The role of whole-pelvic irradiation in the treatment of early-stage uterine carcinosarcoma

Clinico-Pathological Characteristics, Management, and Prognostic Factors of Patients with Uterine Carcinosarcoma: a Retrospective Analysis

Uterine carcinosarcoma is a rare, highly aggressive, rapidly progressing neoplasm associated with a poor prognosis. It comprises 1-5% of all uterine malignancies but accounts for 16.4% of all deaths caused by uterine malignancies. There is a definite paucity of data available from the Indian subcontinent. Hence, we retrospectively conducted this study to analyze the clinical and pathological characteristics and outcomes of women with uterine carcinosarcoma in the past 10 years managed at the tertiary care center. This is a retrospective study of women with histologically proven uterine carcinosarcoma treated at a tertiary cancer center in South India between August 2009 and April 2019. Inpatient and outpatient records were reviewed; clinicopathological data were collected; and follow-up and survival data were ascertained. Over a period of 10 years, 20 patients were diagnosed with uterine carcinosarcoma. The majority of patients were postmenopausal (80%). Post-menopausal bleeding was the main presenting complaint in about 80% of patients. More than two-thirds of patients presented in the early stage (stage I, 55%; stage II, 20%). All patients underwent staging laparotomy. Patients with good performance status (85%) received adjuvant concurrent chemoradiotherapy and chemotherapy. At a median follow-up of 40 months, 7 (35%) patients were alive, out of which 6 are disease-free and 1 had a recurrence. The event-free survival at a median follow-up of 40 months was 40% and the overall survival was 48.5%. The outcome did not significantly differ based on the age, tumor histology (heterologous versus homologous), stage, and depth of myometrial invasion. Uterine carcinosarcoma, though rare, needs to be recognized as a distinct entity, and treated aggressively. Surgery is the cornerstone of therapy. Adjuvant concurrent chemoradiation and chemotherapy improve local control and may delay recurrence, but have shown little survival advantage. The optimal adjuvant treatment for this uncommon disease is yet to be established, highlighting the need for larger multicentric studies on this tumor.

Uterine carcinosarcoma: A 10-year single institution experience

Objective

This study aimed to determine 5-year progression-free and overall survival in patients with uterine carcinosarcoma, to determine clinical and surgical-pathologic features, to recognize patterns of recurrence and to identify prognostic factors influencing progression-free survival (PFS) and overall survival (OS).

Design

This was a single institution, retrospective 10-year review of patients treated at Tygerberg Hospital in South Africa with pathologically confirmed uterine carcinosarcoma.

Methods

A total of 61 patients were studied. Demographic, clinicopathological, treatment and outcome information were obtained. Kaplan-Meier survival analysis and Cox proportional hazards models were used to determine the effects of variables on PFS and OS.

Results

Eighteen patients (29%) presented as FIGO stage I disease, 5 patients (8%) as stage II, 16 patients (26%) as stage III and 22 patients (36%) as stage IV disease. Fifty of the 61 patients (82%) had surgery. Five-year PFS and 5-year OS were 17.3% (CI 8.9%-27.9%) and 19.7% (CI 10.6%-30.8%), respectively. Seventeen patients presented with recurrence of which 5 (29.4%) were local and 12 (70.6%) were outside the pelvis.

In the univariate analysis, tumour diameter ≥ 100mm (HR 4.57; 95% CI 1.59–13.19; p-value 0.005) was associated with 5-year PFS and in univariate analysis of OS, a positive family history (HR 0.42; 95% CI 0.18–0.99; p-value 0.047), receiving a full staging operation (HR 0.37; 95% CI 0.18–0.78; p-value 0.008) and receiving any other modality of treatment, with or without surgery, (HR 0.48; 95% CI 0.27–0.85; p-value 0.012) were associated with better survival. An abnormal cervical smear (HR 2.4; 95% CI 1.03–5.6; p-value 0.041), late-stage disease (HR 3.48; 95% CI 1.79–6.77; p-value < 0.001), presence of residual tumour (HR 3.66; 95% CI 1.90–7.02; p-value < 0.001), myometrial invasion more than 50% (HR 2.29; 95% CI 1.15–4.57; p-value 0.019), cervical involvement (HR 3.38; 95% CI 1.64–6.97; p-value 0.001) and adnexal involvement (HR 3.21; 95% CI 1.56–6.63; p-value 0.002) were associated with a higher risk of death.

In the multivariate analysis, full staging operation was associated with a risk of progression of disease (HR 3.49; 95% CI 1.17–10.41; p-value 0.025). Advanced stage (HR 4.2; 95% CI 2.09–8.44; p-value < 0.001) was associated with a higher risk of death. Any other modality of treatment (HR 0.28; 95% CI 0.15–0.53; p-value < 0.001) and full staging laparotomy (HR 0.27; 95% CI 0.12–0.59; p-value 0.001) was a protective factor for death.

Conclusions

Carcinosarcoma is an aggressive cancer with poorer survival in this specific cohort than has been described in other contemporary cohorts. Biological or genetic factors are a possible explanation for lower overall survival in this population. Although it is also possible that later diagnosis and poor access to health care contribute to poorer survival. Most recurrences occur outside of the pelvis. Full staging surgery (including pelvic lymphadenectomy) and additional use of other modalities (either for radical or palliative intent) improve survival.

The role of multimodal adjuvant therapy for FIGO I-II carcinosarcoma of the uterus: a systematic review

The uterine carcinosarcoma (UCS) is a rare entity with poor prognosis. Treatment of FIGO I-II UCS usually consists of surgery with or without adjuvant treatment. Due to the high metastatic potential, aggressive combined modality adjuvant treatment approaches, consisting of chemo- and radiotherapy, have been of interest. Our systematic review aims to compare survival, disease control and toxicity profiles in patients receiving adjuvant chemoradiation to other adjuvant strategies (e.g.observation, chemotherapy or radiotherapy). A total of ten studies were included for a combined cohort size of 6,520 patients. Generally, the studies showed a trend towards improved disease control and survival in patients undergoing adjuvant multimodal treatment, although statistical significance was often not reached. Selection bias and non-randomized treatment allocation pose serious challenges to extrapolate these outcomes to clinical practice. We recommend additional prospective research on the role of adjuvant chemoradiation in FIGO I-II UCS.

Patterns of adjuvant treatment and survival outcomes in stage I uterine carcinosarcoma

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5-year survival for stage I uterine carcinosarcoma without adjuvant therapy is 43%.

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Nationally 40% of stage I uterine carcinosarcoma do not receive adjuvant therapy.

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Adjuvant chemotherapy alone improved OS and CSS in stage I uterine carcinosarcoma.

Objective

To determine patterns in type and sequence of adjuvant treatment and associated differences in overall survival among women with Stage I uterine carcinosarcoma (UCS).

Methods

Women with stage I UCS from 2000 to 2015 were identified through the National Cancer Institute’s Surveillance, Epidemiology and End Results database linked to Medicare-based claims follow-up data through 2016. Data including demographics, co-morbidities, surgical procedure, surgical pathology and type and sequence of adjuvant treatment were collected. The primary study outcome was overall survival (OS) by type and sequence of adjuvant therapy. Cancer specific survival was also analyzed.

Results

A total of 755 women with Stage I UCS were identified. Of these, 56.3% (n = 445) received adjuvant therapy, whereas 43.7% (n = 330) did not. In comparison to no adjuvant treatment, an overall survival benefit was noted with receipt of chemotherapy alone for women with Stage I disease (log rank p < 0.01). Pairwise comparisons did not show a benefit in OS of concurrent RT-chemo, sequential RT-chemo, or sequential chemo-RT, over chemotherapy alone (p > 0.05 for all). Likewise, radiation alone and no treatment were associated with worse OS compared to chemotherapy alone (p < 0.001 for both). Adjusted Cox regression models demonstrated an OS benefit only in the chemotherapy alone cohort for Stage I disease (HR 0.43 95% CI 0.32, 0.60, p < 0.0001), as well as for CSS (HR 0.41, 95 %CI 0.26, 0.62, p < 0.0001), compared to no treatment.

Conclusions

In comparison to no adjuvant therapy, an overall survival and cancer-specific survival benefit was noted with receipt of chemotherapy alone in Stage I UCS.

