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Modified Radical Hysterectomy Versus Extrafascial Hysterectomy in the Treatment of Stage I Endometrial Cancer: Results From the ILIADE Randomized Study

  • Gynecologic Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Five percent to 20% of stage I endometrial cancer patients undergoing total abdominal hysterectomy and bilateral salpingo-oophorectomy develop vaginal and pelvic recurrences. Adjuvant radiotherapy can improve locoregional control but not survival. This randomized trial aimed to determine whether a modified radical (Piver–Rutledge class II) hysterectomy can improve survival and locoregional control compared to the standard extrafascial (Piver–Rutledge class I) hysterectomy.

Methods

Eligible patients (n = 520) with stage I endometrial cancer were randomized to class I or class II hysterectomy. Primary endpoint was overall survival.

Results

The median length of parametria and vagina removed were 15 and 5 vs. 20 mm and 15 mm for class I and class II hysterectomy, respectively (P > 0.001). Operating time and blood loss were statistically significantly higher for class II hysterectomy. At a median follow-up of 70 months, 51 patients had died. Five-year disease-free and overall survival were similar between arms (87.7 and 88.9% in the class I arm and 89.7 and 92.2% in the class II arm, respectively). The unadjusted hazard ratios for recurrence was 0.91 (95% confidence interval, 0.55–1.51, P = 0.72), and the hazard ratio for death was 0.77 (95% confidence interval, 0.44–1.33, P = 0.35).

Conclusions

Class II hysterectomy did not improve locoregional control and survival compared to class I hysterectomy, but when an adequate vaginal cuff transection is not feasible with class I hysterectomy, a modified radical hysterectomy allows to obtain an optimal vaginal and pelvic control of disease with a minimal increase in surgical morbidity.

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References

  1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin. 2008;58:71–6.

    Article  PubMed  Google Scholar 

  2. Aalders J, Abeler V, Kolstad P, Onsrud M. Postoperative external irradiation and prognostic parameters in stage I endometrial carcinoma. Obstet Gynaecol. 1980;56:419–27.

    CAS  Google Scholar 

  3. Creutzberg CL, van Putten WL, Koper PC, et al. Surgery and postoperative radiotherapy versus surgery alone for patients with stage-1 endometrial carcinoma: multicentre randomised trial. PORTEC Study Group. Post Operative Radiation Therapy in Endometrial Carcinoma. Lancet. 2000;355(9213):1404–11.

    Article  CAS  PubMed  Google Scholar 

  4. Keys HM, Roberts JA, Brunetto VL, Gynecologic Oncology Group, et al. A phase III trial of surgery with or without adjunctive external pelvic radiation therapy in intermediate risk endometrial adenocarcinoma: a Gynecologic Oncology Group study. Gynecol Oncol. 2004;92:744–51.

    Article  PubMed  Google Scholar 

  5. The ASTEC/EN.5 Writing Committee on behalf of the ASTEC/EN.5 Study Group. Adjuvant external beam radiotherapy in the treatment of endometrial cancer (MRC ASTEC and NCIC CTG EN.5 randomised trials): pooled trial results, systematic review, and meta-analysis. Lancet. 2009;373(9658):137–46.

    Article  Google Scholar 

  6. Mariani A, Dowdy SC, Keeney GL, et al. Predictors of vaginal relapse in stage I endometrial cancer. Gynecol Oncol. 2005;97:820–7.

    Article  PubMed  Google Scholar 

  7. Elliott P, Green D, Coates A, et al. The efficacy of postoperative vaginal irradiation in preventing vaginal recurrence in endometrial cancer. Int J Gynecol Cancer. 1994;4:84–93.

    Article  PubMed  Google Scholar 

  8. Alektiar KM, McKee A, Venkatraman E, et al. Intravaginal high-dose-rate brachytherapy for Stage IB (FIGO Grade 1, 2) endometrial cancer. Int J Radiat Oncol Biol Phys. 2002;53:707–13.

    PubMed  Google Scholar 

  9. Creutzberg CL, van Putten WL, Wárlám-Rodenhuis CC, et al.; Postoperative Radiation Therapy in Endometrial Carcinoma Trial. Outcome of high-risk stage IC, grade 3, compared with stage I endometrial carcinoma patients: the Postoperative Radiation Therapy in Endometrial Carcinoma Trial. J Clin Oncol. 2004;22:1234–41.

    Article  PubMed  Google Scholar 

  10. Scholten AN, van Putten WL, Beerman H, PORTEC Study Group, et al. Postoperative radiotherapy for Stage 1 endometrial carcinoma: long-term outcome of the randomized PORTEC trial with central pathology review. Int J Radiat Oncol Biol Phys. 2005;63:834–8.

