Stratified follow-up for endometrial cancer: a move to more personalized cancer care.

OBJECTIVE: Hospital based follow-up has been the standard of care for endometrial cancer. Patient initiated follow-up is a useful adjunct for lower risk cancers. The purpose of this study was to evaluate outcomes of endometrial cancer patients after stratification into risk groupings, with particular attention to salvageable relapses. METHODS: All patients treated surgically for International Federation of Gynecology and Obstetrics (FIGO) stage I-IVA endometrial cancer of all histological subtypes, from January 2009 until March 2019, were analyzed. Patient and tumor characteristics, treatment details, relapse, death, and last follow-up dates were collected. Site of relapse, presence of symptoms, and whether relapses were salvageable were also identified. The European Society of Medical Oncology-European Society of Gynecological Oncology 2020 risk stratification was assigned, and relapse free and overall survival were estimated. RESULTS: 900 patients met the eligibility criteria. Median age was 66 years (range 28-96) and follow-up duration was 35 months (interquartile range 19-57). In total, 16% (n=144) of patients relapsed, 1.3% (n=12) from the low risk group, 3.9% (n=35) from the intermediate risk group, 2.2% (n=20) from the high-intermediate risk group, and 8.7% (n=77) from the high risk group. Salvageable relapses were less frequent at 2% (n=18), of which 33% (n=6) were from the low risk group, 22% (n=4) from the intermediate risk group, 11% (n=2) from the high-intermediate risk group, and 33% (n=6) from the high risk group. There were only three asymptomatic relapses in the low risk patients, accounting for 0.33% of the entire cohort. CONCLUSIONS: Relapses were infrequent and most presented with symptoms; prognosis after relapse remains favorable. Overall salvageable relapses were infrequent and cannot justify intensive hospital based follow-up. Use of patient initiated follow-up is therefore appropriate, as per the British Gynaecological Cancer Society's guidelines, for all risk groupings.

Anaplastic Transformation of Differentiated Papillary Thyroid Carcinoma Presenting as Cauda Equina Syndrome.

BACKGROUND Papillary thyroid carcinoma is usually an indolent disease, with an almost 80% 5-year survival rate for metastatic disease. Conversely, anaplastic thyroid cancer is much more aggressive, with median overall survival rates of 4 months. CASE REPORT A 67-year-old woman presented with metastatic papillary thyroid cancer with bone metastasis, including an unstable L4 pathological fracture. Initially, she underwent lumbar stabilization surgery, followed by high-dose palliative radiotherapy to the lumbar spine. Subsequently, a total thyroidectomy was performed, followed by an ablative dose of radioiodine and supraphysiological doses of levothyroxine to achieve TSH suppression to less than 0.1 mU/L. The treatment dose of radioiodine was administered 4 times at 6-month intervals. The treatment was well tolerated, with a dramatic thyroglobulin response, and the disease remained radioiodine-sensitive. Prior to a fifth planned dose of radioiodine, our patient presented with cauda equina syndrome and underwent urgent decompressive surgery. Further oncological treatment was planned; however, she deteriorated rapidly following surgery, and repeat imaging showed progressive disease at the surgical site. Histopathology from the lumbar decompression revealed anaplastic thyroid cancer. Our patient died 5 weeks after surgery. CONCLUSIONS This is the first published case of transformation from papillary to anaplastic thyroid cancer presenting as cauda equina compression. Transformation from papillary to anaplastic thyroid cancer has been previously described in the literature; however, it is rarely present distant from the neck, and has an aggressive course. Malignant transformation should be considered in cases of differentiated thyroid cancer that do not fit the previous disease trajectory.