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The Impact of Adjuvant Radiation Treatment on Survival of Patients With High-Risk, Early-Stage Endometrial Carcinoma
S418
International Journal of Radiation Oncology Biology Physics
disease with surgical staging followed by adjuvant brachytherapy, external beam radiation, or both, in conjunction with chemotherapy. Materials/Methods: We undertook a retrospective review at two institutions of 43 consecutively treated patients undergoing definitive therapy between 2003 and 2012 with histologically-confirmed carcinosarcoma who underwent a combined regimen of surgery, vaginal brachytherapy, whole pelvic radiation, or both, and chemotherapy. Chemotherapy included carboplatin/taxol, ifosfamide/taxol, cisplatin, and cisplatin/adriamycin given in a sequential or sandwich course. Data with respect to disease and treatment characteristics were recorded. Overall survival and disease recurrence analyses were conducted using Kaplan-Meier and Cox Proportional Hazards models. Results: The median age of women was 64 years (range, 46-78 years). Stage breakdown was as follows: Stage IA (15), Stage IB (6), Stage II (3), Stage IIIA (4), Stage IIIB (1) Stage IIIC (13), Stage IVA (1). Median time to local recurrence (LR) was 14.1 months (range, 8.1-38.8 months). Median time to distant recurrence (DR) was 15.2 months (range, 11.5-38.8 months). The median dose of EBRT was 4650 Gy (range, 2000-6440 Gy) and the median dose of brachytherapy was 1200 Gy (range, 500-2100 Gy). 33 patients received EBRT +/- brachytherapy while 10 received brachytherapy alone. Eighty-one percent of patients received carboplatin/taxol chemotherapy. Median follow-up was 1.9 years (range, 0.3-7.1 years). Rates of 3-year overall survival, LR-free survival, DR-free survival, and overall disease free survival were 64%, 81%, 76%, and 81%, respectively. Cox proportional hazards analysis revealed that decreased overall survival was correlated with advanced cancer stage (HR Z 1.30, p Z 0.02) and that decreased freedom from DR was correlated with the presence of positive lymph nodes at diagnosis (HR Z 4.87, p Z 0.04) as well as cancer stage (HR Z 1.33, p Z 0.04). There was no effect of these variables on LR among 7 total LRs. Among Stage I or II patients who received EBRT +/- brachytherapy (n Z 16) compared to brachytherapy alone (n Z 7), there was also no difference in the rate of LR although only 3 total LRs were observed in this group. Overall, multi-modality therapy was well tolerated with 12% incidence of grade 3 acute toxicity and a 2% incidence of chronic grade 3 toxicity. Conclusions: For patients with uterine carcinosarcoma, the combined approach of surgical debulking followed by radiation therapy in conjunction with chemotherapy is well tolerated with and yields favorable survival and recurrence outcomes. Author Disclosure: D. Guttmann: None. H. Li: None. S. Grover: None. S. Bhatia: None. G. Jacobson: None. L. Lin: None.
Results: Bladder volumes varied greatly throughout treatment. Median bladder full and bladder empty volumes at planning were 278.6 cc (range, 43.7-639.5 cc) and 91.7 cc (range, 30.3-507.4 cc), respectively. Of the 240 daily measurements of bladder volume, a total of 122 (50.8%) had a bladder volume that was either greater or less than the planning bladder full or empty volume, respectively. Median bladder volume for all treatments was 167.6 cc (range, 43.2-514.7 cc). Daily rectal volume also varied during treatment. Median rectal volume for all patients at planning was 66.5 cc (range, 37.0-100.1 cc). Median daily percent variation from the rectal planning volume was 27.2% (range, 52.3-230.3%). Conclusions: This study was initiated as a departmental quality assurance project to assess the reproducibility of daily bladder filling for women receiving post-operative WP-IMRT. Our study demonstrates significant daily variations in bladder filling throughout the course of radiation, despite detailed instructions on bladder filling for daily treatments. Over half of the fractions were performed with bladder volumes that were outside of the bladder full and bladder empty scan volumes defined at planning, indicating that patients cannot reliably fill their bladders to a reproducible volume. Additionally, rectal volumes were found to vary greatly from planning. It is critical to recognize that these large daily variations exist and may potentially lead to variations in target volume in this patient population. Author Disclosure: C.S. Platta: None. E. Urban: None. M. Straub: None. K. Bradley: None.
