今日の臨床サポート

子宮体がん(進行期):Ⅱ期以上

著者: 渡利英道1) 北海道大学大学院医学研究院産婦人科学教室

著者: 三田村卓2) 北海道大学病院 婦人科

監修: 青木大輔 慶應義塾大学医学部産婦人科学教室

著者校正/監修レビュー済:2022/05/11
参考ガイドライン:
  1. 日本婦人科腫瘍学会:子宮体がん治療ガイドライン2018年版(金原出版)
患者向け説明資料

概要・推奨   

  1. 子宮内膜に発生した癌が子宮体部を超えて広がり、子宮頸部や卵巣卵管に浸潤した状態、経卵管的に腹腔内に播種した状態、血行性あるいはリンパ行性に転移した状態で発見される。
  1. 漿液性癌や明細胞癌では、原発巣が子宮体部に限局する比較的小さな腫瘍でも播種や転移を起していることがある。
  1. 再発高リスクであり、術後の補助療法や再発時の治療を見越した集学的な治療戦略を練る必要がある。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
渡利英道 : 未申告[2022年]
三田村卓 : 未申告[2022年]
監修:青木大輔 : 講演料(アストラゼネカ,武田薬品工業,中外製薬),研究費・助成金など(MSD,アストラゼネカ,中外製薬)[2022年]

改訂のポイント:
  1. 新たに保険収載された分子標的療法(ペムブロリズマブ、およびペムブロリズマブ+レンバチニブ併用療法)について追記した。

病態・疫学・診察

疾患情報  
  1. ⼦宮内膜に発⽣した癌が子宮体部を超えて広がり、子宮頸部や卵巣卵管に浸潤した状態、経卵管的に腹腔内に播種した状態、血行性あるいはリンパ行性に転移した状態で発見される。
  1. 臨床病理学的分類(子宮体がん(初期):I期を参照)のうち、漿液性癌や明細胞癌などのⅡ型では、原発巣が子宮体部に限局する比較的小さな腫瘍でも播種や転移を起していることがある[1][2]
  1. すべての症例が再発高リスクであり、術後の補助療法や再発時の治療を見越した集学的な治療戦略を練る必要がある。
問診・診察のポイント  
  1. 閉経後女性が性器出血を訴える場合は、子宮体がんを念頭に置いて内診、細胞診、超音波検査を行う。

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最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
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文献 

R Wendel Naumann
Uterine papillary serous carcinoma: state of the state.
Curr Oncol Rep. 2008 Nov;10(6):505-11.
Abstract/Text Uterine papillary serous carcinoma (UPSC) is an aggressive form of endometrial cancer that is likely to present with deep myometrial invasion and lymph vascular involvement. By the time most affected women are diagnosed, the UPSC has spread outside the uterus. Because many reports include patients who are not completely staged, the risk of recurrence in stage I patients has likely been overestimated. Recently, several large series of well-staged patients have demonstrated that survival in stage I patients is similar to that of poorly differentiated endometrioid tumors. Because of the high risk of extrauterine spread, all patients with UPSC should have an extended surgical staging procedure, including lymphadenectomy and omentectomy. Chemotherapy with or without local or regional radiation is probably the most effective adjuvant therapy in both early and advanced disease. Because patients with stage I UPSC are still at significant risk of recurrence, adjuvant therapy is often recommended for all patients. It has been difficult to conduct prospective randomized trials for patients with UPSC because of the rare nature of these cancers.

