Radiation Oncology/Endometrium/Clear Cell

Endometrium Clear Cell Carcinoma Pathology Endometrioid (75-80%) Clear cell (5-10%) Clear due to presence of glycogen Tubulocystic, papillary, or solid patterns Psammoma bodies not as common Have to be present in at least 25-50% (depending on pathologist) of sample to qualify as clear cell Aggressive, with myometrial invasion in ~80% Papillary serous (1-5%) Complex papillary architecture, similar to papillary serous CA of ovary Presence of psammoma bodies Marked nuclear atypia Believed to transform from endometrial surface epithelium Mixed pattern Serous and endometrioid histology present next to each other in the specimen If >50% serous component, classified as papillary serous If 10-50% serous component, classified as mixed serous Rare tumor types (<2%) Mucinous, squamous cell, transitional cell, small cell Whole Abdomen RT GOG 94 (1986-1994) 2006 16213007 -- "Adjuvant whole abdominal irradiation in clinical stages I and II papillary serous or clear cell carcinoma of the endometrium: a phase II study of the Gynecologic Oncology Group." (Sutton G, Gynecol Oncol. 2006 Feb;100(2):349-54.) Phase II. 21 patients treated with TAH/BSO, PPALND, WART 30/20 and pelvic boost to 50 Gy Outcome: >50% failures within RT field UPSC: 5-year OS 38%, PFS 38% Clear cell: 5-year OS 54%, PFS 54% Toxicity: 17% Grade 3-4 GI toxicity (SBO, proctitis, N/V) Conclusion: WART alone not adequate, chemotherapy needs to be a component of treatment. Clear cell better outcome than UPSC Stanford; 2000 (1979-1998) 11020574 -- "Treatment of high-risk uterine cancer with whole abdominopelvic radiation therapy." (Smith RS, Int J Radiat Oncol Biol Phys. 2000 Oct 1;48(3):767-78.) Retrospective. 48 patients with Stage III-IV endometrial ACA (n=22) or Stage I-IV UPSC or CC (n=26), treated with postop WART. Median dose 30 Gy abdomen (in 1.2-1.5 Gy/fx) and 50 Gy pelvis (in 1.2-1.8 Gy/fx). PALN boost to 44 Gy in 9 patients. Vaginal brachy in 24 patients. Mean F/U 3.1 years Outcome: 3-year OS all patients 77%, ACA 89% vs. UPSC/CC 68%; UPSC/CC Stage I-II OS 87% vs. Stage III-IV 61%; DFS 87% vs. 31% Toxicity: major complications (SBO) 7%, no deaths, 23% required break >1 week Conclusion: WART is safe, effective. Recommend with vaginal cuff brachy for Stage I-II. Recommend with concurrent or sequential chemo in Stage III-IV UPSC/CC until results of GOG 94 and GOG 122 become available (see Advanced Stage chapter). Retrospective results U. Chicago; 2003 (1980-2000) 12654437 PDF -- "Outcome and patterns of failure in pathologic stages I-IV clear-cell carcinoma of the endometrium: implications for adjuvant radiation therapy." (Murphy KT, Int J Radiat Oncol Biol Phys. 2003 Apr 1;55(5):1272-6.) 38 pts with clear cell histology who were treated with TAH/BSO. 22 received post-op RT. 5-yr DFS 38.5%. Median time to failure 18 mos. There was no correlation of outcome with stage, myometrial invasion, cervical invasion, peritoneal fluid, or extrauterine involvement. Of 16 relapses (42%), 8 failed in the pelvis; no pelvic failures for those treated with RT. 6 pts (16%) para-aortic node recurrence; 5% - abdomen; 24% - distant. Conclusion: Recommend RT to the pelvis, even in early stage cases. Phosphorus-32 (P32) HOG 97-01 15721431 -- "Intraperitoneal radioactive phosphorus (32P) and vaginal brachytherapy as adjuvant treatment for uterine papillary serous carcinoma and clear cell carcinoma: a phase II Hoosier Oncology Group (HOG 97-01) study." (Fakiris AJ, Gynecol Oncol. 2005 Mar;96(3):818-23.) Phase II. 21 patients s/p TAH-BSO, residual peritoneal disease <3mm, negative PPALN. Intraperitoneal P-32 15 mCi within 8 weeks. Vaginal BT. Median F/U Outcome: 2-year OS 89%, DFS 80%; recurrences 5/21, but only 2/21 intraperitoneal Toxicity: No Grade 2-4 Conclusion: Adjuvant intraperitoneal P-32 and vaginal BT feasible, well tolerated