2560 Daily Variation in Bladder and Rectal Volume During Postoperative Whole Pelvic Intensity Modulated Radiation Therapy C.S. Platta, E. Urban, M. Straub, and K. Bradley; University of Wisconsin Hospital & Clinics Madison, Madison, WI Purpose/Objective(s): To evaluate daily changes in bladder and rectal volume for women receiving post-operative whole pelvic intensity modulated radiation therapy (WP-IMRT) for cervical or endometrial cancer, as part of a departmental quality assurance initiative. Materials/Methods: Following IRB approval, ten patients that had previously received WP-IMRT following hysterectomy were identified for analysis. All patients were treated on a Tomotherapy unit between 2009 and 2012. Per department protocol, all patients were instructed to have a comfortably full bladder prior to the planning CT and prior to each fraction of therapy. Two CTs were obtained at planning, one with the bladder full, and one empty. No instructions were provided for rectal filling. Prior to each fraction of therapy, patient alignment was confirmed using an onboard megavoltage computed tomography (MVCT) scan. The daily MVCT images and the planning CT images were restored for analysis in a registration software. Bladder full volume, bladder empty volume, and rectal volume was measured on each patient’s planning CT. Each daily MVCT image was then fused to the planning scan. Bladder and rectum were contoured on each MVCT to measure daily structure volume. A total of 240 daily MVCTs were usable to calculate bladder volume, and a total of 255 to calculate rectal volume.
2561 The Impact of Adjuvant Radiation Treatment on Survival of Patients With High-Risk, Early-Stage Endometrial Carcinoma M.A. Elshaikh, S. Patel, M. Mahan, and A. Munkarah; Henry Ford Health System, Detroit, MI Purpose/Objective(s): For patients with early-stage endometrial carcinoma, two prospective randomized studies confirmed the benefits of adjuvant radiation treatment (RT) after hysterectomy in reducing local recurrences. Many have suggested that patients enrolled in these studies were at too low of a risk to demonstrate improved survival with adjuvant RT. The objective of this study is to determine the impact of adjuvant RT on relapse-free (RFS), disease-specific (DSS) and overall survival (OS) of patients with high-risk FIGO stage I-II endometrial carcinoma (EC). Materials/Methods: Our prospectively-maintained database of 1610 uterine cancer patients was reviewed for this IRB-approved study. We identified 382 consecutive patients with high-risk EC 2009 FIGO stage I-II who underwent hysterectomy between 1987 and 2012 with a minimum of one year follow-up after surgery. High-risk was defined as per GOG 249 protocol as patients with endometrioid histology stage I with either a) age 70 years with one risk factor, or age 50 with two risk factors or age 18 with 3 risk factors. Risk factors included grade 2 or 3 tumors, lymphovascular space involvement (LVSI), or myometrial involvement 50%. Patients with stage II endometrioid EC, patients with serous and clear cell histologies stages I-II with negative peritoneal cytology were also included. Recurrence-free survival (RFS), DSS and OS was calculated from the date of hysterectomy using the Kaplan-Meier method. Cox regression modeling was used to explore the risks of various factors on recurrence. Results: Median follow-up was 5.4 years. Median age was 71 years. All patients underwent hysterectomy and salpingoophorectomy, 93% had peritoneal cytology and 85% underwent lymphadenectomy with a median number of lymph node examined of 8. Patients with endometrioid histology constituted 72% of the study cohort, serous in 16%, clear cell in 7% and mixed histology in 4%. 23% were stage II. Adjuvant management included RT alone in 220 patients (57%), chemotherapy alone in 25 patients (7%) and chemoradiation therapy in 27 patients (7%) and 110 patients (29%) were managed with close surveillance. 5-year RFS, DSS and OS is 77%, 88%, and 73%, respectively. On multivariate analysis, significant predictors of longer RFS included adjuvant RT (p < 0.001) and absence of LVSI (p < 0.001). Significant predictors of longer DSS included absence of LVSI (p < 0.001), adjuvant RT (p Z 0.021) and lower FIGO grade (p Z 0.027). Age at diagnosis, and African American race were the only predictors of OS with p < 0.001 and p Z 0.031, respectively.
