Nowadays, the incidence of endometrial cancer is rising, especially of high-grade endometrial tumours. Recently, the FIGO classification of endometrial cancer has changed worldwide. Besides that, treatment strategies are changing. The purpose of this study was to analyse the adherence to the national guidelines of cancer treatment and to analyse patterns of disease relapse and survival. We focused on a group of patients (
Endometrial cancer is the most common cancer of the female genital tract in western countries [
The purpose of this study was to analyse the adherence to the (yet outdated) national protocols of cancer treatment and to analyse patterns of disease relapse and survival in patients having endometrial cancer in our hospital. We focused on a group of 191 patients with endometrial cancer in a time period during which new treatment strategies are not yet completely implemented.
A retrospective analysis was performed on all patients having endometrial cancer (
A total of 191 patients were diagnosed having endometrial cancer. Thirteen patients (6.8%) were diagnosed in 2002, 20 (10.5%) in 2003, 35 (18.3%) in 2004, 30 (15.7%) in 2005, 17 (8.9%) in 2006, 18 (9.4%) in 2007, 34 (17.8%) in 2008, and 24 (12.6%) in 2009. The median age at initial diagnosis was 66.9 years (range 40–94 years). The mean time to followup was 37.6 months (range; 0–82 months; median 34.0 months).
The majority of patients (
A total of 21 women (11.0%) were diagnosed having stage III disease (IIIA in 16 (8.4%); IIIB in 1 (0.5%); IIIC in 4 (2.1%)). Four patients (2.1%) were diagnosed having stage IV disease (all IVB).
Twenty patients (10.5%) died of endometrial carcinoma. Of all deaths, 3 (15.8%) were diagnosed having FIGO stage IB; 5 (26.3%) in IC, 5 (26.3%) in IIIA; 3 (15.8%) in IVB; 1 patient (5.3%) in the stages IIB, IIIB, and IIIC. Twenty-one patients (11.1%) died of causes other than endometrial carcinoma.
The overall 5-year survival was 77.5% in FIGO stage I; 72.5% in FIGO stage II; 51.7% in FIGO stage III; 25% in FIGO stage IV disease (Table
5-year survival rates of
OSa | DSSb | DFSc | |
---|---|---|---|
Histology | |||
Endometrioid | 73.5% | 87.7% | 89.2% |
Papillary serous | 59.6% | 59.6% | 68.6% |
Clear celld | 40.0% | 80.0% | 60.0% |
FIGO | |||
Stage I | 77.5% | 92.6% | 91.0% |
Stage II | 72.5% | 80.0% | 75.0% |
Stage III | 51.7% | 51.7% | 59.6% |
Stage IV | 25.0% | 25.0% | — |
Tumour grade (within FIGO stage I endometrioid) | |||
Grade 1 | 90.7% | 96.0% | 92.4% |
Grade 2 | 74.5% | 93.1% | 90.7% |
Grade 3 | 59.8% | 84.1% | 88.2% |
a: 5-year overall survival.
b: 5-year disease-specific survival.
c: 5-year disease-free survival.
d: maximum follow-up: 46 months.
5-year disease-specific survival of
Adenocarcinoma of the endometrium was present in 165 patients (86.4%), papillary serous tumour in 18 (9.4%). Clear cell and mucinous tumours were present in, respectively, 6 (3.1%) and 2 (1.0%) patients. FIGO stage I disease was most seen in endometrioid adenocarcinomas (137 (86.2%) as opposed to 8 (44.4%) in papillary serous tumours).
Of all tumours, 69 (36.1%) were grade 1, 69 (36.1%) were grade 2, and 50 (26.2%) were grade 3 tumours. In FIGO stage III, the percentage of grade 3 tumours was higher than in FIGO stage I disease (grade I, II, and III in FIGO stage I was 41.3%, 38.0%, and 20.7% as opposed to 14.3%, 33.3%, and 52.4% in FIGO stage III). In stage IV, all tumours were high grade.
