Prognostic factors and treatment outcomes of patients with uterine sarcoma: analysis of 127 patients at a single institution, 1989-2007

Clinicopathological characteristics and prognosis of uterine sarcoma: a 10-year retrospective single-center study in China

BACKGROUND

Uterine sarcoma is a rare and heterogeneous gynecological malignancy characterized by aggressive progression and poor prognosis. The current study aimed to investigate the relationship between clinicopathological characteristics and the prognosis of uterine sarcoma in Chinese patients.

METHODS

In this single-center retrospective study, we reviewed the medical records of 75 patients with histologically verified uterine sarcoma treated at the First Affiliated Hospital of Xi'an Jiaotong University between 2011 and 2020. Information on clinical characteristics, treatments, pathology and survival was collected. Progression-free survival (PFS) and overall survival (OS) were visualized in Kaplan-Meier curves. Prognostic factors were identified using the log-rank test for univariate analysis and Cox-proportional hazards regression models for multivariate analysis.

RESULTS

The histopathological types included 36 endometrial stromal sarcomas (ESS,48%), 33 leiomyosarcomas (LMS,44%) and 6 adenosarcomas (8%). The mean age at diagnosis was 50.2 ± 10.7 years. Stage I and low-grade accounted for the majority. There were 26 recurrences and 25 deaths at the last follow-up. The mean PFS and OS were 89.41 (95% CI: 76.07-102.75) and 94.03 (95% CI: 81.67-106.38) months, respectively. Univariate analysis showed that > 50 years, post-menopause, advanced stage, ≥ 1/2 myometrial invasion, lymphovascular space invasion and high grade were associated with shorter survival (P < 0.05). Color Doppler flow imaging positive signals were associated with shorter PFS in the LMS group (P = 0.046). The ESS group had longer PFS than that of the LMS group (99.56 vs. 76.05 months, P = 0.043). The multivariate analysis showed that post-menopause and advanced stage were independent risk factors of both PFS and OS in the total cohort and LMS group. In the ESS group, diagnosis age > 50 years and high-grade were independent risk factors of PFS, while high-grade and lymphovascular space invasion were independent risk factors of OS.

CONCLUSION

In Chinese patients with uterine sarcoma, post-menopause and advanced stage were associated with a significantly poorer prognosis. The prognosis of ESS was better than that of LMS. Color Doppler flow imaging positive signals of the tumor helped to identify LMS, which needs to be further tested in a larger sample in the future.

Prognostic factors, oncological treatment and outcomes of uterine sarcoma: 10 years' clinical experience from a tertiary care center in Pakistan

BACKGROUND

Uterine sarcoma is an uncommon aggressive malignancy. Optimal management and prognostic factors have yet to be well recognized due to their rarity and various histological subtypes. This study aims to investigate these patients' prognostic factors, treatment modalities, and oncological outcomes.

METHODS

A single-center retrospective cohort study was conducted on all patients diagnosed with uterine sarcoma and treated from January 2010 to December 2019 in a tertiary-care hospital in Pakistan. The data were analyzed using STATA software and stratified on the histological subtype. Survival rates were estimated using the Kaplan-Meier method. Crude and adjusted hazard ratios with 95% CI were estimated using univariate and multivariate analysis.

RESULTS

Of the 40 patients, 16(40%) had uterine leiomyosarcoma (u-LMS), 10(25%) had high-grade endometrial stromal sarcoma (HGESS), 8(20%) had low-grade endometrial stromal sarcoma (LGESS) and 6(15%) had other histological subtypes. The median age of all patients was 49 (40-55.5). Thirty-seven (92.5%) patients underwent primary surgical resection, and 24 (60%) patients received adjuvant systemic chemotherapy. The survival plots showed the overall population's DFS of 64 months and the OS of 88 months (p-value = 0.001). The median DFS in all patients was 12 months, and the median OS was 14 months (p-value = 0.001). A small but significant DFS benefit was found in patients who received adjuvant systemic chemotherapy, 13.5 versus 11 months (p-value = 0.001). Multivariate Cox-regression analysis revealed that large tumor size and advanced FIGO stage were substantial factors associated with decreased survival.

