Surgery A small subset of patients with isolated recurrent endometrial cancer may benefit from surgical intervention. A search for distant recurrences prior to treatment is obligatory as such patients are best treated with chemotherapy. In one small series, upper-abdominal disease was found at laparotomy in three(37.5%) of eightpatients with presumed localized pelvic recurrence. Presence of subclinical extrapelvic metastases was associated with larger pelvic tumor size (>2 cm) and elevated serum CA125 levels (348). As discussed in the next section, isolated vaginal recurrence in patients who have not received prior pelvic radiation is best treated with external radiation plus some type of brachytherapy.
Treatment of patients with pelvic recurrence (generally located on the pelvic sidewall secondary to lymphatic failure) is more complex. Althoughthe study by Aalders et al. reviewed above showed no survivors in patients with pelvic recurrences, there is evidence that a multimodality approach consisting of radiotherapy followed by radical surgical resection and intraoperative radiotherapy (IORT) will cure some patients (347). A retrospective investigation at Mayo Clinic of 25 heavily pretreated patients with recurrent endometrial cancer demonstrated a survival of 71% in patients with complete surgical resection (349). Over 50% of these patients underwent radiation as primary therapy and one-half of those treated with radiationalso received chemotherapy or an attempt at surgical resection at the time of recurrence. Radical procedures performed at the time of IORT included resection of the pelvic sidewall en bloc with the obturator nerve, external iliac vein, psoas, iliacus, or obturator internus muscles, ureter, or boney ileum (Fig. 35.7). Seven patients required exenteration in combination with resection of the pelvic sidewall. Two patients with isolated para-aortic recurrences were alive and diseasefree at 54 and 71 months. Althoughsurvival in this cohort was impressive, the complication rate was similarly impressive at 64%. The most common complication was neuropathy; other complications included functional ureteral obstruction and fourpatients developed fistulas. Until more active agents are developed, radical multimodality treatment remains the only viable alternative for patients with pelvic recurrences. Memorial Sloan-Kettering Cancer Center reported on 36 patients with isolated central pelvic recurrence who underwent pelvic exenteration for recurrent endometrial carcinoma. Seventy-five percent died of their cancer within 1 year of operation, and 14% were alive after 5 years (349).
Radiation Therapy Radiotherapy is the best treatment option for patients with isolated local or regional recurrences who are unable or unwilling to undergo radical pelvic resection (350–356). The best local control and subsequent cure are usually achieved by a combination of ERT followed by a brachytherapy boost to deliver a total tumor dose of at least 6,000 cGy. Women with low-volume disease limited to the pelvis have the best outcome. For patients with isolated vaginal recurrence treated with radiation, reported 5-year survival rates range from 24% to 45%. The reclamation rate was 81% in one multi-institutional series that was limited to stage I patients with isolated vaginal failures (357). Conversely, for those patients who undergo radiation for the pelvic extension of their disease, lower survival rates (0% to 26%) are reported. Factors associated with improved survival and control of pelvic disease in patients with locally recurrent endometrial cancer include initial endometrial cancer grade 1, younger age at recurrence, recurrent tumor size 2 cm or less, time from initial treatment to recurrence of more than 1 year, vaginal versus pelvic disease, and use of vaginal brachytherapy.