Analysis of Failures in Patients with FIGO Stage IIIc1-IIIc2 Endometrial Cancer

Aim: To assess the pattern of failures in patients with FIGO stage IIIc 1 -IIIc 2 endometrial cancer. Patients and Methods: Data were retrospectively analyzed for 34 patients with this malignancy who underwent extra-fascial total hysterectomy, bilateral salpingo-oophorectomy and pelvic/para-aortic node dissection. Postoperative treatment consisted of radiotherapy in 5 patients, 6 cycles of chemotherapy in 9, and 3-4 cycles of chemotherapy followed by radiotherapy in 20. The median follow-up of survivors was 33 months (range, 6 to 133 months). Results: Tumour relapsed in 14 out of 34 patients (41.2%). Median time to recurrence was 17 months (range, 9.5-42 months). Vaginal recurrence developed in 2 patients (5.9%), distant recurrence in 5 (14.7%), pelvic node recurrence in 3 (8.8%) and para- aortic recurrence in 7 (20.6%). Two patients had multiple sites of recurrence. Distant failure occurred in 11.1% of the patients who received 6 cycles of chemotherapy versus 20.0% of those who had 3-4 cycles of chemotherapy followed by radiotherapy. Five-year overall survival was 60.5%, and, in particular, it was 62.5% for stage IIIc 1 and 57.0% for stage IIIc 2 . Conclusion: FIGO stage IIIc 1 -IIIc 2 endometrial cancer relapses in approximately 40% of cases, and distant sites and para-aortic nodes represent the most common sites of failure. Surgery is the primary treatment of endometrial cancer and consists of extra-fascial total hysterectomy and bilateral salpingo-oophorectomy, with or without pelvic and para- aortic lymphadenectomy (1). Unsolved controversy exists regarding the selection of patients who may benefit from lymphadenectomy and the magnitude of such benefit (2-12). Outside clinical trials, this surgical procedure is usually performed for women with non-endometrioid histology or those with endometrioid hystology with poorly differentiated grade (assessed on preoperative biopsy) and/or or deep myometrial invasion (assessed on preoperative magnetic resonance imaging or intraoperative frozen sections). Conversely, lymphadenectomy can be omitted in patients with well or moderately differentiated endometrioid carcinoma and superficial myometrial invasion. Among the 7990 surgically staged endometrial cancer patients reported in the International Federation of Gynecology and Obstetrics (FIGO) Annual Report n. 26, 356 (4.5%) had stage IIIc disease, characterized by the presence of metastases to pelvic and/or para-aortic lymph nodes, and their 5-year overall survival was 57.3% (13). The FIGO staging system has recently been updated (FIGO 2009) (14). Pelvic and para-aortic lymph node metastases have been separated, and stage IIIc is now categorized as IIIc 1 (positive pelvic lymph nodes) and IIIc 2 (positive para-aortic lymph nodes with or without positive pelvic lymph nodes). Radiotherapy and chemotherapy have been widely used as postoperative treatment in this clinical setting, but no definite conclusion regarding the optimal adjuvant therapy can be drawn from the available literature (6, 7, 9, 12, 15-20). The aim of this retrospective study was to assess the pattern for failures of patients with FIGO stage IIIc 1 -IIIc 2 endometrial cancer .