Stage I and II Endometrial Adenocarcinoma: Analysis of 2009 FIGO Staging Revision and Impact on Survival by Adjuvant Therapy.

BACKGROUND: In 2009, the International Federation of Gynecology and Obstetrics revised the staging classification for endometrial cancer. Mucosal cervical involvement was eliminated from the criteria and only those with stromal cervical involvement were considered stage II. We examined the implications of the staging changes and the survival impact of adjuvant therapy in stage I to II endometrial adenocarcinoma. MATERIALS AND METHODS: Data were obtained from the National Oncology Data Alliance. Stage I to II endometrial adenocarcinoma patients diagnosed between 1988 and 2008 were identified and grouped according to the 1988 International Federation of Gynecology and Obstetrics staging. Multivariate analysis (MVA) was performed using proportional hazards model; comparison of Kaplan-Meier survival curves was based on the log-rank statistic. RESULTS: A total of 14,158 patients with stage I to II endometrial adenocarcinoma were identified with a median follow-up of 41 months. Adjuvant external-beam radiation therapy (EBRT) and adjuvant vaginal brachytherapy (VB) were positive predictors for overall survival (OS) only in IC, IIA, and IIB. On MVA, stages IA and IB OS did not differ (P=0.17), IIA had worse OS compared with IC (P<0.05), and IIA OS did not differ from IIB (P=0.57). Neither IA nor IB benefited from adjuvant radiotherapy on MVA. However, both IC and IIA had OS improvements with VB±EBRT (P<0.05) with the greatest impact from the VB. CONCLUSIONS: Mucosal cervical involvement represents a risk factor and should be considered when determining adjuvant therapy. Adjuvant therapy provided no survival benefit in 1988 stage IA or IB; however, adjuvant radiotherapy is recommended in the management of IC, IIA, and IIB.

Phase I/II Trial of Anticarcinoembryonic Antigen Radioimmunotherapy, Gemcitabine, and Hepatic Arterial Infusion of Fluorodeoxyuridine Postresection of Liver Metastasis for Colorectal Carcinoma.

OBJECTIVES: Report the feasibility, toxicities, and long-term results of a Phase I/II trial of 90Y-labeled anticarcinoembryonic antigen (anti-CEA) (cT84.66) radioimmunotherapy (RIT), gemcitabine, and hepatic arterial infusion (HAI) of fluorodeoxyuridine (FUdR) after maximal hepatic resection of metastatic colorectal cancer to the liver. METHODS: Patients with metastatic colorectal cancer to the liver postresection or ablation to minimum disease were eligible. Each cohort received HAI of FUdR for 14 days on a dose escalation schedule. The maximum HAI FUdR dose level planned was 0.2 mg/kg/day, which is the standard dose for HAI FUdR alone. On day 9, 90Y-cT84.66 anti-CEA at 16.6 mCi/m2 as an i.v. bolus infusion and on days 9-11 i.v. gemcitabine at 105 mg/m2 were given. Patients could receive up to three cycles every 6 weeks of protocol therapy. Four additional cycles of HAI FUdR were allowed after RIT. RESULTS: Sixteen patients were treated on this study. A maximum tolerated dose of 0.20 mg/kg/day of HAI FUdR combined with RIT at 16.6 mCi/m2 and gemcitabine at 105 mg/m2 was achieved with only 1 patient experiencing grade 3 reversible toxicity (mucositis). After surgery, 10 patients had no evidence of visible disease and remained without evidence of disease after completion of protocol therapy. The remaining 6 patients demonstrated radiological visible disease after surgery and after protocol therapy 2 patients had a CR, 1 patient had PR, 2 had stable disease, and 1 had progression. With a median follow-up of 41.8 months (18.7-114.6), median progression free survival was 9.6 months. Two patients demonstrated long-term disease control out to 45+ and 113+ months. CONCLUSION: This study demonstrates the safety, feasibility, and potential utility of HAI FUdR, RIT, and systemic gemcitabine. The trimodality approach does not have higher hematologic toxicities than seen in prior RIT-alone studies. Future efforts evaluating RIT in colorectal cancer should integrate RIT with systemic and regional therapies in the minimal tumor burden setting.

Ureteral stent insertion for gynecologic interstitial high-dose-rate brachytherapy.

PURPOSE: To determine the utility of ureteral stents in interstitial gynecological brachytherapy. METHODS AND MATERIALS: We reviewed 289 patients with cervix cancer treated with high-dose-rate interstitial brachytherapy who did not have pretreatment hydronephrosis to determine the relative incidence of benign ureteral strictures after treatment. We also did comparative dosimetry analysis in five cases of high-dose-rate brachytherapy. Bilateral ureteral stents were placed during the procedure. Three dosimetry plans were created to determine the impact of modifying clinical target volume (CTV) and applying ureteral dose constraints. In Plan 1, the ureters were contoured and excluded from the CTV and 120% dose constraints were applied. In Plan 2, the ureters were contoured and excluded, but no dose constraints were applied to the ureter. In Plan 3, the CTV was created as if the location of the ureters was unknown and then ureteral dose was determined. RESULTS: There were 11 ureteral strictures observed in 255 nonstented cases and 0 ureteral strictures in 34 stented cases. Plan 1 reduced the ureter dose (D(0.1cc)) by a median 22% (7.0-53.8%) compared with Plan 2 and by a median of 30.9% (12.3-65%). compared with Plan 3. CONCLUSIONS: Placement of stents and ureteral dose constraints facilitates dosimetry and reduces the dose to ureters. Temporary ureteral stents prevent obstruction during interstitial gynecologic brachytherapy and allows the ureters to be addressed as an organ at risk.

A comparative study of stereotactic radiosurgery, hypofractionated, and fractionated stereotactic radiotherapy in the treatment of skull base meningioma.

OBJECTIVES: To compare the outcomes of skull base meningiomas treated with stereotactic radiosurgery (SRS), hypofractionated stereotactic radiotherapy (hFSRT), and fractionated stereotactic radiotherapy (FSRT). METHODS: A total of 220 basal meningiomas in 213 patients were treated using SRS (N=55), hFSRT (N=22), and FSRT (N=143). The median age was 59 years (28 to 84 y). Prior surgery was performed in 74 cases; 39 patients received adjuvant radiotherapy after incomplete resection and 35 patients received salvage radiotherapy after tumor progression. In 146 cases, radiation was the primary therapy. Ten patients had World Health Organization II or III meningiomas. RESULTS: The median follow-up was 32 months (7 to 97 mo). Median tumor volume was 2.8 cm (0.10 to 16.94 cm), 4.8 cm (0.88 to 20.38 cm), and 11.1 cm (0.43 to 214.00 cm) and the median dose was 1250 cGy in 1 fraction to the 80% isodose line (IDL), 2500 cGy in 5 fractions to the 90% IDL, and 5040 cGy in 28 fractions to the 90% IDL for the SRS, hFSRT, and FSRT groups, respectively. Radiographic control was achieved in 91%, 94%, and 95% (P=0.25), whereas clinical response was seen in 89%, 100%, and 91% (P=0.16) in the SRS, hFSRT, and FSRT groups, respectively. CONCLUSIONS: There is no significant difference in the radiographic and clinical response in patients with skull base meningioma treated with SRS, hFSRT, or FSRT and thus gives the clinician the impetus to tailor treatment techniques to the location and size of the tumor at presentation.