PMID 18928665
Satoru Sagae, Nobuyuki Susumu, Akila N Viswanathan, Daisuke Aoki, Floor J Backes, Diane M Provencher, Michelle Vaughan, Carien L Creutzberg, Christian Kurzeder, Gunnar Kristensen, Chulmin Lee, Jean-Emmanuel Kurtz, Rosalind M Glasspool, William Small
Gynecologic Cancer InterGroup (GCIG) consensus review for uterine serous carcinoma.
Int J Gynecol Cancer. 2014 Nov;24(9 Suppl 3):S83-9. doi: 10.1097/IGC.0000000000000264.
Abstract/Text OBJECTIVES: Uterine serous carcinoma (USC) represents a rare and aggressive histologic subtype of endometrial cancer, associated with a poor prognosis. This article critically reviews the literature pertinent to the epidemiology, pathology, molecular biology, diagnosis, management, and perspectives of patients with USC.
METHODS: As one of a series of The Gynecologic Cancer InterGroup (GCIG) Rare Tumor Working Group in London, November 2013, we discussed about USC many times with various experts among international GCIG groups.
RESULTS: Both USC and approximately 25% of high-grade endometrioid tumors represent extensive copy number alterations, few DNA methylation changes, low estrogen and progesterone levels, and frequent P53 mutations. Uterine serous carcinoma shares molecular characteristics with ovarian serous and basal-like breast carcinomas. In addition to optimal surgery, platinum- and taxane-based chemotherapy should be considered in the treatment of both early- and advanced-stage disease. The combination of radiation and chemotherapy appears to be associated with the highest survival rates. The role of radiation therapy in the management of this disease, with a high propensity for distant failures, remains elusive.
CONCLUSIONS: Uterine serous carcinoma is a unique and biologically aggressive subtype of endometrial cancer and should be studied as a distinct entity. Futures studies should identify the optimized chemotherapy and radiation regimens, sequence of therapy and schedule, and the role of targeted biologic therapy.

PMID 25341586
Hidemichi Watari, Hiroshi Katayama, Taro Shibata, Kimio Ushijima, Toyomi Satoh, Takashi Onda, Daisuke Aoki, Haruhiko Fukuda, Nobuo Yaegashi, Noriaki Sakuragi, Gynecologic Cancer Study Group of the Japan Clinical Oncology Group
Phase III trial to confirm the superiority of pelvic and para-aortic lymphadenectomy to pelvic lymphadenectomy alone for endometrial cancer: Japan Clinical Oncology Group Study 1412 (SEPAL-P3).
Jpn J Clin Oncol. 2017 Oct 1;47(10):986-990. doi: 10.1093/jjco/hyx108.
Abstract/Text To prospectively investigate the survival benefit of para-aortic lymphadenectomy, we launched a new study, the JCOG1412. This is a randomized Phase III trial to confirm the superiority of pelvic and para-aortic lymphadenectomy to pelvic lymphadenectomy alone. Patients corresponding to possible FIGO Stage IB, II, IIIA, IIIB, and a part of IIIC1 are eligible for the first registration before surgery. Next, those patients without evidence of para-aortic lymph node metastasis and multiple pelvic lymph node metastasis during surgery will be included in the second registration and randomized to either the pelvic lymphadenectomy alone arm or the pelvic and para-aortic lymphadenectomy arm. After the initial surgery, patients with post-operative recurrence risks receive adjuvant chemotherapy. The primary endpoint is overall survival. Secondary endpoints include relapse-free survival, short-term surgical outcomes, adverse events related to adjuvant chemotherapy and recurrence patterns. This trial has been registered at the UMIN Clinical Trials Registry [http://www.umin.ac.jp/ctr/index.htm] as UMIN000025399.

© The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
PMID 28981739
Marcus E Randall, Virginia L Filiaci, Hyman Muss, Nick M Spirtos, Robert S Mannel, Jeffrey Fowler, J Tate Thigpen, Jo Ann Benda, Gynecologic Oncology Group Study
Randomized phase III trial of whole-abdominal irradiation versus doxorubicin and cisplatin chemotherapy in advanced endometrial carcinoma: a Gynecologic Oncology Group Study.
J Clin Oncol. 2006 Jan 1;24(1):36-44. doi: 10.1200/JCO.2004.00.7617. Epub 2005 Dec 5.
Abstract/Text PURPOSE: To compare whole-abdominal irradiation (WAI) and doxorubicin-cisplatin (AP) chemotherapy in women with stage III or IV endometrial carcinoma having a maximum of 2 cm of postoperative residual disease.
PATIENTS AND METHODS: Four hundred twenty-two patients were entered onto this trial. Of 396 assessable patients, 202 were randomly allocated to receive WAI, and 194 were allocated to receive AP. Irradiation dosage was 30 Gy in 20 fractions, with a 15-Gy boost. Chemotherapy consisted of doxorubicin 60 mg/m2 and cisplatin 50 mg/m2 every 3 weeks for seven cycles, followed by one cycle of cisplatin.
RESULTS: Most patient and tumor characteristics were well balanced. The median patient age was 63 years; 50% had endometrioid tumors. Median follow-up time was 74 months. The hazard ratio for progression adjusted for stage was 0.71 favoring AP (95% CI, 0.55 to 0.91; P < .01). At 60 months, 50% of patients receiving AP were predicted to be alive and disease free when adjusting for stage compared with 38% of patients receiving WAI. The stage-adjusted death hazard ratio was 0.68 (95% CI, 0.52 to 0.89; P < .01) favoring AP. Moreover, at 60 months and adjusting for stage, 55% of AP patients were predicted to be alive compared with 42% of WAI patients. Greater acute toxicity was seen with AP. Treatment probably contributed to the deaths of eight patients (4%) on the AP arm and five patients (2%) on the WAI arm.
CONCLUSION: Chemotherapy with AP significantly improved progression-free and overall survival compared with WAI. Nevertheless, further advances in efficacy and reduction in toxicity are clearly needed.