Volume 87 Number 2S Supplement 2013
Poster Viewing Abstracts S419
Conclusions: Our study suggests that adjuvant radiation treatment significantly improved relapse-free and disease-specific survival of patients with high risk endometrial carcinoma. These findings need validation from a prospective randomized study. Author Disclosure: M.A. Elshaikh: None. S. Patel: None. M. Mahan: None. A. Munkarah: None.
2562 The Role of Adjuvant Radiation Therapy in Patients With Carcinosarcoma of the Uterus: A Single Institution Analysis S. Rana, A.J. Patel, P. Valente, K. Hall, and T.Y. Eng; University of Texas Health Science Center San Antonio, San Antonio, TX Purpose/Objective(s): Carcinosarcoma of the uterus is a highly aggressive malignancy associated with early metastatic disease and poor prognosis. The current widely accepted primary treatment modality remains surgery involving total abdominal hysterectomy and bilateral salpingooophorectomy. Given its low incidence, optimal treatment protocol has not been extensively extrapolated and the benefit of radiation therapy remains uncertain. In this study, we analyzed whether adjuvant pelvic radiation therapy in patients treated with surgery +/- chemotherapy decreased local recurrence and improved overall survival (OS) compared to patients treated with surgery alone. Materials/Methods: The records of 24 women who underwent TAH/BSO for Stage I-III uterine carcinosarcoma between 1993 and 2011 were reviewed. Subject were divided based on differential treatment modalities which included surgery alone, surgery and chemotherapy, surgery and radiation therapy, and surgery, chemotherapy, and radiation therapy. The median follow-up was 22.1 months (range, 1.3-109.26 months). Radiation therapy consisted of external beam radiation to a prescribed dose of 4550.4 Gy with 10 patients receiving a brachytherapy boost of 9-15 Gy. The most commonly utilized chemotherapy regimen was carboplatin and Taxol. The 3-year OS, disease free survival (DFS), locoregional-recurrence free survival (LRRFS) and distant metastases free survival (DMFS) were calculated using the Kaplan-Meier method and differences evaluated using the log-rank test. Results: Of the 24 patients, 9 were diagnosed as Stage I, 5 as Stage II, and 10 as Stage III, of which 6 (67%), 3 (60%), and 6 (60%) patients received radiation. The 3 year DFS, LRRFS, DMFS, and OS are summarized in the table below. There was a significant difference in DMFS favoring those who received radiation therapy with or without chemotherapy compared those who did not receive radiation with or without chemotherapy (p Z 0.0211). Furthermore, there was a significant difference in DMFS among those undergoing surgery with chemotherapy versus surgery with radiation and chemotherapy (3 year DMFS 33% vs 83%, respectively, p Z 0.0310). Lymph node involvement was a significant prognostic indicator of poor LRRFS (p Z 0.0029). There was no significant difference in overall survival between the treatment groups (p Z 0.2711). Conclusions: In this study, DMFS significantly improved with the use of adjuvant radiation and chemotherapy in the treatment of uterine carcinosarcoma. Author Disclosure: S. Rana: None. A.J. Patel: None. P. Valente: None. K. Hall: None. T.Y. Eng: None.