CONCLUSION

Uterine sarcomas are rare malignancies with poor prognosis. Multiple factors, including tumor size, mitotic count, stage of the disease, and myometrial invasion, impact survival outcomes. Adjuvant treatment may decrease the recurrence rate and improve DFS but do not affect OS.

Retrospective Analysis of Patients with Gynaecological Uterine Sarcomas in a Tertiary Hospital

Uterine sarcomas are rare and heterogeneous malignancies accounting for 1% to 3% of all gynaecological tumours. There are many histological subtypes recognised, including leiomyosarcomas, endometrial stromal sarcoma, and uterine carcinosarcoma, although the latest has been recently discarded in this group. Despite its low incidence, these types of cancer currently entail multiple challenges, either in diagnostics or clinical management, with a poor prognosis associated. The present work aimed to complete a comparative analysis of the different histological subtypes based on the clinicopathological characteristics of our population, the therapeutic characteristics, and associated prognosis in 161 patients treated in our centre during the period between 1985 and 2020. Moreover, a systematic review grouped a total of 2211 patients with a diagnosis of uterine sarcoma from 19 articles published in 16 countries from 2002 to 2021 was performed, all with retrospective analyses. Our results showed that apart from uterine carcinosarcoma, leiomyosarcoma is the most frequent subtype of uterine sarcoma, with unique clinical, demographic, and survival parameters. To our knowledge, this is the first systematic review conducted in this field and, thus, it shows the difficulties of collecting a significant number of patients per year, a valid reason why multicentre or national registries are recommended to allow a more exhaustive analysis of this pathology.

Nomogram to predict overall survival based on the log odds of positive lymph nodes for patients with endometrial carcinosarcoma after surgery

PURPOSE

Aims to compare the prognostic performance of the number of positive lymph nodes (PLNN), lymph node ratio (LNR) and log odds of metastatic lymph nodes (LODDS) and establish a prognostic nomogram to predict overall survival (OS) rate for patients with endometrial carcinosarcoma (ECS).

METHODS

Patients were retrospectively obtained from Surveillance, Epidemiology and End Results (SEER) database from 2004 to 2015. The prognostic value of PLNN, LNR and LODDS were assessed. A prediction model for OS was established based on univariate and multivariate analysis of clinical and demographic characteristics of ECS patients. The clinical practical usefulness of the prediction model was valued by decision curve analysis (DCA) through quantifying its net benefits.

RESULTS

The OS prediction accuracy of LODDS for ECS is better than that of PLNN and LNR. Five factors, age, tumor size, 2009 FIGO, LODDS and peritoneal cytology, were independent prognostic factors of OS. The C-index of the nomogram was 0.743 in the training cohort. The AUCs were 0.740, 0.682 and 0.660 for predicting 1-, 3- and 5-year OS, respectively. The calibration plots and DCA showed good clinical applicability of the nomogram, which is better than 2009 FIGO staging system. These results were verified in the validation cohort. A risk classification system was built that could classify ECS patients into three risk groups. The Kaplan-Meier curves showed that OS in the different groups was accurately differentiated by the risk classification system and performed much better than FIGO 2009.

CONCLUSION

Our results indicated that LODDS was an independent prognostic indicator for ECS patients, with better predictive efficiency than PLNN and LNR. A novel prognostic nomogram for predicting the OS rate of ECS patients was established based on the population in the SEER database. Our nomogram based on LODDS has a more accurate and convenient value for predicting the OS of ECS patients than the FIGO staging system alone.