Effect of adjuvant therapy on the prognosis in stage I/II uterine carcinosarcoma: A meta-analysis

INTRODUCTION

To assess the efficacy of adjuvant chemotherapy, radiotherapy, or both following the primary surgery on the progression-free survival and 5-year overall survival in patients with stage I/II uterine carcinosarcoma.

METHODS

A preliminary investigation was conducted using PubMed and Embase databases to identify relevant studies published up to March, 2020. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated by Revman 5.3 software to analysis outcomes.

RESULTS

Six retrospective cohort studies were involved in the analysis, including 1516 patients in observation group, 956 patients in chemotherapy group, 750 patients in radiotherapy group, and 1082 patients in raidochemotherapy group. The results indicated that chemotherapy alone (HR = 0.59, 95% CI = 0.38-0.91, p < 0.05) and radiochemotherapy (HR = 0.35, 95% CI: 0.24-0.53, p < 0.001) were associated with improved progression-free survival in patients. Similarly, pooled results suggested chemotherapy (HR = 0.49, 95% CI = 0.34-0.71, p < 0.001) and radiochemotherapy (HR = 0.46, 95% CI = 0.29-0.72, p < 0.001) promoted the 5-year overall survival compared with observation. However, radiotherapy alone had no statistical significance in improving progression-free survival (HR = 0.80, 95% CI = 0.49-1.29, p = 0.36) and 5-year overall survival (HR = 0.65, 95% CI = 0.38-1.12, p = 0.12).

DISCUSSION

Chemotherapy and radiochemotherapy appeared to be prognostic beneficial to early-stage uterine carcinosarcoma.

Ovarian Carcinosarcoma with Retroperitoneal Para-Aortic Lymph Node Dissemination Followed by an Unusual Postoperative Complication: A Case Report with a Brief Literature Review

Introduction. Ovarian carcinosarcoma (OCS), also known as malignant mixed Müllerian tumour (MMMT), is one of the rarest histological subtypes of ovarian cancer. It is an aggressive tumour with a dismal prognosis-the median survival of patients is less than two years. The rarity of the disease generates many controversies about histogenesis, prognostic factors and treatment of OCS. Histologically, OCS is composed of an epithelial and sarcomatous component. Case report. In the present case, a patient with bilateral ovarian cysts and bulky paraaortic lymph nodes is reported. Retroperitoneal paraaortic lymph node metastases were the only extrapelvic dissemination of OCS. The patient underwent comprehensive surgical staging procedures, including total abdominal hysterectomy and bilateral salpingo-oophorectomy, supracolic omentectomy and selective para-aortic lymphadenectomy. Histologically the ovarian carcinosarcoma was composed of an epithelial component (high-grade serous adenocarcinoma) and three sarcomatous components (homologous-endometrial stromal cell sarcoma, and heterologous-chondrosarcoma, rhabdomyosarcoma). Immunohistochemistry staining was performed. A postoperative complication (adhesion between the abdominal aorta and terminal ileum causing obstructive ileus) that has never been reported in the medical literature occurred. Conclusion. Carcinosarcomas are carcinomas with epithelial-mesenchymal transition and heterologous differentiation. Retroperitoneal pelvic and paraaortic lymph nodes should be carefully inspected in patients with ovarian tumours. Adhesions between the small bowels and abdominal aorta are possible complications after lymph node dissection in the paraaortic region.

Effect of Adjuvant Therapy on Oncologic Outcomes of Surgically Confirmed Stage I Uterine Carcinosarcoma: a Turkish Gynecologic Oncology Study

Background:

Uterine carcinosarcoma is rare neoplasm that mostly presents as metastatic disease. Stage is one of the most important prognostic factor, however, the management of the early stage uterine carcinosarcoma is still controversial.

Aims:

To evaluate prognostic factors, treatment options, and survival outcomes in patients with surgically approved stage I uterine carcinosarcoma.

Study Design:

Cross-sectional study.

Methods:

Data of 278 patients with uterine carcinosarcoma obtained from four gynecologic oncology centers were reviewed, and 70 patients with approved stage I uterine carcinosarcoma after comprehensive staging surgery were studied.

Results:

The median age of the entire cohort was 65 years (range; 39-82). All patients underwent both pelvic and paraaortic lymphadenectomy. Forty-one patients received adjuvant therapy. The median follow-up time was 24 months (range; 1-129). Nineteen (27.1%) patients had disease failure. The 3-year disease-free survival and cancer-specific survival of the entire cohort was 67% and 86%, respectively. In the univariate analysis, only age was significantly associated with disease-free survival (p=0.022). There was no statistical significance for disease-free survival between observation and receiving any type of adjuvant therapy following staging surgery. Advanced age (<75 vs ≥75 years) was the only independent prognostic factor for recurrence (hazard ratio: 3.8, 95% CI=1.10-13.14, p=0.035) in multivariate analysis. None of the factors were significantly associated with cancer-specific survival.

Conclusion:

Advanced age was the only independent factor for disease-free survival in stage I uterine carcinosarcoma. Performing any adjuvant therapy following comprehensive lymphadenectomy was not related to the improved survival of the stage I disease.

Fluorodeoxyglucose Positron Emission Tomography-computed Tomography Evaluation of an Interesting Case of Uterine Carcinosarcoma with Isolated Appendicular Skeletal Metastases

Uterine carcinosarcomas, also known as malignant mixed mullerian tumors, are one of the rare and most aggressive neoplasms of the uterus. They have an aggressive course and can spread to distant organs. Owing to the low incidence of these tumors, the optimal adjuvant management after surgery is not well established. Many patients develop distant metastases during follow-up. An interesting case of uterine carcinosarcoma who developed metastases to the femur, tibia, and calcaneum during follow is presented.

Management of Leimyosarcoma: A Survey Among Members of the Korean Gynecologic Oncology Group

OBJECTIVE

This study aimed to investigate current clinical management of leiomyosarcoma (LMS) in Korea.

MATERIALS AND METHODS

We conducted a Web-based survey among members of the Korean Gynecologic Oncology Group regarding their treatment of LMS.

RESULTS

In total, 77 (27.8%) of 277 members responded to the survey. For surgical treatment of stage I LMS, 26.8% indicated total hysterectomy only and 16.9% indicated total hysterectomy with bilateral salpingo-oophorectomy. Also, lymph node dissection was indicated by 54.9% of respondents, whereas 46.5% stated that bilateral salpingo-oophorectomy could be omitted in young patients. More than half (57.7%) of the respondents recommended against adjuvant treatment. For stage I LMS diagnosed after morcellation, 79.2% of the respondents recommended lymph node dissection and 56.4% recommended adjuvant therapy. As for advanced-stage LMS, in cases of complete resection, adjuvant chemotherapy was preferred by 63.1%. For incomplete resection, combined radiotherapy/chemotherapy was the most preferred adjuvant therapy (63.1%).

CONCLUSIONS

Among Korean Gynecologic Oncology Group members, there are many discrepancies in the clinical management of LMS. A large-scale prospective study to establish treatment guidelines is needed.

CNS metastasis secondary to malignant-mixed Müllerian tumor: case report and review of therapeutics

This paper reviews CNS involvement secondary to malignant-mixed Müllerian tumor or uterine carcinosarcoma, a rare aggressive biphasic Müllerian tumor. We report a cerebellar metastasis with epithelial and mesenchymal components, demonstrating heterologous rhabdomyogenic and chondroblastic differentiation. The patient had undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy for palliation of symptomatic chemotherapy-resistant node-positive disease. CNS involvement is rare, and prognostically poor, and suggestively poorer in predominantly sarcomatous metastases. Multimodal therapy is indicated; in solitary metastases, surgical resection or stereotactic radiosurgery is included, followed by whole brain radiotherapy. In unresectable brain metastases, stereotactic radiosurgery and whole brain radiotherapy warrant consideration in up to 2-3 metastases. In multiple metastases, palliative steroid therapy or cranial irradiation may be considered. Combination or platinum-based chemotherapy (i.e., ifosfamide-paclitaxel or carboplatin-paclitaxel) is indicated in all stages, with a role in both disease cure and control-directed management. Targeted therapeutics have thus far not demonstrated significant clinical efficacy.

