Peritoneal cytology in endometrial carcinoma

The ultimate role played by peritoneal cytologic evaluation in endometrial cancer remains somewhat ill-defined. Proper assessment of peritoneal cytology as an independent risk factor awaits a prospective study in which patients with malignant peritoneal cytology and surgical Stage I lesions are not treated and survival is compared to controls with negative cytology. Such a study is unlikely to be done, given results available from retrospective analyses and the large number of patients needed to complete such a trial. Whether therapy is needed and which type to use in patients with malignant cytology remain uncertain. Half of these patients will presumably require pelvic radiotherapy for adnexal, nodal, or other pelvic spread. Potish et al. have advocated the use of whole-abdominal radiotherapy in such patients, with favorable results. In patients without extrauterine spread, Creasman et al. have championed the postoperative use of intraperitoneal radioactive phosphate. They based their recommendation on survival results in a group of 23 patients with positive washings who were treated with intraperitoneal radioactive chromic phosphate. In this group, the recurrence rate was reduced, when compared to historic controls, to 13% (3/23), all of whom had extra-abdominal recurrences. Soper et al. confirmed the safety of postoperative radioactive chromic phosphate in doses of approximately 15 millicuries in patients with endometrial cancer. In their study of 65 patients, 56 had percutaneous catheter placement under local anesthesia after laparotomy. In one patient, the catheter could not be used because of poor distribution of the technetium Tc 99m sulfur colloid tracer, and in a second subject, fever and peritoneal signs suggesting bowel perforation led to removal of the insertion catheter. No other significant problems were encountered in 48 patients treated with radioactive chromic phosphate without other therapy. In contrast, five of seventeen patients who received external pelvic radiotherapy in addition to radioactive chromic phosphate suffered bowel complications requiring surgical intervention. Two of these patients died of operative complications, suggesting that radioactive chromic phosphate cannot be safely combined with standard dose external radiotherapy. In a retrospective series, Mazurka et al. intimated that adjunctive chemotherapy might be useful in patients with malignant cytology, but such an approach is untested. A prospective randomized study of radioactive chromic phosphate, whole abdomen radiotherapy, or adjunctive chemotherapy versus no treatment in patients with malignant peritoneal cytology is clearly needed.