FIGO stage IIIC endometrial carcinoma with metastases confined to pelvic lymph nodes: Analysis of treatment outcomes, prognostic variables, and failure patterns following adjuvant radiation therapy

Objectives. This study was undertaken to evaluate the prognostic significan ce of isolated positive pelvic lymph nodes on survival and to analyze other prognostic variables, overall survival, and failure patterns in surgically staged endometrial carcinoma patients with positive pelvic lymph nodes and negative para-aortic lymph nodes following radiation therapy (RT). Methods. Between January 1, 1987, and December 31, 1997, 782 women underwen t primary treatment for uterine cancer at Indiana University Medical Center . Through a review of the medical records, we identified 58 patients with p athologic stage IIIA, 27 patients with pathologic stage IIIB, and 77 patien ts with pathologic stage IIIC endometrial carcinoma. Patients with patholog ically positive or unsampled para-aortic lymph nodes and patients who recei ved preoperative radiation therapy were excluded, leaving a study group of 17 patients with nodal metastases confined to pelvic lymph nodes. Thirteen patients received adjuvant pelvic RT using AP-PA or four-field technique. A median dose of 5040 cGy was delivered. Four patients received whole abdomi nal irradiation (WAI) delivering a median dose of 3000 cGy. Two patients re ceived vaginal cuff boosts of 1000 and 3560 cGy to 0.5 cm from the vaginal surface mucosa via Cs-137 brachytherapy. Two patients also received adjuvan t chemotherapy (cis-platinum and doxorubicin) and/or hormonal therapy (mege strol acetate). Disease-free and overall survivals were estimated using the Kaplan-Meier method of statistical analysis and prognostic variables were analyzed using the log-rank test. Results. With a median follow-up of 51 months the actuarial 5-year disease- free survival was 81% and the actuarial 2-year and 5-year overall survival rates were 81 and 72%, respectively. Univariate analysis revealed that posi tive peritoneal cytology in conjunction with positive pelvic lymph nodes im parts a greater risk of recurrence and decreased overall survival. There we re no pelvic and/or upper abdominal failures, but there were recurrences in the para-aortic lymph nodes (two patients) and distantly (two patients). Conclusion. Surgery followed by postoperative pelvic RT is a viable treatme nt option for pathologically staged stage IIIC endometrial carcinoma with d isease confined to the pelvic lymph nodes. Failures in the para-aortic regi on suggest a possible role for extended-field RT. Patients with positive pe ritoneal cytology in conjunction with nodal metastasis fared poorly with pe lvic RT. Studies evaluating the efficacy of WAI are ongoing. Finally, subst ages within FIGO stage IIIC are recommended in an effort to better understa nd and define treatment strategies which might be appropriate for these pat ients. (C) 1999 Academic Press.