Impact of adjuvant therapy on recurrence patterns in stage I uterine carcinosarcoma

BACKGROUND

To examine recurrence patterns in women with stage I uterine carcinosarcoma (UCS) stratified by adjuvant therapy pattern.

METHODS

We examined 443 cases of stage I UCS derived from a retrospective cohort of 1192 UCS cases from 26 institutions. Adjuvant therapy patterns after primary hysterectomy-based surgery were correlated to recurrence patterns.

RESULTS

The most common adjuvant therapy was chemotherapy alone (41.5%) followed by chemotherapy/radiotherapy (15.8%) and radiotherapy alone (8.4%). Distant-recurrence was the most common recurrence pattern (5-year cumulative rate, 28.1%) followed by local-recurrence (13.3%). On multivariate analysis, chemotherapy but not radiotherapy remained an independent prognostic factor for decreased risk of local-recurrence (5-year cumulative rates 8.7% versus 19.8%, adjusted-hazard ratio [HR] 0.46, 95% confidence interval [CI] 0.25-0.83, P=0.01) and distant-recurrence (21.2% versus 38.0%, adjusted-HR 0.41, 95%CI 0.27-0.62, P<0.001). The chemotherapy/radiotherapy group had a lower 5-year cumulative local-recurrence rate compared to the chemotherapy alone group but it did not reach statistical significance (5.1% versus 10.1%, adjusted-HR 0.46, 95%CI 0.13-1.58, P=0.22). Radiotherapy significantly decreased local-recurrence when tumors had high-grade carcinoma, sarcoma component dominance, and deep myometrial tumor invasion (all, P<0.05); and combining radiotherapy with chemotherapy was significantly associated with decreased local-recurrence compared to chemotherapy alone in the presence of multiple risk factors (5-year cumulative rates, 2.5% versus 21.8%, HR 0.12, 95%CI 0.02-0.90; P=0.013) but not in none/single factor (P=0.36).

CONCLUSION

Adjuvant chemotherapy appears to be effective to control both local- and distant-recurrences in stage I UCS; adding radiotherapy to chemotherapy may be effective to control local-recurrence when the tumor exhibits multiple risk factors.

The Impact of Adjuvant Therapy on Survival and Recurrence Patterns in Women With Early-Stage Uterine Carcinosarcoma: A Multi-institutional Study

OBJECTIVE

The aim of the study was to characterize the impact of adjuvant therapy on survival in women with stage I/II uterine carcinosarcoma after primary surgery.

METHODS

We reviewed records of 118 consecutively treated women with 2009 International Federation of Gynecology and Obstetrics stage I/II uterine carcinosarcoma who underwent hysterectomy between 1990 and 2014 at 4 academic institutions. Patients were categorized by adjuvant treatment group into observation, chemotherapy only, radiation only, and combined chemotherapy and radiation. Survival analyses were conducted using Kaplan-Meier and Cox proportional hazards models.

RESULTS

Median follow-up was 28 months (range, 1-244 months). Lymphadenectomy was performed in 94 patients (80%). Postoperative management included observation (n = 37 [31%]), chemotherapy alone (n = 19 [16%]), radiation therapy (RT) alone (n = 24 [20%]), and combined RT and chemotherapy (n = 38 [32%]). Radiation therapy modality included vaginal brachytherapy in 22 patients, pelvic external beam RT in 21 patients, and combination in 19 patients. In 58% of women, chemotherapy consisted of carboplatin/paclitaxel. Median overall survival for all women was 97 months. On univariate analysis, adjuvant treatment group was associated with improved overall survival (hazard ratio [HR], 0.74; confidence interval [CI], 0.58-0.96; p = 0.02), freedom from vaginal recurrence (HR, 0.55; CI, 0.37-0.82]; p = 0.004), and freedom from any recurrence (HR, 0.70; CI, 0.54-0.92; p = 0.01). Pairwise comparisons demonstrated a significant benefit to chemoradiation over other adjuvant treatments. Adjuvant treatment group remained a significant covariate for all 3 end points on multivariate analysis as well. In addition, lymphadenectomy improved overall survival on multivariate analysis (HR, 0.24; CI, 0.09-0.61; p = 0.003). Of patients under observation only who had a recurrence, 8 (44%) of 18 had a recurrence in the vagina as the sole site of recurrence. By contrast, of women who received vaginal brachytherapy, significantly fewer had a recurrence in the vagina (1/42 [2.3%]; p < 0.003, log-rank test).

CONCLUSIONS

In women with early-stage uterine carcinosarcoma, our data suggest superior survival end points with combined RT and chemotherapy. The frequency of vaginal recurrence suggests a role for incorporating vaginal brachytherapy in the adjuvant management of this disease.

Clinical Characteristics, Surgical Management and Adjuvant Therapy of Patients with Uterine Carcinosarcoma: A Retrospective Case Series

Purpose: To review a single-center experience over a 27-year period of managing uterine carcinosarcoma (UCS), focusing on surgical practice, adjuvant therapy and clinical outcome. Material and Methods: This was a retrospective study of women with histologically proven UCS treated at the Department of Obstetrics and Gynecology, University of Tübingen, Germany, between 1983 and 2010. Inpatient and outpatient records were reviewed; follow-up and survival data were ascertained. Results: The study population comprised 18 patients with UCS. Primary surgical treatment consisted of total abdominal hysterectomy in 12 patients (67 %) and laparoscopic total hysterectomy in 4 patients (22 %). Bilateral salpingo-oophorectomy was performed in 94 % of patients (17/18). Lymph nodes were evaluated in 15 patients (83 %). Positive pelvic lymph nodes were present in 2 patients (11 %). A total of 17 patients (94 %) received adjuvant therapy. Disease recurred in 7 (39 %) patients of our study group, with no recurrence noted in the 4 patients who underwent laparoscopic surgical staging. Median disease-free survival (DFS) was 48.7 months (95 % CI: 0.0-157.3) and median overall survival (OS) was 49.9 months (95 % CI: 0.0-108.2). The 5-year survival rate was 40 %. Conclusion: UCS is a rare and aggressive uterine neoplasm with high recurrence rates and metastatic potential. Surgical staging consisting of total hysterectomy with bilateral salpingo-oophorectomy and systematic lymphadenectomy is the most important treatment for patients with UCS. Adjuvant radiation therapy appears to decrease pelvic recurrence, but there is a high incidence of distant recurrence, indicating the need for additional systemic treatment.

A multi-institutional study of outcomes in stage I-III uterine carcinosarcoma

OBJECTIVE

To evaluate the use of adjuvant therapy after primary surgery for stage I-III uterine carcinosarcoma (CS).

METHODS

A multi-institutional retrospective study of women with stage I-III CS was conducted. Analyses were stratified by stage (I/II and III). Patients were categorized according to adjuvant therapy: observation (OBS), radiation (RT), chemotherapy (CT) or multimodal therapy (CT+RT). Overall survival (OS) and progression-free survival (PFS) were analyzed using log-rank tests and Cox proportional hazards models.

RESULTS

303 patients were identified across four institutions: 195 with stage I/II and 108 with stage III disease. In stage I/II disease, 75 (39.9%) received OBS, 33 (17.6%) CT, 37 (19.7%) RT, and 43 (22.9%) CT+RT. OBS was associated with a fourfold increased risk of death compared to CT (adjusted hazard ratio (aHR)=4.48, p=0.003). Patients receiving CT+RT had significantly improved PFS compared to those receiving CT alone (aHR=0.43, p=0.04), but no difference in OS. In the stage III cohort, 16 (15.0%) received OBS, 34 (31.8%) CT, 20 (18.7%) RT, and 37 (34.6%) CT+RT. OBS was associated with worse OS and PFS compared to CT (OS: aHR=2.46, p=0.04; PFS: aHR=2.39, p=0.03, respectively). A potential improvement in PFS was seen for those treated with CT+RT compared to CT alone, however it was not statistically significant (aHR=0.53, p=0.09).

CONCLUSIONS

Observation after surgery was associated with poor outcomes in uterine CS compared to CT and RT alone. Multimodality therapy for women with stage I/II disease was associated with improved PFS compared to chemotherapy alone. Novel treatment options are needed to improve outcomes in this aggressive disease.

Uterine and ovary carcinosarcomas: outcome, prognosis factors, and adjuvant therapy

OBJECTIVES

The aim of this study was to assess the outcome and the prognosis factors of uterine and ovarian carcinosarcomas.