[Interdisciplinary S2k guidelines on the diagnosis and treatment of uterine sarcomas-recommendations for surgical pathology]

Uterine sarcomas represent a heterogeneous group of rare malignancies, derived from the myometrium, the endometrial stroma, and very rarely from the nonspecialized uterine soft tissue. The actual incidence is about 1.5 for Caucasian and 3.0 for Afro-American women. There is no grading system for leimoysarcoma defined by the WHO classification; however, if clinicians request, the FNCLCC grading can be specified in analogy to soft tissue sarcomas. Adenosarcomas must be distinguished from adenofibromas (the existence of which is questionable)-with the vast majority of these tumors being uterine adenosarcomas. Within adenosarcomas, deep myometrial invasion (>50%), sarcomatous overgrowth, and a high-grade heterologous component are associated with a higher recurrence rate and poor survival. The immunohistochemical panel represents a very helpful tool for distinguishing low-grade from high grade endometrial stromal sarcomas (ESS) and may be supplemented by molecular analyses. Steroid hormone receptor analysis should be performed for all ESS due to the possible therapeutic relevance. Undifferentiated uterine sarcomas represent a diagnosis of exclusion and have a very poor prognosis. Carcinosarcomas represent a special subtype of endometrial carcinomas and are in fact not uterine sarcomas. Uterine sarcomas may present substantial intratumoral heterogeneity and adequate embedding is mandatory. Lesions ≤2 cm in the largest dimension should be processed completely and larger tumors should be processed with one block per centimeter for the largest tumor dimension.

Surgical Management of Gynecologic Cancers

This article addresses the role of surgery in the management of gynecologic cancers with liver metastases. The authors review the short-term and long-term outcomes of aggressive resection through retrospective and randomized studies. Although the data supporting aggressive resection of liver metastasis are largely retrospective and case based, the randomized control data to address neoadjuvant versus chemotherapy have been widely criticized. Residual disease remains an important predictor for survival in ovarian cancer. If a patient cannot achieve near optimal cytoreduction, radical cytoreductive procedures, such as hepatic resection, should be considered for palliation only.

Carcinosarcoma of the Uterus: A Study From the Surveillance Epidemiology and End Result (SEER) Database

Background: Uterine cancer (UC) is one of the leading gynecologic neoplastic disorders in the United States (US), of which over 80% are endometrioid adenocarcinomas (EA). In contrast to EA, carcinosarcoma (CS) of the uterus is a sporadic and highly malignant tumor, phylogenetically containing both epithelial and mesenchymal histologic elements. This study sought to analyze demographic, pathological retrospectively, and survival characteristics of a large cohort of CS patients compared to EA patients to identify prognostic factors and treatment approaches that may improve the current clinical management of CS patients.

Methods: Demographic and clinical data were abstracted from 88,530 patients diagnosed with uterine malignancy from the Surveillance, Epidemiology, and End Results (SEER) database for 38 years (1973-2010). Extracted variables were analyzed using the Chi-square test, paired t-test, and multivariate analysis, while Kaplan-Meier functions were used to compare survival between groups. Statistical analyses were performed with IBM Statistical Product and Service Solutions (SPSS^©), version 20.2 (IBM Corp., Armonk, NY).

Results: A total of 3,706 cases of CS comprised 38.2% of uterine sarcomas (n=9,702), and 4.1% of uterine cancers overall (n=88,530). EA made up 88.6% (n=78,481) of all uterine cancers. CS patients presented later in life (68.3±11.5 years) than EA (61.9±12.5 years). 65.2% of CS and 77.8% of EA occurred in Caucasians. The incidence (per million) of EA was higher in Caucasians compared to African-Americans (AA) (41% vs. 26.8%), while the incidence of CS was higher among AA than Caucasians (4% vs. 1.9%, p<0.001). 33.4% of CS was poorly differentiated at presentation, compared to 13.1% of EA. 27.8% of CS patients presented with a distant disease compared to only 4.7% of EA patients. 29.9% of AA patients with CS presented with metastatic disease, compared to 28.2% of Caucasian patients (p<0.001). Mean survival for CS patients (6.6±0.2 years) was significantly lower than that of EA patients (17.7±0.7 years, p<0.001), and AA CS patients had significantly lower survival than Caucasians CS patients (4.5±0.4 years vs. 7.1±0.3 years, p<0.001). CS patients treated with combined surgery and radiotherapy had the highest survival (9.4±0.5 years, p<0.001), while EA patients treated with surgery alone had the highest survival (20.4±1.2 years, p<0.001). Survival among AA CS patients treated with combination therapy was significantly inferior compared to Caucasians (6.5±0.6 years vs. 9.8±0.5 years, p<0.001). Multivariate analysis identified CS histology (odds ratio [OR] 1.9, CI=1.7-2.1), AA race (OR 1.3, CI=1.2-1.4), age over 40 (OR 3.4, CI=2.9-4.1), undifferentiated grade (OR 3.0, CI=2.6-3.4), and distant metastases (OR 6.2, CI=5.8-6.8) as independently associated with increased mortality (p<0.005). The use of radiotherapy in CS patients was independently associated with decreased mortality (OR 0.1, CI=0.02-0.6, p<0.005).

