Short-term sequelae (diarrhea and urinary frequency) were noted by most subjects but were generally mild and well controlled with oral medication. No subject needed a treatment break for these sequelae. Only three women (5%) developed long-term sequelae. Two subjects had mild vaginal stenosis and one noted intermittent loose stools. No women had severe stenosis, vaginal vault necrosis, small bowel obstruction, proctitis, or fistulae.
The purpose of this study was to determine the outcomes of patients with stage IC endometrial carcinoma treated with surgery and adjuvant pelvic radiation alone. Our results suggested that, in women treated this way, there is excellent local control of the cancer. None of the 61 patients (74% of whom had grade 2 or 3 tumors) had local recurrence with median follow-up of 69.5 months. Our overall pelvic control rate at 5 years was excellent (98.2%). Few investigators focused on stage I endometrial cancer patients with deep myometrial invasion treated with postoperative pelvic radiation without vaginal brachytherapy. Torrisi et al11 evaluated 46 clinically staged IA–B endometrial cancer patients treated with TAH-BSO and pelvic radiation alone. Twenty-three (50%) had myometrial invasion to the outer third and 17 (37%) had middle-third invasion. Three patients (6.5%) had pelvic recurrences (two in the upper vagina). Since the 1988 FIGO staging system was not used, it is unclear how many patients had stage IC disease.11 In contrast, Rush and coworkers12 noted no local recurrences in 53 patients with stage IC disease after postoperative pelvic radiation alone. Similarly, Piver and Hempling14 treated 41 patients who had either grade 3 disease or more than half myometrial invasion by using postoperative pelvic radiation without vaginal brachytherapy. Thirty-two patients had stage IC disease and local recurrence developed in none. A recurrence developed in one in the lateral pelvis. Randall and coworkers13 evaluated the outcome of 52 patients with stage I disease treated with TAH-BSO and pelvic irradiation alone. Because the 1988 FIGO system was not used, it is unclear how many patients had stage IC disease. Of the 20 patients with invasion to the outer third of the myometrium, only one developed a recurrence in the pelvis. As shown in Table 2, there was no increased risk of local recurrence in patients with deep myometrial invasion treated with postoperative pelvic radiation alone compared with those treated with pelvic radiation plus vaginal brachytherapy.
Eliminating vaginal brachytherapy in treatment of stage IC disease has many important potential benefits. The risk of radiation sequelae, including vaginal stenosis and vault necrosis, is reduced. None of our patients treated with pelvic radiation alone developed vaginal necrosis, fistulae, or significant stenosis. In a study of 330 patients with stage I or II endometrial cancer treated with surgery, pelvic radiation, and vaginal brachytherapy, Mandell et al16 reported a 3.7% vaginal complication rate (2.7% stenosis, 1% necrosis). In a similar series, Nori and coworkers7 noted vaginal stenosis and necrosis in 2.5% and 0.5% of their patients, respectively. Randall et al13 analyzed the risk of long-term sequelae in patients with stage I endometrial cancer treated with pelvic radiation with and without vaginal brachytherapy. Patients receiving vaginal brachytherapy had higher rates of chronic diarrhea (9.8% versus 3.8%) and rectal bleeding or proctitis (18.6% versus 3.8%) compared with patients treated with pelvic radiation alone.13 Vaginal brachytherapy also has potential short-term sequelae, particularly when delivered with low-dose-rate techniques that require inpatient hospitalization. Lanciano et al17 noted that age over 50 years was independently correlated with the development of short-term sequelae during vaginal brachytherapy for gynecologic tumors. That correlation is particularly relevant because endometrial cancer patients often present in the sixth and seventh decades of life.
Vaginal brachytherapy can also adversely affect sexual function. We did not have sufficient information from our patients to comment on sexual outcomes; however, others performed detailed analyses of sexual outcomes in patients with endometrial carcinoma. Bruner et al18 conducted a prospective study of sexual function in 48 women treated with postoperative vaginal brachytherapy with and without pelvic radiation. After treatment, 44% of patients complained of dyspareunia. In addition, sexual satisfaction was found to be significantly decreased compared with pretreatment baseline. Cochran and coworkers19 noted that more endometrial cancer patients treated with postoperative pelvic radiation and vaginal brachytherapy had decreased coital frequency (44% versus 25%) compared with surgery alone.19 Neither study included patients who received pelvic radiation without vaginal brachytherapy.
Eliminating vaginal brachytherapy also reduces overall treatment time commitment. Low-dose-rate brachytherapy typically requires 1 or 2 days of hospitalization. Many centers now use high-dose-rate techniques, obviating hospitalization and general anesthesia. High-dose-rate brachytherapy is generally performed over several sessions, which adds time to the overall treatment course and has its own potential short-term sequelae.
In today's cost-containment health care environment, another potential benefit of eliminating vaginal brachytherapy is reduced treatment cost. Konski and coworkers20 did a cost analysis of treatment options for stage I endometrial carcinoma. Adjuvant vaginal brachytherapy added significant costs compared with pelvic radiation alone. The overall costs of low-dose-rate and high-dose-rate vaginal brachytherapy were 1.8 and 2.3 times the cost of pelvic radiation alone.20
Our analysis has several limitations. It is retrospective and suffers from all the limitations inherent in such an analysis. The women were treated over a 15-year period, although they were staged and treated uniformly. Only patients with deep myometrial invasion found in hysterectomy specimens were included, and the median follow-up exceeded 5 years; 74% had grade 2 or 3 disease.
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