METHODS

From January 1993 to January 2010, data from 68 consecutively treated patients with uterine (n=59) and ovarian (n=9) carcinosarcomas were retrospectively analyzed in a single French comprehensive cancer center.

RESULTS

The median follow-up was 24.2 months (interquartile range [IQR]: 13.5 to 54.6). The median age was 69 years (IQR: 63 to 77). Patients were classified as FIGO stage I (n=28; 41%) and FIGO stage II to IV (n=40; 59%), respectively. There were 33 (49%) and 29 (43%) homologous and heterologous type, respectively. The median disease-free survival and overall survival were 21.9 months (IQR: 7.9 to 22.3) and 27.1 months (IQR: 14.5 to 72), respectively. No statistical differences of survival were reported concerning the initial location of the carcinosarcoma (uterine vs. ovarian). Radiation therapy (hazards ratio [HR]=0.3; 95% confidence interval [CI], 0.16-0.67) and FIGO stage I (HR=0.4; 95% CI, 0.17-0.9) were associated with an increased disease-free survival. Homologous type (HR=3; 95% CI, 1.4-6.3) and FIGO stage II to IV (HR=2.64; 95% CI, 1.3-5.4) were associated with a decreased overall survival. There was no survival improvement for the 12% of patients receiving a multimodal adjuvant therapy.

CONCLUSIONS

Uterine and ovary carcinosarcomas present a worse prognosis. On the basis of the present study data, although it should be prospectively confirmed, a sequential or multimodal adjuvant therapy should be proposed to patients with early-stage uterine and ovary carcinosarcomas.

Evaluation of brachytherapy and external beam radiation therapy for early stage, node-negative uterine carcinosarcoma

PURPOSE

There is limited evidence to guide treatment decision making for patients with early stage uterine carcinosarcoma (UCS) regarding the use of pelvic external beam radiation therapy (RT) vs. vaginal brachytherapy (BT) after hysterectomy. We analyzed a population-based database to compare survival outcomes after adjuvant BT vs. pelvic external beam RT for patients with Stages I-II UCS.

METHODS AND MATERIALS

We searched the Surveillance, Epidemiology, and End Results registry to identify a cohort of patients with International Federation of Gynecology and Obstetrics I/II UCS diagnosed during 1998-2010, who received a total hysterectomy and for whom radiotherapy type was known. χ(2) tests were used to test associations between patient characteristics and radiotherapy type. Overall and cancer-specific survival, measured from date of diagnosis, were summarized within each covariate. Cox proportional hazards models were used to model the impact of RT type on survival while adjusting for other factors.

RESULTS

A total of 1581 subjects were identified, including 803 (50.8%) no radiotherapy; 636 (40.2%) external beam radiotherapy ± BT; and 142 (9.0%) BT alone. The use of BT alone increased from 4.5% in 1988-1999 to 12.5% in 2005-2010. Multivariate models of overall and cause-specific survival showed that radiotherapy type was not associated with survival after adjustment for other covariates.

CONCLUSIONS

For patients with Stages I-II UCS, adjuvant radiotherapy type did not influence survival after hysterectomy. This study addresses an existing evidence gap and identifies a trend toward increasing utilization of BT alone. Prospective trials are warranted to provide high-quality evidence to guide adjuvant therapy decisions for these patients.

Vaginal brachytherapy for early-stage carcinosarcoma of the uterus

OBJECTIVE

Uterine carcinosarcoma (CS) is an aggressive malignancy and the optimal adjuvant treatment is not well-established. We report outcomes with vaginal brachytherapy (VB) for women with early-stage CS.

METHODS AND MATERIALS

A multi-institutional retrospective study of Stage I-II CS treated with hysterectomy, surgical staging, and adjuvant high-dose-rate VB without external-beam pelvic radiotherapy was performed. Rates of vaginal control, pelvic control, locoregional control, disease-free survival, and overall survival were determined using the Kaplan-Meier method.

RESULTS

33 patients were identified. Prescribed VB dose was 21 Gy in three fractions (n = 15 [45%]) or 24 Gy in six fractions (n = 18 [55%]). Eighteen patients (55%) received chemotherapy. Median followup was 2.0 years. Twenty-seven patients (82%) underwent pelvic lymphadenectomy, 5 (15%) had nodal sampling, and 1 (3%) had no lymph node assessment. Relapse occurred in 11 patients (33%), all of whom had lymph node evaluation. Locoregional relapse was a component of failure in 6 patients (18%), of whom 3 (9%) failed in the pelvis alone. Three patients (9%) had simultaneous distant and locoregional relapse (two vaginal, one pelvic). Five additional patients (15%) had distant relapse. Six of the 11 patients (55%) with disease recurrence received chemotherapy. Two-year vaginal control and pelvic control were 94% and 87%. Two-year locoregional control, disease-free survival, and overall survival were 81%, 66%, and 79%.

CONCLUSIONS

Despite having early-stage disease and treatment with VB, patients in this series had relatively high rates of local and distant relapse. Patients who undergo lymphadenectomy and VB remain at risk for relapse. Novel treatment strategies are needed.

Uterine carcinosarcoma: A review of the literature

OBJECTIVE

Uterine carcinosarcomas (UCSs) are aggressive tumors previously considered to be sarcomas, but now recognized as malignancies composed of metaplastic transformation of epithelial elements. Much of the management for UCS has been extrapolated from studies of endometrial carcinomas and sarcomas. This article critically reviews the literature pertinent to the pathology, pathogenesis, diagnosis and management of women with UCS.

METHODS

MEDLINE was searched for English language literature on UCS with a focus on the past 20years. Given the rarity of this tumor, studies were not limited by design or number of reported patients.

RESULTS

UCS is biologically a de-differentiated endometrial carcinoma with its own pathogenesis and molecular profile. It commonly presents with extrauterine disease which can be identified by comprehensive surgical staging. Most UCS patients are candidates for adjuvant chemotherapy. The role of radiation is less clear. Combination therapy, while commonly used, has not been studied in depth. The high recurrence rate and poor overall survival for UCS suggest an ongoing need for clinical trials for UCS specifically.

CONCLUSIONS

UCS represents a distinct subtype of uterine malignancy, and should be studied as such via focused clinical trials.

Outcome analysis in patients with uterine sarcoma

PURPOSE

To analyze the prognostic factors for survivals and to evaluate the impact of postoperative whole pelvic radiotherapy (WPRT) on pelvic failure in patients with uterine sarcoma treated with radical surgery.

MATERIALS AND METHODS

We retrospectively analyzed 75 patients with uterine sarcoma who underwent radical surgery with (n = 22) or without (n = 53) radiotherapy between 1990 and 2010. There were 23 and 52 patients with carcinosarcoma and non-carcinosarcoma (leiomyosarcoma, 22; endometrial stromal sarcoma, 25; others, 5), respectively. The median follow-up period was 64 months (range, 17 to 269 months).

RESULTS

The 5-year overall survival (OS) and pelvic failure-free survival (PFFS) of total patients was 64.2% and 83.4%, respectively. Multivariate analysis revealed that mitotic count (p = 0.006) was a significant predictor of OS. However, factors were not found to be associated with PFFS. On analyzing each of the histologic subtypes separately, postoperative WPRT significantly reduced pelvic failure in patients with carcinosarcoma (10.0% vs. 53.7%; p = 0.046), but not in patients with non-carcinosarcoma (12.5% vs. 9.9%; p = 0.866). Among the patients with carcinosarcoma, 4 patients (17%) had recurrence within the pelvis and 3 patients (13%) had recurrence in other sites as an initial failure, whereas among the patients with non-carcinosarcoma, 3 patients (6%) experienced pelvic failure and 13 patients (25%) experienced distant failure.

CONCLUSION

The most significant predictor of OS was mitotic count. Based on the improved PFFS after postoperative WPRT only in patients with carcinosarcoma and the difference in patterns of failure between histologic subtypes, optimal adjuvant treatment options should be offered to patients based on the risk of recurrence patterns.

Clinical Outcomes of Uterine Carcinosarcoma: Results of 94 Patients

Objective

We aimed to determine the clinicopathologic features and identify prognostic factors of patients with uterine carcinosarcoma.

