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