Poster Viewing Abstract 2562; Table
Treatment modality Surgery Surgery Surgery Surgery P value Surgery Surgery P value
alone + chemo + RT + chemo +RT +/- chemo + RT +/- chemo
DFS
LRRFS
DMFS
OS
N
3 yr %
3 yr %
3 yr %
3 yr %
3 6 7 8
67 16.7 83 50 .2656 45 63 .2955
67 83 100 50 .3055 74 69 .7156
67 33 83 83 .1007 44 83 .0211
100 60 100 88 .2711 75 92 .2931
9 15
2563 Ultrasound Sonographic Guided High-Dose-Rate Intracavitary Brachytherapy for Medically Inoperable Uterine Endometrial Cancer Y.O. Kaneyasu; Hiroshima University, Hiroshima, Japan Purpose/Objective(s): In Japan, first choice of uterine endometrial cancer treatment is surgery. Only few patients with medically inoperable uterine endometrial cancer were treated with radical radiation therapy. In 2007, a total of 5005 patients with cancer of uterine endometrium were treated. Only 28 patients (0.67%) were treated with radical radiation therapy for stage I-II disease in Japan. We evaluate the efficacy of ultrasound sonographic guided high-dose rate intracavitary brachytherapy (ICBT) for uterine endometrial cancer. Materials/Methods: Eleven patients with endometrial cancer who were treated by radical radiation therapy with curative intent at Hiroshima University from 2007 to 2012 were evaluated. Seven patients were in Stage I disease, 1 in Stage II, 2 in Stage III, 1 in Stage IV. Mean age was 73 years (range, 52-86 years). All patients were medically inoperable because of complications such as hypertension, or diabetes mellitus. External beam radiation therapy (EBRT) was given to the whole pelvis for 5 patients, small pelvis for 5 patients, and extended field for 1 patient using four opposing parallel fields with 18 MV linear accelerator unit. Total doses of EBRT were 40-60 Gy (median 50 Gy). Central shield was used after 30-40 Gy with external whole pelvic irradiation for 3 patients. High-dose rate (HDR) brachytherapy was given with Ir-192 micro-Slectron. Rotte endometrial applicators were inserted using the ultrasound sonographic guide, and checked that the tip of tandem reached to a fundus of uterus. The dose at dose point III (mid portion of uterine body serosa) was 6 Gy per fraction, 1 fractions per week, and the total number of fractions was either 2 or 3 (mean: 2.6). The distance of uterine serosa to applicator was measured by ultrasound for each patient, and determined the dose point III. We have used the Rotte endometrial applicator for 25 times, tandem-ovoid applicator for 4 times in all 11 patients. Maximum actual total rectal doses were 2.1 to 14.2 Gy (mean: 9.3 Gy), total bladder doses (ICRU) were 2.9 to 18.8 Gy (mean: 12.2 Gy). Results: Follow-up periods were 11 to 58 month (median: 28 months). One patient dead with lung metastases. Local control rates were 91%. Late radiation complications (RTOG/EORTC) occurred 3 cases for rectum (grade 2; 2 patients, grade1; 1 patient,), 1case for bone (grade1), and none of bladder and small intestine complications were seen. Conclusions: The local control of endometrial cancer by radical radiation therapy was good. It is important to insert the applicator safely using the ultrasound sonographic guide. And, it is useful for measuring the distance of uterine serosa to applicator by ultrasound. Author Disclosure: Y.O. Kaneyasu: None.