Materials and Methods

A total of 94 patients with uterine carcinosarcoma who were diagnosed between January 1993 and October 2013 were included. Staging surgery consisted of total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, peritoneal cytology, and omentectomy. Staging is undertaken according to the 2009 International Federation of Gynecology and Obstetrics staging system. Kaplan-Meier survival analysis was used to determine the effects of variables on disease-free survival (DFS) and overall survival (OS).

Results

Seventy-nine patients underwent staging surgery and none of them had residual tumor after surgery. Three-year DFS and 3-year OS were 42.7% and 59.2%, respectively. In the univariate analysis, stage, presence of para-aortic metastatic lymph nodes, uterine serosal spread, positive peritoneal cytology, and extrapelvic metastases were associated with 3-year DFS and stage, presence of para-aortic metastatic lymph nodes, uterine serosal spread, positive peritoneal cytology, adnexal involvement, and extrapelvic metastases were associated with 3-year OS. Seventy-four patients received adjuvant therapy. Adjuvant therapy did not reduce recurrence or improve survival. Any of the chemotherapy regimens was not superior to the others. In the multivariate analysis, only age was an independent prognostic factor for 3-year DFS and no parameter was statistically significant for 3-year OS.

Conclusions

Age was an independent prognostic factor for 3-year DFS. Older age was associated with poor survival. Extrauterine spread was associated with survival. The aims of surgery should be both staging and providing tumoral debulking. Prospective randomized trials are needed to better define the necessity and modality of the administered adjuvant therapy.

F-18 fluorodeoxyglucose positron emission tomography/computed tomography in a rare case of recurrent malignant mixed mullerian tumor

We report a case of 66-year-old female with previous history of histopathologically proven. Malignant mixed mullerain tumor of the uterus in whom positron emission tomography/computed tomography (CT) done for characterization of soft tissue lesion in pelvis noticed on CT, showed extensive recurrent disease in the pelvis with pulmonary metastases.

A review of treatment of uterine leiomyosarcomas

Uterine leiomyosarcomas are rare but challenging tumours. They occur most commonly around or shortly after the menopause. Their clinical behaviour is very variable, from highly aggressive to very indolent. Most are diagnosed unexpectedly and thus initially operated on by general gynaecologists. This article discusses the important surgical issues and the role of adjuvant treatments such as radiotherapy and chemotherapy. Important new international trials are opening to address these issues. Relapsed disease is usually incurable, but a subgroup of patients may benefit from repeated surgical procedures, hormones and ablative therapies. The choice of drugs for chemotherapy is discussed. New approaches with targeted agents have yet to establish themselves in treatment of leiomyosarcomas.

Uterine carcinosarcoma

PURPOSE OF REVIEW

To summarize the clinical characteristics, epidemiology, and treatment of uterine carcinosarcoma.

RECENT FINDINGS

Recent studies have suggested that uterine carcinosarcomas are aggressive neoplasms that carry a poor prognosis even when diagnosed at an early stage. Treatment is typically surgical. The ideal adjuvant treatment remains unknown. A number of recent studies have examined the influence of radiation, chemotherapy, and combinations of chemotherapy and radiation for uterine carcinosarcoma.

SUMMARY

Carcinosarcoma is an aggressive neoplasm. A number of studies are underway to determine the optimal adjuvant therapy for these tumors.

Tamoxifen in breast cancer ipse dixit in uterine malignant mixed Müllerian tumor and sarcoma-A report of 8 cases and review of the literature

AIM

Report the outcome of 8 patients (pts) with breast cancer (BC) treated with Tamoxifen (TAM) that developed malignant mixed Müllerian tumor (MMMT) and rare uterine sarcoma (RUS).

PATIENTS AND METHODS

Retrospective study based on data collected from the department medical records between April 1999 and September 2010 among 583 pts with endometrial cancer, 36 pts with MMMT and RUS histopathology. Among them, 8 pts underwent TAM between 4 and 10 years due to a previous diagnosis of BC; all pts were post-menopausal with regular gynecological surveillance; 6 pts (75%) with abnormal uterine bleeding. The diagnosis of 6 pts (MMMT) and 2 pts (RUS) occurred at median interval of 8 years (range 4-12) after initial BC treatment. Pts underwent surgical treatment and were staged as stage I (3pts), IIIA (3pts) and IIIC (2 pts) (FIGO 1988); followed by whole pelvis irradiation (50 Gy) and intracavitary HDR brachytherapy boost (24 Gy). Two pts underwent chemotherapy (CT). Overall and disease free survival was calculated by Kaplan Meier method.

RESULTS

With a median follow-up of 47 months (range 17-130), 3 pts remain alive recurrence-free of BC and RUS. Four pts died with distant metastasis within the first follow-up year, without BC. One pt died from non-related cancer cause. No evidence of local recurrence was found in the whole group of pts. At two years, DFS and OS were 40% and 80%, respectively.

CONCLUSION

As reported in the literature, TAM administration and causal effect on MMMT and RUS in BC pts is still unknown. No reports about outcome from these specific pts were found.

The reasonable timing of the adjuvant radiotherapy in the treatment of uterine carcinosarcoma according to the surgical intent: suggestion based on progression patterns

Purpose

We designed this study to identify and suggest the reasonable timing of adjuvant radiotherapy in the treatment of uterine carcinosarcoma according to the surgical intent and patterns of progression.

Materials and Methods

We retrospectively analyzed a total of 50 carcinosarcoma patients diagnosed between 1995 and 2010. Among these 50 patients, 32 underwent curative surgery and 13 underwent maximal tumor debulking surgery. The remaining five patients underwent biopsy only. Twenty-six patients received chemotherapy, and 15 patients received adjuvant radiotherapy.

Results

The median follow-up period was 17.3 months. Curative resection (p < 0.001) and stage (p < 0.001) were statistically significant factors affecting survival. During follow-up, 30 patients showed progression. Among these, eight patients (16.0%) had loco-regional progression only. The patients who had received adjuvant radiotherapy did not show loco-regional progression, and radiotherapy was a significant negative risk factor for loco-regional progression (p = 0.01). The time to loco-regional progression was much earlier for non-curative than curative resection (range, 0.7 to 7.6 months vs. 7.5 to 39.0 months).

Conclusion

Adjuvant radiotherapy in the treatment of carcinosarcoma might be related to a low loco-regional progression rate. Radiotherapy should be considered in non-curatively resected patients as soon as possible.

A population-based series of uterine carcinosarcomas with long-term follow-up

BACKGROUND

Carcinosarcomas are a highly malignant type of endometrial carcinomas where extra uterine spread and recurrences are frequent. There is no consensus regarding the best treatment of this group of malignancies.

MATERIAL AND METHODS

In a complete geographic series of 322 cases of primary uterine carcinosarcomas prophylactic pelvic irradiation and/or chemotherapy was used as postoperative treatment in the majority of the cases. Vaginal brachytherapy was also added as a boost. The primary surgery was extended hysterectomy in 23 cases (10%), and simple hysterectomy in 220 cases (90%). In 46 cases (14%) no major surgery was possible.

RESULTS

In the complete series 123 recurrences (38%) were recorded. Locoregional recurrences (11%) and distant recurrences (28%) were most frequent. Type and extent of surgery was not associated with the risk of tumor recurrence. Extended surgery did not reduce the risk of local and regional recurrences. In the complete series, the five-year overall survival rate was 30% and the recurrence-free survival (RFS) rate was 27%. The five-year pelvic disease control was 82% in stage I, 68% in stage II, and 76% for more advanced stages. The five-year locoregional RFS rate was 63% for patients treated with surgery alone, 68% after addition of adjuvant chemotherapy, 86% after adjuvant radiotherapy, and 95% after combined chemotherapy and radiotherapy.

CONCLUSION

Radiotherapy seems to be the most important constituent of the adjuvant therapy. Serious late tissue reactions, requiring surgery, from the bladder and intestine occurred in 2.5% of the irradiated cases. The death of three patients could be related to radiotherapy and of four patients due to the cytotoxic treatment. This population-based series may serve as a baseline for improvements by, e.g. standard care programs and referral to a few specialist centers for this rare and serious disease.