Conclusions: Uterine CS is a highly malignant tumor with a significantly worse prognosis than EA. AA has a considerably higher CS incidence compared to EA. Moreover, AA CS had higher tumor grades, higher rates of metastatic disease, and experienced significantly lower overall survival compared to Caucasians despite receiving similar therapy. Primary radiotherapy or combination radiotherapy confers a survival advantage to AA uterine CS patients.

Outcomes of patients with pelvic leiomyosarcoma treated by surgery and relevant auxiliary diagnosis

BACKGROUND

Leiomyosarcoma is a subtype of soft tissue sarcoma with adverse outcomes. Leiomyosarcoma accounts for nearly 70% of all uterine sarcomas and is responsible for a considerable proportion of deaths because of uterine cancer. Clinical characteristics and relevant diagnosis of pelvic leiomyosarcoma should be further explored.

AIM

To identify the outcome and relevant perioperative evaluation of patients with pelvic leiomyosarcoma.

METHODS

The Kaplan-Meier method was used to determine progression-free survival and overall survival rates. Factors predictive of outcomes were identified using univariate and multivariate Cox proportional hazards models.

RESULTS

Fifty-one patients with pelvic leiomyosarcoma were enrolled and divided into two groups including uterine leiomyosarcoma and non-uterine leiomyosarcoma. Overall, 28.6% and 45.5% of uterine leiomyosarcoma and non-uterine leiomyosarcoma patients, respectively, had elevated carbohydrate antigen 125 levels, whereas 45.7% and 68.8%, respectively, underwent ultrasonography. Although 68.8% of uterine leiomyosarcoma patients were initially diagnosed with hysteromyoma, 72.7% of non-uterine leiomyosarcoma patients had pelvic and abdominal masses. Moreover, 93.3% of the recurrent lesions were detected using ultrasonography. Patients with International Federation of Gynaecology and Obstetrics (FIGO) stages III–IV disease had poorer progression-free survival values than those with FIGO stages I–II (P = 0.027) disease. FIGO stage was significantly associated with poor progression-free survival in the univariate (hazard ratio = 2.64, P = 0.03) and multivariate (hazard ratio = 2.49, P = 0.048) analyses.

CONCLUSION

Serum tumour biomarkers cannot be used for pelvic leiomyosarcoma diagnosis. FIGO stage is critical to predict the outcome of uterine leiomyosarcoma. Ultrasonography is more reliable for postoperative follow-up than preoperative diagnosis.

Response to eribulin in a patient with metastatic uterine leiomyosarcoma: a case report

We report the case of a 51 year-old patient affected by an advanced uterine leiomyosarcoma treated with eribulin as fourth-line therapy. The patient, with a previous history of leiomyomas of the myometrium, had undergone total hysterectomy for repeated metrorrhagias. After 7 years, metastases in the liver, bone and lung were documented. A fine needle liver biopsy demonstrated leiomyosarcoma metastasis. The patient was treated with first-line doxorubicin chemotherapy; after six cycles, disease progression was observed. A second-line trabectedin chemotherapy and a third-line gemcitabine chemotherapy were performed; no objective responses were seen after two cycles. The patient was then treated with eribulin on the basis of an EORTC Phase II trial showing preliminary activity in uterine leiomyosarcoma. After six cycles, CT scan showed partial remission of liver lesion. Disease progression was observed after nine cycles with eribulin, without severe side effects and preserving a good quality of life.

