99%) for those without HR disease (p = 0.48). Even when the CSS effect was taken into account, the influence of HR features on pelvic control was still not significant (p = 0.51). In contrast, pelvic control was significantly influenced when patients were grouped according to CSS and stage/grade substages. For those with Stage IB Grade 3-IIB and no CSS, the 5-year pelvic control rate was 86% compared with 97% for those with Stage IB Grade 3-IIB and CSS, 97% for Stage IB, Grade 1-2 without CSS, and 100% for those with Stage IB, Grade 1-2 and CSS (p = 0.027). The 5-year disease-free survival rate was 93% (95% CI, 90-96%). On multivariate analysis, poor disease-free survival correlated with age <60 years (RR, 5; 95% CI, 1-18; p = 0.002), FIGO Grade 3 (RR 5, 95% CI 2-17; p = 0.013), and LVI (RR 3, 95% CI 1-8; p = 0.054). Unlike pelvic control, disease-free survival was significantly affected by GOG#99 HR features, with a 5-year rate of 87% (95% CI, 76-99%) vs. 94% (95% CI, 91-97%) for those without HR features (p = 0.027). The 5-year overall and disease-specific survival rate was 93% and 97%, respectively. The overall 5-year actuarial rate of Grade 3 or worse complications was 1% (95% CI, 0-2%). Conclusion: Tumor grade, depth of invasion, and the use of CSS were better predictors of pelvic control than the GOG#99 HR factors. IVRT alone seemed to provide adequate tumor control with very low morbidity. Therefore, it seems prudent to consider it for intermediate-risk patients because of its superior therapeutic ratio compared with that for surgery alone or pelvic RT. Additional follow-up, however, with a larger number of patients is needed, especially for those with LVI. © 2005 Elsevier Inc.
Keywords: adult; human tissue; aged; aged, 80 and over; disease-free survival; middle aged; major clinical study; cancer risk; cancer patient; radiation dose; radiotherapy, adjuvant; cancer staging; follow up; endometrial cancer; lymph node metastasis; hysterectomy; endometrial neoplasms; cancer grading; endometrium cancer; neoplasm recurrence, local; radiotherapy dosage; radiotherapy; morbidity; prediction; risk assessment; risk; cancer invasion; confidence interval; confidence intervals; correlation analysis; statistical analysis; tumors; brachytherapy; organization; surgery; multivariate analysis; cancer control; patient treatment; toxicity; gynecology; carcinoma, endometrioid; intermediate risk; diseases; myometrium; correlation methods; gog#99; intravaginal brachytherapy; comprehensive surgical staging (css); intravaginal brachytherapy (ivrt); lymphovascular invasion (lvi)
Journal Title: International Journal of Radiation Oncology, Biology, Physics
Volume: 62
Issue: 1
ISSN: 0360-3016
Publisher: Elsevier Inc.  
Date Published: 2005-05-01
Start Page: 111
End Page: 117
Language: English
DOI: 10.1016/j.ijrobp.2004.09.054
PUBMED: 15850910
PROVIDER: scopus
DOI/URL:
Notes: --- - "Cited By (since 1996): 56" - "Export Date: 24 October 2012" - "CODEN: IOBPD" - "Source: Scopus"
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MSK Authors
  1. Venkatraman Ennapadam Seshan
    343 Seshan
  2. Richard R Barakat
    629 Barakat
  3. Dennis S Chi
    601 Chi
  4. Kaled M Alektiar
    291 Alektiar