PMID 16330675
Nobuyuki Susumu, Satoru Sagae, Yasuhiro Udagawa, Kenji Niwa, Hiroyuki Kuramoto, Shinji Satoh, Ryuichi Kudo, Japanese Gynecologic Oncology Group
Randomized phase III trial of pelvic radiotherapy versus cisplatin-based combined chemotherapy in patients with intermediate- and high-risk endometrial cancer: a Japanese Gynecologic Oncology Group study.
Gynecol Oncol. 2008 Jan;108(1):226-33. doi: 10.1016/j.ygyno.2007.09.029. Epub 2007 Nov 9.
Abstract/Text OBJECTIVE: To establish an optimal adjuvant therapy for intermediate- and high-risk endometrial cancer patients, we conducted a multi-center randomized phase III trial of adjuvant pelvic radiation therapy (PRT) versus cyclophosphamide-doxorubicin-cisplatin (CAP) chemotherapy in women with endometrioid adenocarcinoma with deeper than 50% myometrial invasion.
METHODS: Among 385 evaluated patients, 193 patients received PRT and 192 received CAP. The PRT group received at least 40 Gy. The CAP group received cyclophosphamide (333 mg/m2), doxorubicin (40 mg/m2) and cisplatin (50 mg/m2) every 4 weeks for 3 or more courses.
RESULTS: No statistically significant differences in progression-free survival (PFS) and overall survival (OS) were observed. The 5-year PFS rates in the PRT and CAP groups were 83.5% and 81.8% respectively, while the 5-year OS rates were 85.3% and 86.7% respectively. These rates were also not significantly different in a low- to intermediate-risk group defined as stage IC patients under 70 years old with G1/2 endometrioid adenocarcinoma. However, among 120 patients in a high- to intermediate-risk group defined as (1) stage IC in patients over 70 years old or with G3 endometrioid adenocarcinoma or (2) stage II or IIIA (positive cytology), the CAP group had a significantly higher PFS rate (83.8% vs. 66.2%, log-rank test P=0.024, hazard ratio 0.44) and higher OS rate (89.7% vs. 73.6%, log-rank test P=0.006, hazard ratio 0.24). Adverse effects were not significantly increased in the CAP group versus the PRT group.
CONCLUSION: Adjuvant chemotherapy may be a useful alternative to radiotherapy for intermediate-risk endometrial cancer.