Optimization of the Therapeutic Approach to Patients with Sarcoma: Delphi Consensus

Soft tissue sarcomas (STS) constitute a heterogeneous group of rare solid tumors associated with significant morbidity and mortality. The evaluation and treatment of STS require a multidisciplinary team with extensive experience in the management of these types of tumors. National and international clinical practice guidelines for STS do not always provide answers to a great many situations that specialists have to contend with in their everyday practice. This consensus provides a series of specific recommendations based on available scientific evidence and the experience of a group of experts to assist in decision-making by all the specialists involved in the management of STS.

Prognostic factors, survival outcomes, and surgical practices when dealing with uterine sarcomas: 8 years’ clinical experience

Objective

To determine the clinical and pathologic characteristics, prognostic factors, surgical practice, adjuvant therapies, and survival outcomes of patients with uterine sarcoma diagnosed and treated in our institution.

Material and Methods

Patients diagnosed and treated for uterine sarcomas at our institution from 2009 to 2017 were retrospectively evaluated. All histologic slides from the specimens underwent a thorough pathologic review by a gynecologic pathologist. The following variables were assessed: age, family history of cancer, smoking status, age of menarche, parity, age at first delivery, related symptoms, clinical staging, histologic type, treatment received, disease-free period, and the time and site of recurrence, as well as treatment of the latter and overall survival.

Results

Ten patients were diagnosed as having leiomyosarcoma, a further 10 patients had malignant mixed mullerian tumors, and five had endometrial stromal sarcoma; the remaining nine patients had other tumors. At the end of our study, 12 (35.3%) patients were alive and in remission, four (11.8%) were alive with disease, 10 (29.4%) were lost to follow-up, and eight (23.5%) had died. The mean survival time was 80.92 months, and the 2-year survival rate was 75.6%. We found that survival was significantly shorter in the presence of lymph node involvement, residual tumor, and recurrence.

Conclusion

This study serves to inform physicians about the outcome of various uterine sarcomas that were diagnosed and managed at our center. We found that 35.3% of our patients were alive and in remission, 11.8% were alive with disease, 29.4% were lost to follow-up, and 23.5% of patients died.

Secondary cytoreductive surgery potentially improves the oncological outcomes of patients with recurrent uterine sarcomas

Uterine sarcomas are some of the most malignant and aggressive tumor types among the gynecologic malignancies, and they are associated with a high rate of recurrence and a poor prognosis. Due to their rarity and diversity, the optimal treatment for recurrent uterine sarcomas has not yet been elucidated. The aim of the present study was to investigate the potential of secondary cytoreductive surgery (SCS) for patients with recurrent uterine sarcomas. A total of 18 patients with recurrent uterine sarcomas were retrospectively identified at the Department of Obstetrics and Gynecology, Nagoya University (Nagoya, Japan) between January 2002 and December 2015. This included 8 patients with leiomyosarcoma, 6 with carcinosarcoma, 3 with endometrial stromal sarcoma and 1 with adenosarcoma. All patients underwent primary debulking surgery as the initial treatment. In summary, 9 patients were treated with SCS when they experienced their first recurrence, and the other 9 patients were treated with non-SCS methods, including chemotherapy or radiotherapy. In the SCS group, 5/9 patients had confined pelvic recurrences, 3 patients had extra-pelvic diseases, including pulmonary metastasis, and one patient had intra- and extra-pelvic recurrence. The 3-year overall survival (OS) rates were 77.8 and 11.1% in the SCS and non-SCS groups, respectively. The patients who underwent SCS experienced a significantly longer OS time compared with those in the non-SCS group (P=0.006). In addition, the disease-free survival after second-line therapy was significantly longer in the SCS group than in the non-SCS group (P=0.0496). These findings suggest that resection of recurrent uterine sarcomas may be beneficial for the improvement of patient survival. Prospective studies with sufficient statistical power are warranted for further evaluation of the effect of SCS.