2564 Impact of Adjuvant Pelvic Radiation Therapy in Stage I Uterine Sarcoma W.J. Magnuson,1 D.G. Petereit,2 B.M. Anderson,1 H.M. Geye,1 and K.A. Bradley1; 1University of Wisconsin Department of Human Oncology, Madison, WI, 2Department of Radiation Oncology, John T. Vucurevich Cancer Care Institute, Rapid City, SD Purpose/Objective(s): The optimal adjuvant therapy for stage I uterine sarcoma remains unresolved and may consist of observation, radiation therapy, chemotherapy (for leiomyosarcoma or carcinosarcoma) or hormonal therapy (for endometrial stromal sarcoma). We analyzed the impact of adjuvant pelvic radiation therapy on overall survival (OS), cause specific survival (CSS), disease free survival (DFS) and pelvic control (PC). Materials/Methods: The medical records of 152 patients with FIGO stage I uterine sarcoma treated at the University of Wisconsin between April 1969 and July 2011 were reviewed. Radiation therapy (RT) was administered postoperatively to the whole pelvis to a dose of 45-51 Gy in 28-30 fractions. The decision to recommend radiation was based on physician preference. Patients who received vaginal cuff brachytherapy (alone or
International Journal of Radiation Oncology Biology Physics
disease with surgical staging followed by adjuvant brachytherapy, external beam radiation, or both, in conjunction with chemotherapy. Materials/Methods: We undertook a retrospective review at two institutions of 43 consecutively treated patients undergoing definitive therapy between 2003 and 2012 with histologically-confirmed carcinosarcoma who underwent a combined regimen of surgery, vaginal brachytherapy, whole pelvic radiation, or both, and chemotherapy. Chemotherapy included carboplatin/taxol, ifosfamide/taxol, cisplatin, and cisplatin/adriamycin given in a sequential or sandwich course. Data with respect to disease and treatment characteristics were recorded. Overall survival and disease recurrence analyses were conducted using Kaplan-Meier and Cox Proportional Hazards models. Results: The median age of women was 64 years (range, 46-78 years). Stage breakdown was as follows: Stage IA (15), Stage IB (6), Stage II (3), Stage IIIA (4), Stage IIIB (1) Stage IIIC (13), Stage IVA (1). Median time to local recurrence (LR) was 14.1 months (range, 8.1-38.8 months). Median time to distant recurrence (DR) was 15.2 months (range, 11.5-38.8 months). The median dose of EBRT was 4650 Gy (range, 2000-6440 Gy) and the median dose of brachytherapy was 1200 Gy (range, 500-2100 Gy). 33 patients received EBRT +/- brachytherapy while 10 received brachytherapy alone. Eighty-one percent of patients received carboplatin/taxol chemotherapy. Median follow-up was 1.9 years (range, 0.3-7.1 years). Rates of 3-year overall survival, LR-free survival, DR-free survival, and overall disease free survival were 64%, 81%, 76%, and 81%, respectively. Cox proportional hazards analysis revealed that decreased overall survival was correlated with advanced cancer stage (HR Z 1.30, p Z 0.02) and that decreased freedom from DR was correlated with the presence of positive lymph nodes at diagnosis (HR Z 4.87, p Z 0.04) as well as cancer stage (HR Z 1.33, p Z 0.04). There was no effect of these variables on LR among 7 total LRs. Among Stage I or II patients who received EBRT +/- brachytherapy (n Z 16) compared to brachytherapy alone (n Z 7), there was also no difference in the rate of LR although only 3 total LRs were observed in this group. Overall, multi-modality therapy was well tolerated with 12% incidence of grade 3 acute toxicity and a 2% incidence of chronic grade 3 toxicity. Conclusions: For patients with uterine carcinosarcoma, the combined approach of surgical debulking followed by radiation therapy in conjunction with chemotherapy is well tolerated with and yields favorable survival and recurrence outcomes. Author Disclosure: D. Guttmann: None. H. Li: None. S. Grover: None. S. Bhatia: None. G. Jacobson: None. L. Lin: None.
Results: Bladder volumes varied greatly throughout treatment. Median bladder full and bladder empty volumes at planning were 278.6 cc (range, 43.7-639.5 cc) and 91.7 cc (range, 30.3-507.4 cc), respectively. Of the 240 daily measurements of bladder volume, a total of 122 (50.8%) had a bladder volume that was either greater or less than the planning bladder full or empty volume, respectively. Median bladder volume for all treatments was 167.6 cc (range, 43.2-514.7 cc). Daily rectal volume also varied during treatment. Median rectal volume for all patients at planning was 66.5 cc (range, 37.0-100.1 cc). Median daily percent variation from the rectal planning volume was 27.2% (range, 52.3-230.3%). Conclusions: This study was initiated as a departmental quality assurance project to assess the reproducibility of daily bladder filling for women receiving post-operative WP-IMRT. Our study demonstrates significant daily variations in bladder filling throughout the course of radiation, despite detailed instructions on bladder filling for daily treatments. Over half of the fractions were performed with bladder volumes that were outside of the bladder full and bladder empty scan volumes defined at planning, indicating that patients cannot reliably fill their bladders to a reproducible volume. Additionally, rectal volumes were found to vary greatly from planning. It is critical to recognize that these large daily variations exist and may potentially lead to variations in target volume in this patient population. Author Disclosure: C.S. Platta: None. E. Urban: None. M. Straub: None. K. Bradley: None.