Adjuvant radiotherapy and/or chemotherapy after surgery for uterine carcinosarcoma

BACKGROUND

Uterine carcinosarcomas are uncommon with about 35% not confined to the uterus at diagnosis. The survival of women with advanced uterine carcinosarcoma is poor with a pattern of failure indicating greater likelihood of upper abdominal and distant metastatic recurrence.

OBJECTIVES

To evaluate the effectiveness and safety of adjuvant radiotherapy and/or systemic chemotherapy in the management of uterine carcinosarcoma.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), 2012, Issue 10, MEDLINE and EMBASE up to November 2012. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing adjuvant radiotherapy and/or chemotherapy in women with uterine carcinosarcoma.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Hazard ratios (HRs) for overall survival (OS) and progression-free survival (PFS) and risk ratios (RRs) comparing adverse events in women who received radiotherapy and/or chemotherapy were pooled in random-effects meta-analyses.

MAIN RESULTS

Three trials met the inclusion criteria and these randomised 579 women, of whom all were assessed at the end of the trials. Two trials assessing 373 participants with stage III to IV persistent or recurrent disease, found that women who received combination therapy had a significantly lower risk of death and disease progression than women who received single agent ifosfamide, after adjustment for performance status (HR = 0.75, 95% confidence interval (CI): 0.60 to 0.94 and HR = 0.72, 95% CI: 0.58 to 0.90 for OS and PFS respectively). There was no statistically significant difference in all reported adverse events, with the exception of nausea and vomiting, where significantly more women experienced these ailments in the combination therapy group than the Ifosamide group (RR = 3.53, 95% CI: 1.33 to 9.37).In one trial there was no statistically significant difference in the risk of death and disease progression in women who received whole body irradiation and chemotherapy, after adjustment for age and FIGO stage (HR = 0.71, 95% CI: 0.48 to 1.05 and HR = 0.79, 95% CI: 0.53 to 1.18 for OS and PFS respectively). There was no statistically significant difference in all reported adverse events, with the exception of haematological and neuropathy morbidities, where significantly less women experienced these morbidities in the whole body irradiation group than the chemotherapy group (RR= 0.02, 95% CI: 0.00 to 0.16) for haematological morbidity and all nine women in the trial experiencing neuropathy morbidity were in the chemotherapy group).

AUTHORS' CONCLUSIONS

In advanced stage metastatic uterine carcinosarcoma as well as recurrent disease adjuvant combination, chemotherapy with ifosfamide should be considered. Combination chemotherapy with ifosfamide and paclitaxel is associated with lower risk of death compared with ifosfamide alone. In addition, radiotherapy to the abdomen is not associated with improved survival.

Wilms' tumor 1 protein and estrogen receptor beta expression are associated with poor outcomes in uterine carcinosarcoma

BACKGROUND

Uterine carcinosarcoma (CS) is an aggressive malignancy. Increased expression of Wilms' tumor 1 (WT1) protein and estrogen receptor beta (ER-β) protein is associated with worse outcomes in gynecologic cancers; therefore, we sought to assess this association in CS patients.

METHODS

A retrospective analysis was conducted for women diagnosed with uterine CS from departmental databases. WT1/ER-β expression was determined by immunohistochemical staining and scoring of specimens. Univariate and multivariate models were used to correlate progression-free survival (PFS) and overall survival (OS) with WT1/ER-β expression and clinicopathologic factors.

RESULTS

Ninety four patients had mean follow-up of 27 months. Postoperative treatments included chemotherapy for 52 (55 %) subjects and radiotherapy for 25 (27 %). Sixty-four (68 %) and 74 (79 %) tumor samples expressed WT1 and ER-β by immunohistochemistry, respectively. On univariate analysis, stage (p = .02) and lower uterine segment invasion (LUSI) (p = .001) were associated with decreased PFS. Only stage (p = .003) was linked to OS. In the total sample, increased WT1 expression was marginally associated with impaired PFS (p = .07) and OS (p = .09) but ER-β expression was not associated with PFS (p = .89) or OS (p = .30). WT1 and ER-β concurrent expression was associated with impaired OS (p = .02) and PFS (p = .02). On multivariate analysis, LUSI was a significant prognostic factor for PFS [hazard ratio (HR) 2.21, 95 % confidence interval (CI) = 1.12-4.32, p = .03] and stage for OS (HR 3.20, 95 % CI = 1.23-8.35, p = .02). Increased WT1/ER-β expression was associated with impaired OS (HR 1.31, 95 % CI = 1.02-1.69, p = .04).

CONCLUSIONS

Concurrent increased WT1 and ER-β expression impairs prognosis for women with uterine CS. Further research is warranted to define how relevant pathways interact and whether targeting these pathways improves OS.

Uterine carcinosarcomas: 8-year single center experience of 25 cases

Objectives:

The aim of this retrospective study was to evaluate the behavior and treatment outcomes of uterine carcinosarcomas in relation to their clinical and pathogenic features and to determine the optimal treatment strategy. Secondary objectives were to identify parameters predictive of survival.

Materials and Methods:

The hospital records of all 25 patients of uterine carcinosarcoma operated between 2000 and 2008 in Gujarat cancer research institute, Ahmedabad, were reviewed. Patients who presented with clinical evidence of recurrent disease or those who had incomplete medical records were excluded from our analysis. The status of these patients was updated up to November, 2010. Patients were classified according to the new 2009 FIGO staging system for endometrial carcinoma, to see what difference the assigned stage has on survival with the old treatment strategy. Survival was calculated by Kaplan-Meier method and compared by Log-Rank test. Median survival time was derived with the Brookmeyer 95% confidence interval. For comparison of qualitative data, Chi-Square test and Fisher extract χ² were used.

Results:

Median age of patients was 56 years (range, 36-77 years). Only 36% of patients had stage I at diagnosis and another 36% were stage III. Most of the tumors (56%) were with homologous sarcomatous components and 64% of tumors were high grade (grade 2/3) at diagnosis. Fifty-two percent patients received postoperative adjuvant treatment. Twelve patients had no postoperative treatment: two were lost to follow-up immediately after surgery, four could not receive adjuvant treatment on account of severe medical complications and age factor which could have increased morbidity, and six patients declined treatment. Four of these patients expired within one year of diagnosis, two other within 18 months, and rest were lost to follow-up. The difference in survival of 13 patients who had taken adjuvant treatment was significantly more than the group who had not taken adjuvant therapy (P=0.025). The overall 3-year disease-free survival of 13 patients who had taken adjuvant therapy was 40%. However, these adjuvant treatment modalities had borderline statistical significance on overall survival of patients (P=0.075). The only statistically significant predictor of survival in this study was stage of the disease (P=0.035).

Conclusions:

This highly aggressive uterine malignancy warrants comprehensive surgical staging to assess tumor dissemination followed by systematic adjuvant therapy in patients with both early and advanced disease. The value of pelvic Radiotherapy in addition to systemic treatment remains ill-defined. Stage is the significant predictor of survival for the disease. Our results indicate that in this highly aggressive malignancy, further exploration of potential outcome benefits of postoperative treatment, especially chemoradiation, is warranted in larger group of patients after comprehensive surgical staging.

Uterine sarcomas: then and now

OBJECTIVE

The purpose of this article is to provide an updated review of uterine sarcomas. The traditionally described neoplasms are reviewed as well as several recently characterized entities in terms of their imaging and clinical aspects. We attempt to provide a longitudinal imaging overview, from initial presentation to follow-up. Imaging features are also described of response to traditional therapeutic agents and newer targeted agents.

CONCLUSION

A greater understanding of the pathogenesis has improved our ability to image and treat uterine sarcomas, both at initial staging and on follow-up. Targeted therapy is assuming an increasingly important role in the management of these lesions. It is imperative for radiologists to be aware of response characteristics and potential complications of these agents as well as conventional chemotherapeutic agents.

Phase II trial of adjuvant pelvic radiation "sandwiched" between ifosfamide or ifosfamide plus cisplatin in women with uterine carcinosarcoma

OBJECTIVE

Uterine carcinosarcoma (CS) is a rare uterine tumor with an extremely poor prognosis. In the adjuvant setting, efficacy has been shown with radiotherapy (RT), systemic chemotherapy, or both. This is the first report describing the efficacy and toxicity of adjuvant ifosfamide or ifosfamide plus cisplatin "sandwiched" with RT in patients with surgically staged and completely resected uterine carcinosarcoma.