    PubMed  Google Scholar 

  11. Creutzberg CL, van Putten WL, Koper PC, PORTEC Study Group, et al. The postoperative radiation therapy in endometrial carcinoma. The morbidity of treatment for patients with Stage I endometrial cancer: results from a randomized trial. Int J Radiat Oncol Biol Phys. 2001;51:1246–55.

    CAS  PubMed  Google Scholar 

  12. Ng TY, Perrin LC, Nicklin JL, Cheuk R, Crandon AJ. Local recurrence in high-risk node-negative stage I endometrial carcinoma treated with postoperative vaginal vault brachytherapy. Gynecol Oncol. 2000;79:490–4.

    Article  CAS  PubMed  Google Scholar 

  13. Chadha M, Nanavati PJ, Liu P, Fanning J, Jacobs A. Patterns of failure in endometrial carcinoma stage IB grade 3 and IC patients treated with postoperative vaginal vault brachytherapy (review). Gynecol Oncol. 1999;75:103–7.

    Article  CAS  PubMed  Google Scholar 

  14. Horowitz NS, Peters WA 3rd, Smith MR, et al. Adjuvant high dose rate vaginal brachytherapy as treatment of stage I and II endometrial carcinoma. Obstet Gynecol. 2002;99:235–40.

    Article  PubMed  Google Scholar 

  15. Röper B, Astner ST, Heydemann-Obradovic A, et al. Ten-year data on 138 patients with endometrial carcinoma and postoperative vaginal brachytherapy alone: no need for external-beam radiotherapy in low and intermediate risk patients. Gynecol Oncol. 2007;107:541–8.

    Article  PubMed  Google Scholar 

  16. Jolly S, Vargas C, Kumar T, et al. Vaginal brachytherapy alone: an alternative to adjuvant whole pelvis radiation for early stage endometrial cancer. Gynecol Oncol. 2005;97:887–92.

    Article  PubMed  Google Scholar 

  17. Rittenberg PV, Lotocki RJ, Heywood MS, Jones KD, Krepart GV. High-risk surgical stage 1 endometrial cancer: outcomes with vault brachytherapy alone. Gynecol Oncol. 2003;89:288–94.

    Article  PubMed  Google Scholar 

  18. Vaginal brachytherapy versus external beam pelvic radiotherapy for high-intermediate risk endometrial cancer: results of the randomized PORTEC-2 trial (abstract LBA5503). Paper presented at: 2008 ASCO Annual Meeting, Chicago, IL.

  19. Greven KM, Lanciano RM, Herbert SH, Hogan PE. Analysis of complications in patients with endometrial carcinoma receiving adjuvant irradiation. Int J Radiat Oncol Biol Phys. 1991;21:919–23.

    CAS  PubMed  Google Scholar 

  20. Anderson JM, Stea B, Hallum AV, Rogoff E, Childers J. High-dose-rate postoperative vaginal cuff irradiation alone for stage IB and IC endometrial cancer. Int J Radiat Oncol Biol Phys. 2000;46:417–25.

    Article  CAS  PubMed  Google Scholar 

  21. Piver MS, Rutledge FN, Smith JP. Five classes of extended hysterectomy of women with cervical cancer. Obstet Gynecol. 1974;44:265–70.

    CAS  PubMed  Google Scholar 

  22. Landoni F, Maneo A, Colombo A, et al. Randomised study of radical surgery versus radiotherapy for stage Ib–IIa cervical cancer. Lancet. 1997;350(9077):535–40.

    Article  CAS  PubMed  Google Scholar 

  23. Javert CT, Douglas RG. Treatment of endometrial adenocarcinoma; a study of 381 cases at the New York Hospital; a preliminary report. Am J Roentgenol Radium Ther Nucl Med. 1956;75:508–14.

    CAS  PubMed  Google Scholar 

  24. Rutledge FN. The role of radical hysterectomy in adenocarcinoma of the endometrium. Gynecol Oncol. 1974;2:331–47.

    Article  CAS  PubMed  Google Scholar 

  25. Pagel J, Bock JE. Endometrial cancer. A review. Dan Med Bull. 1984;31:333–45.

    CAS  PubMed  Google Scholar 

  26. Sartori E, Gadducci A, Landoni F, et al. Clinical behavior of 203 stage II endometrial cancer cases: the impact of primary surgical approach and of adjuvant radiation therapy. Int J Gynecol Cancer. 2001;11:430–7.

    Article  CAS  PubMed  Google Scholar 

  27. Cohn DE, Woeste EM, Cacchio S, et al. Clinical and pathologic correlates in surgical stage II endometrial carcinoma. Obstet Gynecol. 2007;109:1062–7.