2560 Daily Variation in Bladder and Rectal Volume During Postoperative Whole Pelvic Intensity Modulated Radiation Therapy C.S. Platta, E. Urban, M. Straub, and K. Bradley; University of Wisconsin Hospital & Clinics Madison, Madison, WI Purpose/Objective(s): To evaluate daily changes in bladder and rectal volume for women receiving post-operative whole pelvic intensity modulated radiation therapy (WP-IMRT) for cervical or endometrial cancer, as part of a departmental quality assurance initiative. Materials/Methods: Following IRB approval, ten patients that had previously received WP-IMRT following hysterectomy were identified for analysis. All patients were treated on a Tomotherapy unit between 2009 and 2012. Per department protocol, all patients were instructed to have a comfortably full bladder prior to the planning CT and prior to each fraction of therapy. Two CTs were obtained at planning, one with the bladder full, and one empty. No instructions were provided for rectal filling. Prior to each fraction of therapy, patient alignment was confirmed using an onboard megavoltage computed tomography (MVCT) scan. The daily MVCT images and the planning CT images were restored for analysis in a registration software. Bladder full volume, bladder empty volume, and rectal volume was measured on each patient’s planning CT. Each daily MVCT image was then fused to the planning scan. Bladder and rectum were contoured on each MVCT to measure daily structure volume. A total of 240 daily MVCTs were usable to calculate bladder volume, and a total of 255 to calculate rectal volume.
2561 The Impact of Adjuvant Radiation Treatment on Survival of Patients With High-Risk, Early-Stage Endometrial Carcinoma M.A. Elshaikh, S. Patel, M. Mahan, and A. Munkarah; Henry Ford Health System, Detroit, MI Purpose/Objective(s): For patients with early-stage endometrial carcinoma, two prospective randomized studies confirmed the benefits of adjuvant radiation treatment (RT) after hysterectomy in reducing local recurrences. Many have suggested that patients enrolled in these studies were at too low of a risk to demonstrate improved survival with adjuvant RT. The objective of this study is to determine the impact of adjuvant RT on relapse-free (RFS), disease-specific (DSS) and overall survival (OS) of patients with high-risk FIGO stage I-II endometrial carcinoma (EC). Materials/Methods: Our prospectively-maintained database of 1610 uterine cancer patients was reviewed for this IRB-approved study. We identified 382 consecutive patients with high-risk EC 2009 FIGO stage I-II who underwent hysterectomy between 1987 and 2012 with a minimum of one year follow-up after surgery. High-risk was defined as per GOG 249 protocol as patients with endometrioid histology stage I with either a) age 70 years with one risk factor, or age 50 with two risk factors or age 18 with 3 risk factors. Risk factors included grade 2 or 3 tumors, lymphovascular space involvement (LVSI), or myometrial involvement 50%. Patients with stage II endometrioid EC, patients with serous and clear cell histologies stages I-II with negative peritoneal cytology were also included. Recurrence-free survival (RFS), DSS and OS was calculated from the date of hysterectomy using the Kaplan-Meier method. Cox regression modeling was used to explore the risks of various factors on recurrence. Results: Median follow-up was 5.4 years. Median age was 71 years. All patients underwent hysterectomy and salpingoophorectomy, 93% had peritoneal cytology and 85% underwent lymphadenectomy with a median number of lymph node examined of 8. Patients with endometrioid histology constituted 72% of the study cohort, serous in 16%, clear cell in 7% and mixed histology in 4%. 23% were stage II. Adjuvant management included RT alone in 220 patients (57%), chemotherapy alone in 25 patients (7%) and chemoradiation therapy in 27 patients (7%) and 110 patients (29%) were managed with close surveillance. 5-year RFS, DSS and OS is 77%, 88%, and 73%, respectively. On multivariate analysis, significant predictors of longer RFS included adjuvant RT (p < 0.001) and absence of LVSI (p < 0.001). Significant predictors of longer DSS included absence of LVSI (p < 0.001), adjuvant RT (p Z 0.021) and lower FIGO grade (p Z 0.027). Age at diagnosis, and African American race were the only predictors of OS with p < 0.001 and p Z 0.031, respectively.
