Lancet
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.
Abstract
Background
Postoperative radiotherapy for International Federation of Gynaecology and Obstetrics (FIGO) stage-1 endometrial carcinoma is a subject of controversy due to the low relapse rate and the lack of data from randomised trials. We did a multicentre prospective randomised trial to find whether postoperative pelvic radiotherapy improves locoregional control and survival for patients with stage-1 endometrial carcinoma.
Methods
Patients with stage-1 endometrial carcinoma (grade 1 with deep [> or =50%] myometrial invasion, grade 2 with any invasion, or grade 3 with superficial [<50%] invasion) were enrolled. After total abdominal hysterectomy and bilateral salpingo-oophorectomy, without lymphadenectomy, 715 patients from 19 radiation oncology centres were randomised to pelvic radiotherapy (46 Gy) or no further treatment. The primary study endpoints were locoregional recurrence and death, with treatment-related morbidity and survival after relapse as secondary endpoints.
Findings
Analysis was done according to the intention-to-treat principle. Of the 715 patients, 714 could be evaluated. The median duration of follow-up was 52 months. 5-year actuarial locoregional recurrence rates were 4% in the radiotherapy group and 14% in the control group (p<0.001). Actuarial 5-year overall survival rates were similar in the two groups: 81% (radiotherapy) and 85% (controls), p=0.31. Endometrial-cancer-related death rates were 9% in the radiotherapy group and 6% in the control group (p=0.37). Treatment-related complications occurred in 25% of radiotherapy patients, and in 6% of the controls (p<0.0001). Two-thirds of the complications were grade 1. Grade 3-4 complications were seen in eight patients, of which seven were in the radiotherapy group (2%). 2-year survival after vaginal recurrence was 79%, in contrast to 21% after pelvic recurrence or distant metastases. Survival after relapse was significantly (p=0.02) better for patients in the control group. Multivariate analysis showed that for locoregional recurrence, radiotherapy and age below 60 years were significant favourable prognostic factors.
Interpretation
Postoperative radiotherapy in stage-1 endometrial carcinoma reduces locoregional recurrence but has no impact on overall survival. Radiotherapy increases treatment-related morbidity. Postoperative radiotherapy is not indicated in patients with stage-1 endometrial carcinoma below 60 years and patients with grade-2 tumours with superficial invasion.
Related Questions
When do you expect the 2023 FIGO staging for endometrial cancer to become adopted clinically in the US?
Agree with the previous comment. Current adjuvant RT for stage I and II are based on mainly histopathological classification (PORTEC-I/II). However, the recent publication of PORTEC-4a (Horeweg et al., PMID 37487144) for stage I/II showed molecular classification predicts response for stage I/II. Mo...
Given patients with substantial LVSI experience a pelvic recurrence rate of ~25%, how do you counsel patients with stage IA endometrioid endometrial cancer with LVSI regarding the relative risks/benefits of EBRT versus VBT alone?
Updated analysis of PORTEC-1 and 2 noted that 5-year pelvic lymph node recurrence was 26.3% when >4 vessels had LVSI involvement, compared to 6.7% with 1-3 foci and 3.3% with no LVSI1. Based on the data from PORTEC-2 which randomized patients to vaginal cuff brachytherapy or EBRT, on multivariable a...
Do you follow GOG, ASTRO, or PORTEC recommendations for adjuvant therapy in stage I endometrial cancer patients?
I believe the current ASTRO guidelines encompass the older GOG and PORTEC guidelines for the most part and we follow these guidelines though we review all for the sake of completeness.For the first patient, barring other risk factors, I would offer adjuvant vaginal cuff brachytherapy; for the second...
In patients diagnosed with endometrial cancer who do not undergo SLNB or LND at the time of hysterectomy, what criteria is used to recommend completion surgery for LN assessment?
The value of nodal dissection was negative for survival in two trials and PORTEC 1 and 2 (no nodal staging), and GOG 99 (nodal staging) didn’t show any difference in nodal recurrence for most endometroid stage I cancer. Unless management would change, we usually limit redo surgical staging to advers...
Would the presence of multifocal LVSI change your adjuvant treatment recommendation for a surgically staged IA dedifferentiated endometrial carcinoma?
Dedifferentiated is considered a high-grade lesion. There is admittedly low quality evidence on optimal management given lower incidence.I would recommend treatment with vaginal brachytherapy and very much offer chemotherapy. Would prefer vaginal brachytherapy, given the patient was surgically stage...
Would you change your approach to adjuvant radiation for an incompletely staged, at least IB, grade 1 endometrial cancer, if a uterine perforation occurred at time of surgery?
Similarly to the above authors, I agree with offering this patient vaginal brachytherapy. Though she does not definitively meet GOG99 criteria, given the situation with deep myometrial invasion and perforation, this is a reasonable and low-risk treatment opportunity to decrease local recurrence. The...