The Contemporary Presentation and Diagnosis of Endometrial Cancer Recurrence: When, Where, and How?
Authors: Riedinger Courtney J. , Patterson Jenna M. , Backes Floor J. , O'Malley David , Bixel Kristin L. , Copeland Larry J. , Cohn David E. , Goodfellow Paul J. , Cosgrove Casey M. 
Published: March 2023

ABSTRACT
Endometrial cancer (EC) is the most common gynecologic cancer in the United States. Despite a favorable prognosis in many, EC is one of the few cancers with rising mortality rates. This is in part due to recurrence rates, being as high as 50% in patients at high risk. Survival differences between locoregional and distant disease recurrence have prompted increased focus on multimodality adjuvant treatment. Disease surveillance using routine imaging for early detection of recurrence has not shown a survival benefit in those at low risk, and a more accurate profile of recurrence pattern and presentation may aid the screening current infrastructure.
This retrospective review aimed to examine patterns of recurrence, presentation, and method of diagnosis of recurrent EC in a large contemporary cohort from a single, high-volume institution. Patients who underwent surgery for an EC diagnosis between June 2014 and December 2020 at Ohio State University Comprehensive Cancer Center were included. Disease recurrence was defined as evidence of disease after a 3-month disease-free interval following primary treatment. In the setting of metastatic disease, only those with a complete radiographic response after adjuvant therapy were eligible for recurrence. Locoregional recurrence was confined to the vaginal vault or pelvis. Multiple logistic regression analysis was used to assess the impact of covariates on the likelihood of receipt of treatment for recurrent disease, overall survival, and time from recurrence to death.
A total of 1723 patients were included in the study cohort with a median follow-up time of 2.3 years. A total of 201 participants (11.6%) were included in the recurrence analysis. Of these patients, 120 (59.7%) were symptomatic, with abdominal and pelvic pain being the most common symptoms. Among asymptomatic recurrence cases, 15.4% were diagnosed by imaging at provider discretion, 13.4% were diagnosed by pelvic examination, and 7.5% were diagnosed by CA-125 at provider discretion. Patients diagnosed by pelvic examination were more likely to be at an early stage (66.7% vs 34.5%; P = 0.001), of endometrioid histology (66.7% vs 36.8%; P = 0.003), and without prior adjuvant therapy (48.2% vs 17.9%; P = 0.001). Patients who received adjuvant therapy experienced significantly more locoregional recurrences (60.5% vs 19.7%; P ≤ 0.001), but there was no difference in the median time to recurrence of 12.7 months. Patients with asymptomatic recurrence were more likely to be able to receive treatment than those with symptomatic presentations (91.3% vs 76.7%; P = 0.005). Age at initial diagnosis was associated with receipt of treatment for recurrence. Patients with symptomatic recurrence had a significantly shorter median time from recurrence to death (6.5 vs 11.1 months; P = 0.0053) than asymptomatic patients; however, this was driven by receipt of treatment. Overall survival did not differ significantly between mode of presentation or method of diagnosis.
The results of this study find that recurrence for EC was observed in 12% of women, the majority of whom experienced symptoms, and symptomatic patients were less likely to receive treatment, which contributed to a shorter time from recurrence to death. These findings in the context of an increasing mortality for EC suggest improvements in providing timely treatment for recurrent disease are essential.