PMID 17996926
David M O'Malley, Giovanni Mendonca Bariani, Philippe A Cassier, Aurelien Marabelle, Aaron R Hansen, Ana De Jesus Acosta, Wilson H Miller, Tamar Safra, Antoine Italiano, Linda Mileshkin, Lei Xu, Fan Jin, Kevin Norwood, Michele Maio
Pembrolizumab in Patients With Microsatellite Instability-High Advanced Endometrial Cancer: Results From the KEYNOTE-158 Study.
J Clin Oncol. 2022 Mar 1;40(7):752-761. doi: 10.1200/JCO.21.01874. Epub 2022 Jan 6.
Abstract/Text PURPOSE: Pembrolizumab demonstrated durable antitumor activity in patients with previously treated, advanced microsatellite instability-high or mismatch repair-deficient (MSI-H/dMMR) tumors, including endometrial cancer, in the nonrandomized, open-label, multicohort, phase II KEYNOTE-158 study (NCT02628067). We report efficacy and safety outcomes for patients with MSI-H/dMMR endometrial cancer enrolled in KEYNOTE-158.
METHODS: Eligible patients from cohorts D (endometrial cancer, regardless of MSI-H/dMMR status) and K (any MSI-H/dMMR solid tumor, except colorectal) with previously treated, advanced MSI-H/dMMR endometrial cancer received pembrolizumab 200 mg once every 3 weeks for 35 cycles. The primary end point was objective response rate per RECIST version 1.1 by independent central radiologic review. Secondary end points included duration of response, progression-free survival, overall survival, and safety.
RESULTS: As of October 5, 2020, 18 of 90 treated patients (20%) had completed 35 cycles of pembrolizumab and 52 (58%) had discontinued treatment. In the efficacy population (patients who received ≥ 1 dose of pembrolizumab and had ≥ 26 weeks of follow-up; N = 79), the median time from first dose to data cutoff was 42.6 (range, 6.4-56.1) months. The objective response rate was 48% (95% CI, 37 to 60), and median duration of response was not reached (2.9-49.7+ months). Median progression-free survival was 13.1 (95% CI, 4.3 to 34.4) months, and median overall survival was not reached (95% CI, 27.2 months to not reached). Among all treated patients, 76% had ≥ 1 treatment-related adverse event (grades 3-4, 12%). There were no fatal treatment-related events. Immune-mediated adverse events or infusion reactions occurred in 28% of patients (grades 3-4, 7%; no fatal events).
CONCLUSION: Pembrolizumab demonstrated robust and durable antitumor activity and encouraging survival outcomes with manageable toxicity in patients with previously treated, advanced MSI-H/dMMR endometrial cancer.

PMID 34990208
Vicky Makker, Nicoletta Colombo, Antonio Casado Herráez, Alessandro D Santin, Emeline Colomba, David S Miller, Keiichi Fujiwara, Sandro Pignata, Sally Baron-Hay, Isabelle Ray-Coquard, Ronnie Shapira-Frommer, Kimio Ushijima, Jun Sakata, Kan Yonemori, Yong Man Kim, Eva M Guerra, Ulus A Sanli, Mary M McCormack, Alan D Smith, Stephen Keefe, Steven Bird, Lea Dutta, Robert J Orlowski, Domenica Lorusso, Study 309–KEYNOTE-775 Investigators
Lenvatinib plus Pembrolizumab for Advanced Endometrial Cancer.
N Engl J Med. 2022 Feb 3;386(5):437-448. doi: 10.1056/NEJMoa2108330. Epub 2022 Jan 19.
Abstract/Text BACKGROUND: Standard therapy for advanced endometrial cancer after failure of platinum-based chemotherapy remains unclear.
METHODS: In this phase 3 trial, we randomly assigned, in a 1:1 ratio, patients with advanced endometrial cancer who had previously received at least one platinum-based chemotherapy regimen to receive either lenvatinib (20 mg, administered orally once daily) plus pembrolizumab (200 mg, administered intravenously every 3 weeks) or chemotherapy of the treating physician's choice (doxorubicin at 60 mg per square meter of body-surface area, administered intravenously every 3 weeks, or paclitaxel at 80 mg per square meter, administered intravenously weekly [with a cycle of 3 weeks on and 1 week off]). The two primary end points were progression-free survival as assessed on blinded independent central review according to the Response Evaluation Criteria in Solid Tumors, version 1.1, and overall survival. The end points were evaluated in patients with mismatch repair-proficient (pMMR) disease and in all patients. Safety was also assessed.
RESULTS: A total of 827 patients (697 with pMMR disease and 130 with mismatch repair-deficient disease) were randomly assigned to receive lenvatinib plus pembrolizumab (411 patients) or chemotherapy (416 patients). The median progression-free survival was longer with lenvatinib plus pembrolizumab than with chemotherapy (pMMR population: 6.6 vs. 3.8 months; hazard ratio for progression or death, 0.60; 95% confidence interval [CI], 0.50 to 0.72; P<0.001; overall: 7.2 vs. 3.8 months; hazard ratio, 0.56; 95% CI, 0.47 to 0.66; P<0.001). The median overall survival was longer with lenvatinib plus pembrolizumab than with chemotherapy (pMMR population: 17.4 vs. 12.0 months; hazard ratio for death, 0.68; 95% CI, 0.56 to 0.84; P<0.001; overall: 18.3 vs. 11.4 months; hazard ratio, 0.62; 95% CI, 0.51 to 0.75; P<0.001). Adverse events of grade 3 or higher occurred in 88.9% of the patients who received lenvatinib plus pembrolizumab and in 72.7% of those who received chemotherapy.
CONCLUSIONS: Lenvatinib plus pembrolizumab led to significantly longer progression-free survival and overall survival than chemotherapy among patients with advanced endometrial cancer. (Funded by Eisai and Merck Sharp and Dohme [a subsidiary of Merck]; Study 309-KEYNOTE-775 ClinicalTrials.gov number, NCT03517449.).

