Neoadjuvant radiotherapy with or without chemotherapy followed by extrafascial hysterectomy for locally advanced endometrial cancer clinically extending to the cervix or parametria

•Clinical stage II or IIIB endometrial cancer, pre-operative chemoradiotherapy followed by extrafascial hysterectomy.•High rates of clinical and pathologic response, low rates of toxicity.•Impact of image-based HDR brachytherapy, chemotherapy, and PET/CT staging.

PurposeFor locally-advanced uterine cancer clinically extending to the cervix, two treatment paradigms exist: surgical staging radical hysterectomy with tailored adjuvant therapy or neoadjuvant therapy followed by a less extensive simple hysterectomy. Currently, insufficient data exists to guide consensus guidelines and practical application of preoperative radiotherapy.Materials and methodsRetrospective IRB approved cohort study from 1999 to 2014 of 36 endometrial cancer patients with clinical involvement of cervix ± parametria treated with neoadjuvant external beam radiotherapy (45-50.4 Gy in 25-28 fractions) and image-based HDR brachytherapy (5-5.5 Gy times 3-4 fractions) ± chemotherapy followed by extrafascial hysterectomy performed at a median of 6 weeks after radiotherapy.ResultsAll patients had clinical cervical extension, 50% also had parametria extension, and 31% had nodal involvement. At the time of surgery 91% had no clinical cervical involvement, 58% had no pathologic cervical involvement, and all had margin negative resection. The pathologic complete response rate was 24%. Median follow-up from the time of surgery was 20 months (range: 0-153). The 3-year local control, regional control, distant control, disease free survival and overall survival rates were 96%, 89%, 84%, 73%, and 100%. The 3-year rate of grade 3 complications was 11%, with no grade 4 + toxicity.ConclusionsNeoadjuvant radiation therapy ± chemotherapy followed by extrafascial hysterectomy appears to be a viable option for patients with endometrial cancer clinically extending to the cervix and parametria. The HDR brachytherapy schema of 5-5.5 Gy times 3-4 fractions, for a cumulative EQD2 of 60-70 Gy, is well tolerated with high rates of clinical and pathological response.