Volume 87 Number 2S Supplement 2013
Poster Viewing Abstracts S419
Conclusions: Our study suggests that adjuvant radiation treatment significantly improved relapse-free and disease-specific survival of patients with high risk endometrial carcinoma. These findings need validation from a prospective randomized study. Author Disclosure: M.A. Elshaikh: None. S. Patel: None. M. Mahan: None. A. Munkarah: None.
2562 The Role of Adjuvant Radiation Therapy in Patients With Carcinosarcoma of the Uterus: A Single Institution Analysis S. Rana, A.J. Patel, P. Valente, K. Hall, and T.Y. Eng; University of Texas Health Science Center San Antonio, San Antonio, TX Purpose/Objective(s): Carcinosarcoma of the uterus is a highly aggressive malignancy associated with early metastatic disease and poor prognosis. The current widely accepted primary treatment modality remains surgery involving total abdominal hysterectomy and bilateral salpingooophorectomy. Given its low incidence, optimal treatment protocol has not been extensively extrapolated and the benefit of radiation therapy remains uncertain. In this study, we analyzed whether adjuvant pelvic radiation therapy in patients treated with surgery +/- chemotherapy decreased local recurrence and improved overall survival (OS) compared to patients treated with surgery alone. Materials/Methods: The records of 24 women who underwent TAH/BSO for Stage I-III uterine carcinosarcoma between 1993 and 2011 were reviewed. Subject were divided based on differential treatment modalities which included surgery alone, surgery and chemotherapy, surgery and radiation therapy, and surgery, chemotherapy, and radiation therapy. The median follow-up was 22.1 months (range, 1.3-109.26 months). Radiation therapy consisted of external beam radiation to a prescribed dose of 4550.4 Gy with 10 patients receiving a brachytherapy boost of 9-15 Gy. The most commonly utilized chemotherapy regimen was carboplatin and Taxol. The 3-year OS, disease free survival (DFS), locoregional-recurrence free survival (LRRFS) and distant metastases free survival (DMFS) were calculated using the Kaplan-Meier method and differences evaluated using the log-rank test. Results: Of the 24 patients, 9 were diagnosed as Stage I, 5 as Stage II, and 10 as Stage III, of which 6 (67%), 3 (60%), and 6 (60%) patients received radiation. The 3 year DFS, LRRFS, DMFS, and OS are summarized in the table below. There was a significant difference in DMFS favoring those who received radiation therapy with or without chemotherapy compared those who did not receive radiation with or without chemotherapy (p Z 0.0211). Furthermore, there was a significant difference in DMFS among those undergoing surgery with chemotherapy versus surgery with radiation and chemotherapy (3 year DMFS 33% vs 83%, respectively, p Z 0.0310). Lymph node involvement was a significant prognostic indicator of poor LRRFS (p Z 0.0029). There was no significant difference in overall survival between the treatment groups (p Z 0.2711). Conclusions: In this study, DMFS significantly improved with the use of adjuvant radiation and chemotherapy in the treatment of uterine carcinosarcoma. Author Disclosure: S. Rana: None. A.J. Patel: None. P. Valente: None. K. Hall: None. T.Y. Eng: None.