Copyright © 2022 Massachusetts Medical Society.
PMID 35045221
Mandira Ray, Gini Fleming
Management of advanced-stage and recurrent endometrial cancer.
Semin Oncol. 2009 Apr;36(2):145-54. doi: 10.1053/j.seminoncol.2008.12.006.
Abstract/Text Endometrial carcinoma is frequently diagnosed at an early stage, at which point it is usually surgically curable. Some less common subtypes of endometrial carcinoma, such as serous and clear cell carcinomas, have a worse prognosis than most endometrioid carcinomas. Patients with advanced or recurrent disease, regardless of histologic subtype, have a poor prognosis. Both single-agent and combination chemotherapy regimens (such as doxorubicin, cisplatin, and paclitaxel) have antitumor activity but are not curative. Recently, adjuvant chemotherapy has been shown to improve outcomes in high-risk nonmetastatic (stage III) disease. Newer agents such as mammalian target of rapamycin (mTOR) inhibitors show promise, and are currently being tested in a clinical trials.

PMID 19332249
C E Humber, J F Tierney, R P Symonds, M Collingwood, J Kirwan, C Williams, J A Green
Chemotherapy for advanced, recurrent or metastatic endometrial cancer: a systematic review of Cochrane collaboration.
Ann Oncol. 2007 Mar;18(3):409-20. doi: 10.1093/annonc/mdl417. Epub 2006 Dec 5.
Abstract/Text BACKGROUND: Cytotoxic chemotherapy has a limited place in the management of advanced or recurrent endometrial cancer. Commonly used agents include cisplatin and doxorubicin, but the side-effect profile may be unacceptable for many patients. The feasibility of administration of combination chemotherapy is limited in many patients on account of significant co-morbidity. While early-stage endometrial adenocarcinoma is a common gynaecological cancer with a favourable prognosis, advanced or recurrent disease presents a difficult management problem. The platinum and anthracycline compounds have been widely used for many years, but their impact on progression-free survival (PFS) and overall survival (OS) is not clear. This systematic review aimed to evaluate both the benefits and adverse effects of cytotoxic chemotherapy in these women.
PATIENTS AND METHODS: We carried out systematic searches for randomised controlled trials (RCTs) comparing chemotherapy with another intervention. Data were extracted from trial reports or supplied by investigators. Where possible, hazard ratios (HRs) were calculated for OS and PFS and odds ratios (ORs) were calculated for acute toxicity. The impact of more versus less intensive chemotherapy on OS, PFS and acute toxicity was assessed in a meta-analysis.
RESULTS: Eleven eligible RCTs were identified that recruited 2288 patients. A meta-analysis of six of these trials found that PFS [HR = 0.80, 95% confidence interval (CI) 0.71-0.90; P = 0.004], but not OS (HR = 0.90, 95% CI 0.80-1.03; P = 0.12), was significantly improved when more intensive chemotherapy was compared with less intensive chemotherapy. OS was improved when doxorubicin, cisplatin and other drugs were compared with doxorubicin and cisplatin. Toxicity was generally higher with more chemotherapy. There was insufficient evidence to assess the effect of chemotherapy on symptom control or quality of life (QoL). Platinums, anthracyclines and taxanes were the most studied in phase II trials and combinations gave the best responses, but patient selection and pre-treatment was very variable.
CONCLUSIONS: More intense combination chemotherapy significantly improves the disease-free survival and the data indicate a modest improvement in OS. The addition of anthracyclines (e.g. doxorubicin) or the taxanes [e.g. paclitaxel (Taxol)] to cisplatin increases the response rate. More intensive regimens are associated with the gain in survival. However, grade 3 and 4 myelosuppression and gastrointestinal toxicity are also increased. Future developments are likely to exploit specific molecular characteristics of endometrial cancers, including their hormone dependence, growth factor target overexpression and PTEN loss. While no one drug or regimen offers a clear benefit for women with advanced endometrial cancer, platinum drugs, anthracyclines and paclitaxel seem the most promising agents. Future trials should address the impact of such agents on QoL and symptom control in addition to survival. Chemotherapy and endocrine therapy need to be compared directly in an RCT.