The overall 5-year survival was 73.5% in endometrioid adenocarcinomas and 59.6% in papillary serous tumours. The disease-specific survival in endometrioid tumours was 87.7% and in serous tumours 59.6% (Figure
5-year disease-specific survival of
In FIGO stage I adenocarcinomas, the overall 5-year survival in grade 1 tumours was 90.7%, 74.5% in grade 2, and in 59.8% grade 3 tumours. Disease-specific survival was 96.0% in grade 1 tumours, 93.1% in grade 2 tumours, and 84.1% in grade 3 tumours (Figure
5-year disease-specific survival within FIGO stage I endometrioid adenocarcinoma
Of all patients, 183 (95.8%) underwent a surgical procedure. Eight patients (4.1%) did not get any form of surgical therapy. In all records, the reason for noninvasive management was described (2 patients died before therapy could have been started; 5 refused therapy because of severe comorbidity (2 of those 5 received hormonal therapy); 1 refused therapy on personal arguments).
In 178 women (97.3%), the surgical procedure was according to national guidelines. Of all patients that were not treated according to the guidelines, 1 patient underwent a BSO without hysterectomy because of massive extrauterine extension of the tumour into the distal vagina and 4 patients underwent a hysterectomy without the adnexa (because of multiple adnexal adhesions (
During the study period, we did not routinely perform a lymphadenectomy in endometrial cancer patients unless there were palpable lymph nodes. Three (1.7%) patients underwent a lymph node extirpation. All of them had serous tumours. The number of lymph nodes that were dissected was 1–5 nodes. All nodes were negative. There was no additional perioperative morbidity.
From late 2009 onwards, we performed a complete lymph node dissection in two patients with high-grade endometrial cancer. One of them had a clear cell endometrial carcinoma, the other a papillary serous endometrial carcinoma. In these cases, a gynaecologic oncologist performed the procedure (dissected lymph nodes 20–29).
Only the lymph nodes of the patient with the clear cell tumour were positive (4/29). She was upgraded from FIGO stage IC to FIGO stage IIIC and received adjuvant radiotherapy and chemotherapy.
In 9 cases (4.9%), adjuvant radiotherapy was not given according to the Dutch national guidelines of 2000. Three patients were not treated with adjuvant radiotherapy because of severe comorbidity. One patient did not wish to receive adjuvant therapy due to personal reasons. Two patients died before start of adjuvant therapy. For 3 patients, there was no documented argumentation.
Of all recurrences (
In FIGO stage I disease, local recurrences were seen in 5 patients (41.7%), regional recurrences in 1 patient (8.3%), and distant metastases in 6 patients (50.0%). In FIGO stage II, 1 patient (50.0%) had a local recurrence and 1 (50.0%) had a distant metastasis. In FIGO stage III, 6 patients (75.0%) had distant metastases and 1 patient (12.5%) developed a local recurrence.
In FIGO stage I with adjuvant radiotherapy (
A description of a cohort of patients having endometrial cancer is not unique. The patient characteristics, tumour characteristics, survival, and recurrence outcomes in this study are in accordance with large (multicenter) international studies [
A Dutch study in the same region has shown that the incidence of endometrial cancer is increasing [
Besides the changes in patients’ and tumour characteristics, surgical treatment strategies have also undergone some important changes. Since 2010, in low-grade endometrial cancer, a laparoscopic approach is preferred to a laparotomic surgical procedure. Also, a lymphadenectomy is believed to be beneficial in a “selective group” of patients with endometrial cancer [
Aside from these changes in surgical treatment strategies, the indications for adjuvant therapy following surgery are also expanding. Particularly, there is a lot of ongoing research to determine the value of and the indication for chemotherapy or chemoradiation therapy in women with high-risk endometrial cancer [
In the very last period of inclusion for this study, we were already routinely performing a complete lymphadenectomy. The FIGO stage of this patient was upgraded and chemotherapy was added to the adjuvant therapy. In the future, these changes in adjuvant treatment will have influences on the patients’ morbidity.
Boll and coauthors have found that comorbidity decreases the likelihood of receiving adjuvant radiotherapy in patients with FIGO stage I endometrial cancer that were qualified to receive adjuvant radiotherapy according to the Dutch national guidelines [
Yet from today, all those changes will have their effects on the followup of endometrial cancer treatment. In our opinion, it is, therefore, valuable to have the current, more homogenous, cohort clearly described.