Poster Viewing Abstract 2562; Table
Treatment modality Surgery Surgery Surgery Surgery P value Surgery Surgery P value
alone + chemo + RT + chemo +RT +/- chemo + RT +/- chemo
DFS
LRRFS
DMFS
OS
N
3 yr %
3 yr %
3 yr %
3 yr %
3 6 7 8
67 16.7 83 50 .2656 45 63 .2955
67 83 100 50 .3055 74 69 .7156
67 33 83 83 .1007 44 83 .0211
100 60 100 88 .2711 75 92 .2931
9 15
2563 Ultrasound Sonographic Guided High-Dose-Rate Intracavitary Brachytherapy for Medically Inoperable Uterine Endometrial Cancer Y.O. Kaneyasu; Hiroshima University, Hiroshima, Japan Purpose/Objective(s): In Japan, first choice of uterine endometrial cancer treatment is surgery. Only few patients with medically inoperable uterine endometrial cancer were treated with radical radiation therapy. In 2007, a total of 5005 patients with cancer of uterine endometrium were treated. Only 28 patients (0.67%) were treated with radical radiation therapy for stage I-II disease in Japan. We evaluate the efficacy of ultrasound sonographic guided high-dose rate intracavitary brachytherapy (ICBT) for uterine endometrial cancer. Materials/Methods: Eleven patients with endometrial cancer who were treated by radical radiation therapy with curative intent at Hiroshima University from 2007 to 2012 were evaluated. Seven patients were in Stage I disease, 1 in Stage II, 2 in Stage III, 1 in Stage IV. Mean age was 73 years (range, 52-86 years). All patients were medically inoperable because of complications such as hypertension, or diabetes mellitus. External beam radiation therapy (EBRT) was given to the whole pelvis for 5 patients, small pelvis for 5 patients, and extended field for 1 patient using four opposing parallel fields with 18 MV linear accelerator unit. Total doses of EBRT were 40-60 Gy (median 50 Gy). Central shield was used after 30-40 Gy with external whole pelvic irradiation for 3 patients. High-dose rate (HDR) brachytherapy was given with Ir-192 micro-Slectron. Rotte endometrial applicators were inserted using the ultrasound sonographic guide, and checked that the tip of tandem reached to a fundus of uterus. The dose at dose point III (mid portion of uterine body serosa) was 6 Gy per fraction, 1 fractions per week, and the total number of fractions was either 2 or 3 (mean: 2.6). The distance of uterine serosa to applicator was measured by ultrasound for each patient, and determined the dose point III. We have used the Rotte endometrial applicator for 25 times, tandem-ovoid applicator for 4 times in all 11 patients. Maximum actual total rectal doses were 2.1 to 14.2 Gy (mean: 9.3 Gy), total bladder doses (ICRU) were 2.9 to 18.8 Gy (mean: 12.2 Gy). Results: Follow-up periods were 11 to 58 month (median: 28 months). One patient dead with lung metastases. Local control rates were 91%. Late radiation complications (RTOG/EORTC) occurred 3 cases for rectum (grade 2; 2 patients, grade1; 1 patient,), 1case for bone (grade1), and none of bladder and small intestine complications were seen. Conclusions: The local control of endometrial cancer by radical radiation therapy was good. It is important to insert the applicator safely using the ultrasound sonographic guide. And, it is useful for measuring the distance of uterine serosa to applicator by ultrasound. Author Disclosure: Y.O. Kaneyasu: None.
2564 Impact of Adjuvant Pelvic Radiation Therapy in Stage I Uterine Sarcoma W.J. Magnuson,1 D.G. Petereit,2 B.M. Anderson,1 H.M. Geye,1 and K.A. Bradley1; 1University of Wisconsin Department of Human Oncology, Madison, WI, 2Department of Radiation Oncology, John T. Vucurevich Cancer Care Institute, Rapid City, SD Purpose/Objective(s): The optimal adjuvant therapy for stage I uterine sarcoma remains unresolved and may consist of observation, radiation therapy, chemotherapy (for leiomyosarcoma or carcinosarcoma) or hormonal therapy (for endometrial stromal sarcoma). We analyzed the impact of adjuvant pelvic radiation therapy on overall survival (OS), cause specific survival (CSS), disease free survival (DFS) and pelvic control (PC). Materials/Methods: The medical records of 152 patients with FIGO stage I uterine sarcoma treated at the University of Wisconsin between April 1969 and July 2011 were reviewed. Radiation therapy (RT) was administered postoperatively to the whole pelvis to a dose of 45-51 Gy in 28-30 fractions. The decision to recommend radiation was based on physician preference. Patients who received vaginal cuff brachytherapy (alone or