Abstract: Endometrial cancer (EC) is one of the most common gynecological cancers among women in the developed countries. Vaginal cuff is the main location of relapses after a curative surgical procedure and postoperative radiation therapy have proven to diminish it. Nevertheless, these results have not translated into better survival results. The preeminent place of vaginal cuff brachytherapy (VCB) in the postoperative treatment of high- to intermediate-risk EC was given by the PORTEC-2 trial, which demonstrated a similar reduction in relapses with VCB than with external beam radiotherapy (EBRT), but VCB induced less late toxicity. As a result of this trial, the use of VCB has increased in clinical practice at the expense of EBRT. A majority of the clinical reviews of VCB usually address the risk categories and patient selection but pay little attention to technical aspects of the VCB procedure. Our review aimed to address both aspects. First of all, we described the risk groups, which guide patient selection for VCB in clinical practice. Then, we depicted several technical aspects that might influence dose deposition and toxicity. Bladder distension and rectal distension as well as applicator position or patient position are some of those variables that we reviewed.
Keywords: endometrial cancer, vaginal cuff brachytherapy, rectum, bladder, technique
Endometrial cancer (EC) is a leading cause of female cancer in developed countries. It is the fifth most common cancer worldwide in women. Approximately 40% of EC is diagnosed in Europe, representing the fourth neoplasm among women and the third gynecological cancer after breast and ovarian cancers.1 The annual incidence in developed countries varies from 12.9 to 15.6 per 100000 women in the European countries and up to 19.1 per 100000 women in the US, while these figures drop to <5 per 100000 women in Africa and 2.7 in South-Central Asia.2
Most EC is diagnosed in its early stages due to the promptness of symptoms, mainly postmenopausal vaginal bleeding. The cornerstone of treatment, after metastases are ruled out, is surgery, which aside from its curative nature is the main staging procedure, and postoperative irradiation is added for patients at risk of relapse.3 The majority of EC patients have low-to-intermediate-risk (55%) or high-to-intermediate-risk (30%) tumors; only 15% of patients have high-risk tumors.3 Patient selection for adjuvant treatment depends on the clinicopathological factors of risk and the type of surgery undertaken.3 Brachytherapy has, since 1903, been a well-established radiotherapy technique to treat cancer in several locations, such as the prostate, penile, skin and head-and-neck tumors, in addition to gynecological tumors.4–7
While the current standard surgical management for early EC clearly involves a total hysterectomy with bilateral salpingo-oophorectomy, the role of lymphadenectomy is controversial at the moment and its practice varies worldwide. Pelvic lymphadenectomy or multiple site sampling remains the standard procedure in many departments except for patients at high risk of surgical morbidity. Para-aortic lymphadenectomy is more controversial besides its use on high-risk patients with high-grade or stage II tumors. Despite single-center and retrospective reports having reported lymphadenectomy benefits,8,9 randomized trials have failed to demonstrate an overall or a progression-free survival advantage.10,11 In addition, low-risk disease patients have not benefited from this procedure,12 which is associated with 8%–50% of lymphedema. In any case, lymphadenectomy has shown benefits as a staging procedure. Laparoscopic surgery improves patient recovery compared with the laparotomic approach.13 The LAP2 study14 demonstrated a significant reduction in moderate-to-severe postoperative adverse complications of the laparoscopy compared to the laparotomy (14% vs 21%) despite the longer operation time (mean, 204 vs 130 minutes). In all, 25.8% of the patients assigned to laparotomy required conversion to laparotomy. Significantly, pelvic and para-aortic nodes were not removed in 8% of laparoscopic patients compared to 4% of laparotomy patients. A step forward in reducing surgical morbidity further has been the removal of selective sentinel lymph nodes. The FIRES trial15 successfully mapped at least one sentinel lymph node in 86% of patients. No lymph node metastases were identified in 3% of patients with node-positive disease. Sensitivity and negative predictive values were of 97.2% and 99.6%, respectively.