PMID 17150999
M C Fleisch, P Pantke, M W Beckmann, H G Schnuerch, R Ackermann, M O Grimm, H G Bender, P Dall
Predictors for long-term survival after interdisciplinary salvage surgery for advanced or recurrent gynecologic cancers.
J Surg Oncol. 2007 May 1;95(6):476-84. doi: 10.1002/jso.20686.
Abstract/Text BACKGROUND AND OBJECTIVES: We wanted to identify factors which allow predicting long-term survival after pelvic exenteration (PE) for locally advanced or recurrent gynecologic malignancies.
METHODS: All patients undergoing PE at our institution from 1983 to 2002 were screened. In 203 cases data were obtainable and analyzed with respect to factors predicting outcome considering morbidity, mortality, and survival. Follow-up data and data concerning late complications not documented in our records were obtained by telephone interviews.
RESULTS: Mean age was 55 (22-77) years. PE was performed for locally advanced (36%) or recurrent (64%) cervical (n = 133), endometrial (n = 26), vaginal (n = 23), vulvar (n = 10), and ovarian cancer (n = 11, cases with rectum and/or bladder resections). In 13.4% (n = 26) the intent of the procedure was palliation in the remaining cure. Procedures performed were anterior (n = 91), posterior (45), or total (n = 67) PE. 53% of patients underwent preoperative radio-chemotherapy, 11.8% as a neoadjuvant treatment. Mean OR time was 8.1 hr, an average of 5.6 units of packed red blood cells were perioperatively transfused. Microscopically complete resection was achievable in n = 69 patients. Perioperative mortality was 1% (n = 2). Seventy-one percent (n = 144) of patients were available for follow-up. Five-year overall survival in patients treated with a curative intent was 21%, 5-year survival in those patients with complete resection was 32%. Forty-two percent of patients with a complete resection without lymph node involvement, age 30-50, curative intention, and the absence of a pelvic sidewall infiltration survived 5 years or longer.
CONCLUSION: In our series a 5-year survival rate of over 40% could be achieved for nodal-negative patients without pelvic sidewall infiltration when treated with curative intent and after complete resection.

Copyright 2007 Wiley-Liss, Inc.
PMID 17192947
Sean C Dowdy, Andrea Mariani, William A Cliby, Michael G Haddock, Ivy A Petersen, Franklin H Sim, Karl C Podratz
Radical pelvic resection and intraoperative radiation therapy for recurrent endometrial cancer: technique and analysis of outcomes.
Gynecol Oncol. 2006 May;101(2):280-6. doi: 10.1016/j.ygyno.2005.10.018.
Abstract/Text OBJECTIVE: To describe the technique and assess outcomes and morbidity following radical resection combined with intraoperative electron radiation therapy (IOERT) in patients with recurrent endometrial cancer.
METHODS: From 1986 to 2002, 25 patients received treatment including radical resection and IOERT for recurrent endometrioid, endometrial cancer. Relevant clinical information was extracted through retrospective chart review.
RESULTS: Treatment prior to referral included radiation in 56% and either a secondary surgery or chemotherapy in 48%. External radiation (EBRT) was administered in addition to IOERT in 84%. Radical procedures performed at the time of IOERT included resection of the pelvic sidewall en bloc with the obturator nerve, external iliac vein, psoas, iliacus, or obturator internus muscles, ureter, or boney ileum. Seven patients required exenteration in combination with resection of the pelvic sidewall. The median IOERT dose was 1500 cGy (range 1000-2500 cGy). Overall five-year survival was 47% vs. 71% for those with a gross total resection but close margins. Two patients with recurrences limited to the para-aortic area are alive without evidence of disease at 54 and 71 months. Proportional hazards modeling showed concurrent EBRT, tumor size after resection, grade, and age to be associated with improved survival. The most common complications were peripheral neuropathy, functional ureteral obstruction, and fistula formation.
CONCLUSIONS: With an aggressive treatment approach including radical resection combined with IOERT, long-term survival is possible in a significant number of patients with localized recurrent endometrial cancer. Preoperative radiation paired with complete surgical resection utilizing extended procedures is paramount to achieving optimal outcomes.

PMID 16321431

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