METHODS

Women with surgically staged CS with no gross residual disease were initially administered ifosfamide (1.2 g/m(2)/day×5 days) with cisplatin (20 mg/m(2)/day×5 days) every 3 weeks for 3 cycles followed by pelvic external beam RT and brachytherapy followed by 3 additional cycles of ifosfamide (1.0 g/m2/day) with cisplatin (20 mg/m(2)/day×5 days) every 3 weeks. Similar to the GOG trial in recurrent CS (Sutton et al., 2000), the addition of cisplatin added toxicity without additional efficacy, so mid-study, the cisplatin was eliminated from the regimen. Toxicities were recorded and disease-free survival (DFS) was calculated with Kaplan-Meier statistical methods.

RESULTS

In total, 12 patients received ifosfamide and cisplatin and 15 patients received ifosfamide alone, both 'sandwiched' with RT. The median follow up was 35.9 months (range 6-88). The 2 year DFS was similar in both the ifosfamide/cisplatin and ifosfamide groups (log-rank p=0.16), so they were combined for analysis. 19 patients (70%) completed the protocol. As expected, stage 1 patients had a better 2-year DFS (18.75 ± 1.12 months; log-rank p=0.008 when compared to stages 2, 3, 4). Also, in stages 2, 3 and 4 patients, the DFS was 15.81 ± 1.73 months. Grade 3/4 neutropenia, anemia and thrombocytopenia occurred in 18%, 4% and 4% of cycles, respectively.

CONCLUSIONS

Ifosfamide "sandwiched" with RT appears to be an efficacious regimen for surgically staged CS patients with no residual disease, even in patients with advanced stage. The addition of cisplatin to the regimen added toxicity without improving efficacy. Even with ifosfamide alone, the efficacy of this 'sandwich' regimen comes with a moderate but tolerable toxicity profile.

Malignant mixed Mullerian tumor of the ovary with two cases and review of the literature

INTRODUCTION

Malignant mixed Müllerian tumor (MMMT) of the ovary is a rare and highly aggressive tumor. It accounts <1% of all ovarian carcinomas. It is characterized by the presence of both carcinomatous and sarcomatous components and tends to occur in low parity postmenopausal woman. These are mixed, mostly monoclonal tumors, and the predominance of the stromal component aggravates the prognosis. The staging system for ovarian and primary peritoneal cancer is also used for MMMT. After complete surgical staging, patient with stage II-IV at the time of surgery should have postoperative chemotherapy. Chemotherapy can be considered for stage I MMMT. Its optimal treatment is debatable. Taxane and platinum combination is standard for the epithelial ovarian carcinoma. There is very limited literature reporting this combination therapy in ovarian MMMTs. CASE 1 AND CASE 2: We presented two cases of stage III primary ovarian MMMT. The patients were treated with the taxane/platin combination, without adverse events following surgery, and remained in clinical remission in Case 1 at follow-up. Case 2 has progressed after first line taxane/platin regimen and treated like epithelial ovarian carcinoma. Case 1 was in complete remission in the follow-up visit 2 years later. Case 2 died 14 months later after the tumor was initially diagnosed.

CONCLUSION

Predominating carcinomatous or sarcomatous component should be taken into consideration in predicting the response and planning the chemotherapy protocol.

Adjuvant radiotherapy and/or chemotherapy after surgery for uterine carcinosarcoma

BACKGROUND

Uterine carcinosarcomas are uncommon with about 35% not confined to the uterus at diagnosis. The survival of patients with advanced uterine carcinosarcoma is poor with pattern of failure indicating greater likelihood of upper abdominal and distant metastatic recurrence.

OBJECTIVES

To evaluate the effectiveness and safety of radiotherapy and/or systemic chemotherapy in the management of stage III-IV persistent or recurrent uterine carcinosarcoma.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, CENTRAL, The Cochrane Library 2010, Issue 2, MEDLINE and EMBASE to May 2010. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials comparing adjuvant radiotherapy and/or chemotherapy in women with uterine carcinosarcoma.

DATA COLLECTION AND ANALYSIS

We independently abstracted data and assessed risk of bias. We pooled hazard ratios (HRs) for overall and progression-free survival and risk ratios (RRs) comparing adverse events in women who received radiotherapy and/or chemotherapy in meta-analyses.

MAIN RESULTS

Three trials (579 women, of whom all were assessed at the end of the trials) met the inclusion criteria. Two trials (373 women with stage III-IV persistent or recurrent disease) found that women who received combination therapy had a significantly lower risk of death and disease progression than women who received single agent ifosfamide. There was no statistically significant difference in all reported adverse events, with the exception of nausea and vomiting, which affected significantly more women in the combination therapy group than in the ifosamide group.One trial found no statistically significant difference in the risk of death and disease progression in women who received whole abdominal irradiation and chemotherapy, after adjustment for age and FIGO stage (HR = 0.71, 95% CI 0.48 to 1.05 and HR = 0.79, 95% CI 0.53 to 1.18 for overall survival and progression-free survival respectively). There was no statistically significant difference in all reported adverse events, with the exception of haematological and neuropathy morbidities, which affected significantly fewer women in the whole body irradiation group than in the chemotherapy group (RR = 0.02, 95% CI 0.00 to 0.16).

AUTHORS' CONCLUSIONS

The results of this review are limited to two trials. In the primary treatment/ first line therapy of advanced stage metastatic uterine carcinosarcoma, as well as in recurrent disease, adjuvant combination chemotherapy with ifosfamide and paclitaxel should be considered. None of the included studies reported on quality of life.

The role of radiation in improving survival for early-stage carcinosarcoma and leiomyosarcoma

OBJECTIVE

We examined the effect of radiation on survival for early-stage uterine carcinosarcomas and leiomyosarcomas.

STUDY DESIGN

The surveillance, epidemiology, and end results database was used to identify patients with stage I/II carcinosarcomas and leiomyosarcomas. Logistic regression and Cox models were developed to determine radiation use and survival.

RESULTS

Among 1819 women with carcinosarcomas and 1088 women with leiomyosarcomas, radiation was administered to 667 of the patients (37%) with carcinosarcomas and to 235 of the patients (22%) with leiomyosarcomas. In a multivariate model, adjuvant radiation reduced the risk of death by 21% in women with carcinosarcomas (hazard ratio, 0.79; 95% CI, 0.7-0.9). Radiation reduced mortality rates in patients with carcinosarcomas who had not undergone node dissection but had only a marginal effect on survival in node-negative women. Adjuvant radiation had no effect on survival for early-stage leiomyosarcomas (hazard ratio, 1.1; 95% CI, 0.9-1.4).

CONCLUSION

Adjuvant radiotherapy improves survival for select patients with early-stage carcinosarcomas but is of limited value for leiomyosarcomas.

Combination chemotherapy with carboplatin, paclitaxel and pegylated liposomal doxorubicin for advanced or recurrent carcinosarcoma of the uterus: clinical experience of a single institution

OBJECTIVES

The purpose of this study was to evaluate the activity and toxicity of carboplatin, paclitaxel and pegylated liposomal doxorubicin combination in advanced or recurrent of the uterine carcinosarcoma.

METHODS

Twenty-nine eligible patients with measurable disease were treated with carboplatin [area under the curve (AUC) 5], paclitaxel 175 mg/m(2) and pegylated liposomal doxorubicin 25 mg/m(2) every 3 weeks for 6-8 cycles.

RESULTS

There were 10 complete responses (CRs) (34%) and 8 partial responses (PRs) (28%) for an overall response rate (RR) of 62% (95% confidence interval [CI], 43-81%). The median progression-free survival (PFS) was 8.2 months (95% CI, 4.1-12.2 months) and the median overall survival (OS) was 16.4 months (95% CI, 14.7-18.0 months). There was no statistically significant difference between histology and response to therapy. Patients with PS of 0 or 1 had a higher RR than those with worst PS. Toxicity was generally mild except for myelotoxicity. Neutropenia grade 3/4 was recorded in 52% of patients and 10% experienced febrile neutropenia. Anemia grade 3 or 4 developed in 27% of patients and thrombocytopenia grade 3 or 4 in 31% of patients. Three patients (10%) developed grade 3 sensory neuropathy and only 2 patients (8%) grade 3 palmar-plantar erythrodysesthesias. No treatment-related deaths were recorded in our series.