    PubMed  Google Scholar 

  28. Eltabbakh GH, Moore AD. Survival of women with surgical stage II endometrial cancer. Gynecol Oncol. 1999;74:80–5.

    Article  CAS  PubMed  Google Scholar 

  29. Maggino T, Romagnolo C, Zola P, et al. An analysis of approaches to the treatment of endometrial cancer in Western Europe: a CTF study. Eur J Cancer. 1995;31:1993–7.

    Article  Google Scholar 

  30. Panici PB, Basile S, Maneschi F, et al. Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial. J Natl Cancer Inst. 2008;100:1707–16.

    Article  Google Scholar 

  31. Huh WK, Straughn JM Jr, Mariani A, et al. Salvage of isolated vaginal recurrences in women with surgical stage I endometrial cancer: a multiinstitutional experience. Int J Gynecol Cancer. 2007;17:886–9.

    Article  CAS  PubMed  Google Scholar 

  32. Creutzberg CL, van Putten WL, Koper PC, PORTEC Study Group, et al. Survival after relapse in patients with endometrial cancer: results from a randomized trial. Gynecol Onco.l 2003;89:201–9.

    Article  PubMed  Google Scholar 

  33. Arndt-Miercke H, Martin A, Briese V, et al. Transection of vaginal cuff is an independent prognostic factor in stage I endometrial cancer. Eur J Surg Oncol. 2008;34:241–6.

    CAS  PubMed  Google Scholar 

  34. Landoni F, Maneo A, Cormio G, et al. Class II versus class III radical hysterectomy in stage Ib–IIa cervical cancer: a prospective randomized study. Gynecol Oncol. 2001;80:3–12.

    Article  CAS  PubMed  Google Scholar 

  35. Raspagliesi F, Ditto A, Fontanelli R, et al. Type II versus type III nerve-sparing radical hysterectomy: comparison of lower urinary tract dysfunctions. Gynecol Oncol. 2006;102:256–62.

    Article  PubMed  Google Scholar 

  36. Zola P, Maggino T, Sacco M, et al. Prospective multicenter study on urologic complications after radical surgery with or without radiotherapy in the treatment of stage IB–IIA cervical cancer. Int J Gynecol Cancer. 2000;10:59–66.

    Article  PubMed  Google Scholar 

Download references

Acknowledgment

We thank Fondazione Mattioli, who provided support for Data Management. Trial registered in the National Monitoring Centre for Clinical Trials (http://oss-sper-clin.agenziafarmaco.it/project.htm), trial code ILIADE.

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Authors and Affiliations

  1. Department of Obstetrics and Gynecology, University of Milano-Bicocca, S. Gerardo Hospital, Monza, Italy

    Mauro Signorelli, Andrea Alberto Lissoni, Antonio Pellegrino, Rodolfo Milani & Costantino Mangioni

  2. Department of Obstetrics and Gynecology, University of Bari, Bari, Italy

    Gennaro Cormio & Luigi Selvaggi

  3. Department of Obstetrics and Gynecology, Policlinico University of Turin, Turin, Italy

    Dionyssios Katsaros

  4. Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy

    Fabio Ghezzi

  5. Department of Obstetrics and Gynecology, Gemelli Hospital, Rome, Italy

    Giovanni Scambia

  6. Department of Obstetrics and Gynecology, Mauriziano Hospital, Turin, Italy

    Paolo Zola

  7. Department of Obstetrics and Gynecology, Treviglio Hospital, Treviglio, Italy

    Roberto Grassi

  8. Department of Gynecology, Istituto Clinico Humanitas, Milan, Italy

    Raffaella Giannice

  9. Department of Obstetrics and Gynecology, Lecco Hospital, Lecco, Italy

    Giovanna Caspani

  10. Department of Oncology, “Mario Negri” Institute, Milan, Italy

    Irene Floriani, Eliana Rulli & Roldano Fossati MD

Authors
  1. Mauro Signorelli
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  2. Andrea Alberto Lissoni
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  6. Luigi Selvaggi
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  8. Giovanni Scambia
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  9. Paolo Zola
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  10. Roberto Grassi
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  11. Rodolfo Milani
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  13. Giovanna Caspani
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  14. Costantino Mangioni
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  15. Irene Floriani
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  16. Eliana Rulli
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  17. Roldano Fossati MD
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Corresponding author

Correspondence to Roldano Fossati MD.

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Signorelli, M., Lissoni, A.A., Cormio, G. et al. Modified Radical Hysterectomy Versus Extrafascial Hysterectomy in the Treatment of Stage I Endometrial Cancer: Results From the ILIADE Randomized Study. Ann Surg Oncol 16, 3431–3441 (2009). https://doi.org/10.1245/s10434-009-0736-6

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  • DOI: https://doi.org/10.1245/s10434-009-0736-6

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