EFFECTIVE TREATMENT OF STAGE-I UTERINE PAPILLARY SEROUS CARCINOMA WITH HIGH-DOSE-RATE VAGINAL APEX RADIATION (IR-192) AND CHEMOTHERAPY

Purpose: Uterine papillary serous carcinoma (UPSC) is a morphologicall y distinct variant of endometrial carcinoma that is associated with a poor prognosis, high recurrence rate, frequent clinical understaging, and poor response to salvage treatment. We retrospectively analyzed lo cal control, actuarial overall survival (OS), actuarial disease-free s urvival (DFS), salvage rate, and complications for patients with Feder ation International of Gynecology and Obstetrics (FIGO) (1988) Stage I UPSC. Methods and Materials: This retrospective analysis describes 38 patients with FIGO Stage I UPSC who were treated with the combination s of radiation therapy, chemotherapy, total abdominal hysterectomy, an d bilateral salpingo-oophorectomy (TAH/BSO), with or without a surgica l staging procedure. Twenty of 38 patients were treated with a combina tion of low dose-rate (LDR) uterine/vaginal brachytherapy using Ra-226 or Cs-137 and conventional whole-abdomen radiation therapy (WART) or whole-pelvic radiation therapy (WPRT). Of 20 patients (10%) in this tr eatment group, 2 received cisplatin chemotherapy. Eighteen patients we re treated with high dose-rate (HDR) vaginal apex brachytherapy using Ir-192 With an afterloading device and cisplatin, doxorubicin, and cyc lophosphamide (CAP) chemotherapy (5 of 18 patients). Only 6 of 20 UPSC patients treated with combination LDR uterine/vaginal brachytherapy a nd conventional external beam radiotherapy underwent complete surgical staging, consisting of TAH/BSO, pelvic/para-aortic lymph node samplin g, omentectomy, and peritoneal fluid analysis, compared to 15 of 18 pa tients treated with HDR vaginal apex brachytherapy. Results: The 5-yea r actuarial OS for patients with complete surgical staging and adjuvan t radiation/chemotherapy treatment was 100% vs. 61% for patients witho ut complete staging (p = 0.002). The 5-year actuarial OS for all Stage I UPSC patients treated with postoperative HDR vaginal apex brachythe rapy and systemic chemotherapy was 94% (18 patients). The 5-year actua rial OS for Stage I UPSC patients treated with HDR vaginal apex brachy therapy and chemotherapy who underwent complete surgical staging was 1 00% (15 patients). The 5-year actuarial OS for the 20 Stage I UPSC pat ients treated with combinations of pre-and postoperative LDR brachythe rapy and postop WART was 65%. None of the 6 surgically staged UPSC pat ients treated with LDR radiation and WART/WPRT developed recurrent dis ease. For patients with FIGO Stage IA, IB, and IC UPSC who underwent c omplete surgical staging, the 5-year actuarial DFS by depth of myometr ial invasion was 100, 71, and 40%, respectively (p = 0.006). The overa ll salvage rate for local and distant recurrence was 0%. Complications following HDR vaginal apex brachytherapy included only Radiation Ther apy Oncology Group (RTOG) grade 1 and 2 toxicity in 16% of patients. H owever, complications from patients treated with WART/WPRT, and/or LDR brachytherapy, included RTOG grade 3 and 4 toxicity in 15% of patient s. Conclusion: Patients with UPSC should undergo complete surgical sta ging, and completely surgically staged FIGO Stage I UPSC patients can be effectively and safely treated with HDR vaginal apex brachytherapy and chemotherapy. Both OS and DFS of patients with UPSC are dependent on depth of myometrial invasion. The salvage rate for both local and d istant UPSC recurrences is extremely poor. Complications from HDR vagi nal apex brachytherapy were minimal. (C) 1998 Elsevier Science Inc.