CONCLUSION

The combination of carboplatin, paclitaxel and pegylated liposomal doxorubicin appears to have activity in advanced, persistent or recurrent endometrial carcinosarcoma with an acceptable toxicity profile.

Determining predominating histologic component in malignant mixed mllerian tumors: is it worth it?

Malignant mixed müllerian tumors (MMMT) are highly aggressive tumors, usually diagnosed in advanced stage. Cases of MMMT derive from either ovary or uterus. In our study, we investigated the role of carcinomatous and sarcomatous component on response to chemotherapy and disease outcome. We retrospectively analyzed 25 patients with MMMT who were treated in our outpatient clinic from 1998 to 2003. All the paraffin specimens were reevaluated according to the histopathologic features (primary site and percentages of carcinomatous and sarcomatous component) and the effect of predominant histologic type on response to treatment. Primary tumor sites were ovary and endometrium in 36% and 64% of patients, respectively. Ten of 25 patients (40%) were treated with a combination chemotherapy regimen of cisplatin-ifosfamide (PI) and 7 patients (28%) were treated with paclitaxel-carboplatin (PC) protocol. Despite chemotherapy, 17.6% of patients had progressive disease. The remaining 13 patients (54.2%) responded to chemotherapy. Response rates of patients treated with PC (100%) were remarkably higher than the response rates of patients treated with PI (66.6%). Moreover, patients with predominating carcinomatous component had a higher response rate (87.5%) than patients with predominating sarcomatous component (66.6%). MMMT are highly chemoresponsive tumors, irrespective of primary site. One of the best predictors to response is the histologic pattern. Predominating histopathologic feature (carcinoma or sarcoma) should be taken into consideration in predicting the response and planning the chemotherapy regimen.

The impact of adjuvant radiation therapy on survival in women with uterine carcinosarcoma

BACKGROUND AND PURPOSE

Uterine carcinosarcoma is an aggressive neoplasm and the benefit of adjuvant radiation therapy (RT) is unclear. This retrospective study analyzes the influence of RT on survival using a large population database.

MATERIALS AND METHODS

Data were obtained from the Surveillance, Epidemiology, and End Results (SEER) program of the US National Cancer Institute. Women with uterine carcinosarcoma who underwent primary surgery were eligible. Survival rates and multivariate analyses were performed by standard methods.

RESULTS

Of the 2461 women in the analysis, 890 received adjuvant RT. Five-year rates of overall survival were 41.5% and 33.2% (P<0.001) and uterine-specific survival were 56.0% and 50.8% (P=0.005), for women receiving RT compared to those who did not. Women with stages I-III disease experienced a benefit in overall survival (HR 0.87, P=0.03) while women with stage IV disease experienced benefits in overall (HR 0.63, P<0.001) and uterine-specific survival (HR 0.63, P=0.004) with RT.

CONCLUSIONS

RT predicted for improved overall and disease specific survival in women with uterine carcinosarcoma within the SEER database. The benefit in disease specific survival was restricted to stage IV disease. These benefits may indicate a role for adjuvant RT in future prospective trials in the treatment of uterine carcinosarcoma.

A gynecologic oncology group randomized phase III trial of whole abdominal irradiation (WAI) vs. cisplatin-ifosfamide and mesna (CIM) as post-surgical therapy in stage I-IV carcinosarcoma (CS) of the uterus

PURPOSE

After initial surgery, there has been no established consensus regarding adjunctive therapy for patients with uterine carcinosarcoma (CS). This study was designed to compare patient outcome following treatment with adjuvant whole abdominal irradiation (WAI) versus (vs.) chemotherapy for patients with this rare group of female pelvic malignancies.

PATIENTS AND METHODS

Eligible, consenting women with stage I-IV uterine CS, no more than 1 cm postsurgical residuum and/or no extra-abdominal spread had their treatments randomly assigned as either WAI or three cycles of cisplatin (C), ifosfamide (I), and mesna (M).

RESULTS

232 patients were enrolled, of whom 206 (WAI=105; CIM=101) were deemed eligible. Patient demographics and characteristics were similar between arms. FIGO stage (both arms) was: I=64 (31%); II=26 (13%); III=92 (45%); IV=24 (12%). The estimated crude probability of recurring within 5 years was 58% (WAI) and 52% (CIM). Adjusting for stage and age, the recurrence rate was 21% lower for CIM patients than for WAI patients (relative hazard [RH]=0.789, 95% confidence interval [CI]: (0.530-1.176), p=0.245, 2-tail test). The estimated death rate was 29% lower among the CIM group (RH=0.712, 95% CI: 0.484-1.048, p=0.085, two-tail test).

CONCLUSION

We did not find a statistically significant advantage in recurrence rate or survival for adjuvant CIM over WAI in patients with uterine CS. However, the observed differences favor the use of combination chemotherapy in future trials.

The management of patients with uterine sarcoma: a debated clinical challenge

Uterine sarcomas include a heterogeneous group of rare tumours that usually have an aggressive clinical behaviour and a poor prognosis. Total abdominal hysterectomy and bilateral salpingo-oophorectomy represents the standard surgical treatment. Pelvic and/or para-aortic lymphadenectomy is indicated for carcinosarcoma, but not for leiomyosarcoma and undifferentiated endometrial sarcoma. Some recent data on low numbers of patients with low-grade endometrial stromal sarcoma appear to show an incidence of nodal involvement higher than previously expected, thus suggesting a role for lymphadenectomy in this malignancy. Carcinosarcoma also requires a comprehensive surgical peritoneal staging. Postoperative treatment of uterine sarcomas has been long debated. Adjuvant pelvic radiotherapy appears to improve local control without any significant impact on overall survival. There is little evidence in the literature supporting the use of adjuvant chemotherapy in any gynaecological sarcomas except for carcinosarcomas. However, uterine sarcomas have a high tendency to develop distant recurrences, and recent data on adjuvant chemotherapy in soft tissue sarcomas are promising. As for the drugs to be used, it is worth noting that in a Swiss study, the combination of ifosfamide (IFO) and doxorubicin (DOX) obtained similar response rates in advanced gynaecological sarcomas and in advanced soft tissue sarcomas of other sites. In our decision-making scheme for early-stage disease, patients with leiomyosarcoma or undifferentiated endometrial sarcoma should receive adjuvant doxorubicin/epidoxorubicin (EPIDX)+ifosfamide, and those with carcinosarcoma should be treated with adjuvant cisplatin (CDDP)-based chemotherapy. The same drug regimens are used for the treatment of advanced disease. Sequential pelvic radiotherapy following chemotherapy could be delivered to selected cases. Recurrent disease often requires the integration of different therapeutic modalities, but no curative option is currently available with the possible exception of surgery for lung metastases and hormone therapy with or without debulking surgery for recurrent low-grade endometrial stromal sarcoma. Patients should be encouraged to enter clinical trials designed to identify new active drugs for these malignancies.

Early-stage carcinosarcoma of the uterus: the significance of lymph node count

Carcinosarcoma is a rare tumor of the uterus with a poor prognosis, even when identified and treated at an early stage. The purpose of this study was to identify and analyze prognostic pathologic features and treatment outcomes in patient with stages I and II carcinosarcoma of the uterus. Patients with carcinosarcoma of the uterus who received primary surgical treatment between 1984 and 2004 were identified through an institutional tumor registry. Inclusion criteria were clinical stage I/II disease following hysterectomy and selective pelvic and para-aortic lymph node sampling. Regression analysis was used to determine risk factors for recurrence and survival. Disease-free and overall survival were then determined using Kaplan-Meier analysis. Forty-seven patients with stages I and II carcinosarcoma of the uterus were identified. Age, heterologous or homologous histology, and type of adjuvant treatment were not associated with recurrence or survival. Depth of myometrial invasion was found to correlate to disease-free survival but not overall survival. The number of lymph nodes collected correlated to risk of recurrence and survival. Disease-free and overall survival were greater in patients with higher lymph node count. We conclude that the number of lymph nodes collected was the only risk factor that was found to be correlated to recurrence and survival in patients with early-stage carcinosarcoma. These results support mounting evidence that lymphadenectomy is crucial in patients with carcinomas of the uterus in order to discover occult metastatic disease and potentially provide patients with a therapeutic benefit.