Elsevier

Gynecologic Oncology

Volume 131, Issue 3, December 2013, Pages 598-603
Gynecologic Oncology

Early stage papillary serous or clear cell carcinoma confined to or involving an endometrial polyp: outcomes with and without adjuvant therapy

https://doi.org/10.1016/j.ygyno.2013.10.010Get rights and content

Highlights

  • Clinical outcomes of patients with stage IA UPSC/CC involving a polyp were reviewed

  • 3/32 patients with disease confined to a polyp and 1/19 patients with endometrial surface spread or myometrial invasion progressed

  • No vaginal recurrences occurred

Abstract

Objective

To investigate clinical outcomes of stage IA uterine papillary serous (UPSC) and clear cell carcinoma (CC) arising from or associated with a polyp.

Methods

From 1995 to 2011, we identified 51 cases of stage IA UPSC (67%), CC (8%) or mixed histology (26%) endometrial cancer. Of these, 32 had disease confined to polyp (seven with no residual disease after hysterectomy), 14 had surface spread, 1 had myometrial invasion (MMI) and 4 had both. The majority of patients did not receive adjuvant therapy (80%). Patients given adjuvant treatment (either platinum-based chemotherapy alone, radiation alone, or a combination of the two) had incomplete staging or abnormal cytology.

Results

At mean follow-up of 58.3 months, only 4 patients had progressed, via pelvic adenopathy, carcinomatosis or both. There were no vaginal cuff recurrences. Kaplan–Meier 5 year estimates were pelvic control of 92.1%, disease-free survival 93% and OS 80.6%. Only 9% (3/32) of cases confined to polyp progressed. One responded to salvage chemoradiation, but two died despite salvage. Only 5% (1/19) of cases with surface and MMI progressed. On univariate analysis, only MMI and abnormal/positive cytology were significantly associated with increased pelvic recurrence (MMI p = 0.0059, cytology p = 0.0036) and worse DFS (MMI p = 0.0018, cytology p = 0.0054). Two patients given adjuvant treatment developed new gynecologic malignancies.

Conclusion

In our study, patients with limited UPSC/CC disease involving a polyp who have complete workup did well without adjuvant therapy, with recurrence rates similar to UPSC/CC stage IA disease. Late and extensive pelvic relapses may occur in the few who do relapse.

Introduction

Endometrial cancer is the fourth most common cancer diagnosis in women with 49,560 new cases expected from 2013 [1]. While the 5 year survival for stage IA endometrioid adenocarcinoma is approximately 99% [2], type II subtypes are known to carry a worse prognosis. Included among type II are uterine papillary serous carcinoma (UPSC) and clear cell (CC) carcinoma, considered more high-risk endometrial carcinoma subtypes compared to endometrial adenocarcinoma.

UPSC and CC appear to have higher tendency for lymphovascular invasion, with pattern of failure commonly involving spread via intraperitoneal or extra-abdominal invasion [3], [4]. Prognostic factors for UPSC/CC appear to differ from endometrioid adenocarcinoma. Only stage has consistently been shown to correlate with survival, while myometrial invasion (MMI) has prognostic significance in some but not all studies [4], [5], [6], [7], [8]. No standard treatment regimen exists for early stage UPSC or CC, and stage I–II disease has variably been treated with observation, radiation, chemotherapy or combination modality treatment [8], [9], [10], [11]. In addition, radiation options include therapy given by external beam (EBRT) to the pelvis or by high-dose rate vaginal brachytherapy (VB). Recent papers suggest VB alone may be adequate adjuvant treatment for patients with surgical stage I papillary serous or clear cell carcinoma, given subsequent low vaginal recurrence rates after VB from 0% to 3% and pelvic recurrence of 4–9% [12], [13], [14]. Overall recurrence rates for FIGO 2002 stage IA UPSC from retrospective studies have been reported from 9% to 11%, and up to 13% for stage IA by currently used FIGO 2009 criteria [7], [15]. Observation has been proposed as a reasonable option for stage IA disease, particularly if no myometrial invasion is present [15].

Endometrial cancer confined to a polyp is a clinical scenario that offers particular difficulty given rarity of disease and limited available published data. Given the limited extent of disease but aggressive biologic behavior of UPSC/CC it is unclear whether adjuvant therapy is warranted. While case reports and small series have been published mainly in the pathology literature [16], [17], [18], [19], these often include all stages of UPSC, with inconsistent description of the adjuvant treatment given or details of patients' clinical outcomes. We conducted a retrospective review of our institution's incidence and clinical outcomes of patients with surgical stage IA UPSC/CC involving a polyp observed after surgery or given adjuvant therapy (radiation, chemotherapy, or both).

Section snippets

Materials and methods

Following Institutional Review Board approval, we queried our institution's Cancer Registry for cases of endometrial cancer. Based on stage and histology, we identified 236 cases of stage IA pure UPSC, pure CC or mixed endometrial cancer, diagnosed from 1995 to 2011. The mixed endometrial cancer patients included data of all histologic subtypes, which we then sorted for UPSC/CC. The International Federation of Gynecology and Obstetrics (FIGO) previously defined stage IA disease as endometrial

Results

We identified 51 cases of stage IA UPSC, CC or mixed UPSC/CC involving a polyp, from 1997 to 2011. An additional two patients qualified, but lacked sufficient follow-up data. Medical records of the 51 patients were reviewed for work-up, potential prognostic factors, and clinical outcomes. Slides were reviewed with a gynecological-oncology pathologist specialist if there were incomplete reports, if patients had later progression of disease, or if later development of other gynecologic

Discussion

To our knowledge, this is the largest series reported of stage IA UPSC/CC involving a polyp, with 51 patients in total, 32 of which had disease limited to polyp either at time of hysterectomy or at time of biopsy. Our investigation is limited in retrospective nature (heterogeneity in work-up and staging, variable follow-up time) and by the rarity of this disease, but contributes to the limited body of knowledge on this topic. Previous series have been small with conflicting data, citing

Conclusions

In our study, stage IA UPSC or CC involving a polyp (with limited spread outside of polyp) appeared to have a low recurrence rate similar to that of other stage IA UPSC/CC patients, although late relapses did occur with relapse pattern of failure consisting of extensive pelvic recurrence. Presence of MMI or abnormal cytology may warrant consideration of adjuvant treatment. If recurrence occurs, confirmatory tissue sample may be useful if feasible as it is not impossible for appearance of a new

Conflict of interest statement

None

References (27)

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