Long-Lasting Response to Trabectedin in a Patient with Metastatic Uterine Leiomyosarcoma: A Case Report

Background

Uterine leiomyosarcoma (uLMS) is a rare tumor that accounts for 1% of all uterine malignancies. In spite of adequate surgical resection of uLMS, even in the early stage, patients remain at high risk for local and distant recurrence. Therefore, the treatment of advanced uLMS represents a considerable challenge.

Methods

We report the case of a 47-year-old woman who presented with uLMS with abnormal vaginal bleeding.

Results

The patient underwent a total hysterectomy and bilateral adnexectomy, which was followed by 1 year progression-free survival without adjuvant therapy. Thereafter, new lung metastases and local progression at the vaginal stump were observed. Chemotherapy with ifosfamide and doxorubicin was administered. However, after 4 cycles, a CT scan revealed disease progression in the lung metastases. Subsequently, the patient was treated with trabectedin at a dose of 1.5 mg/m² for 6 cycles resulting in complete remission of the lung metastases as well as partial remission of the mass in the vaginal stump after 9 cycles of trabectedin. The patient is currently on maintenance therapy with trabectedin and has no recurrence.

Conclusion

Trabectedin seems to be an efficient option for patients with uLMS as demonstrated by a long-lasting response in a pretreated patient with an acceptable safety profile with no signs of cumulative toxicity.

European Society of Gynecological Oncology Statement on Fibroid and Uterine Morcellation

Recently, there has been an intense discussion about the issue of fibroid and uterine morcellation in relation to the risk of unrecognized uterine sarcoma spread. Morcellation can negatively influence the prognosis of patients, and transecting the specimen into pieces prevents the pathologist from performing proper disease staging. Many societies have published their statements regarding this issue. The European Society for Gynecological Oncology has established a working group of clinicians involved in diagnostics and treatment of oncogynecological patients to provide a statement from the oncological point of view. Leiomyosarcomas and undifferentiated endometrial sarcomas have generally dismal prognosis, whereas low-grade endometrial stromal sarcomas and adenosarcomas have variable prognosis based on their stage. A focus on the detection of patients at risk of having a sarcoma should be mandatory before every surgery where morcellation is planned by evaluation of risk factors (African American descent, previous pelvic irradiation, use of tamoxifen, rapid lesion growth particularly in postmenopausal patients) and exclusion of patients with any suspicious ultrasonographic signs. Preoperative endometrial biopsy should be mandatory, although the sensitivity to detect sarcomas is low. An indication for myomectomy should be used only in patients with pregnancy plans; otherwise en bloc hysterectomy is preferred in both symptomatic and postmenopausal patients. Eliminating the technique of morcellation could lead to an increased morbidity in low-risk patients; therefore, after thorough preoperative evaluation and discussion with patients, morcellation still has its place in the armamentarium of gynecologic surgery.

A Case of Renal Metastasis of Uterine Leiomyosarcoma

A 49-year-old woman with a distant history of uterine leiomyosarcoma underwent robotic-assisted laparoscopic partial nephrectomy for a 3.5 cm right renal mass, which was presumed to be a primary renal cell carcinoma. Surgical margins were negative, and the histologic analysis confirmed leiomyosarcoma. Uterine leiomyosarcoma is traditionally a locally aggressive disease with only rare reports of renal involvement. We report a case of a metastatic leiomyosarcoma to the kidney four years following initial treatment for uterine leiomyosarcoma.

Outcome and prognostic factors in 110 consecutive patients with primary uterine leiomyosarcoma: A Rare Cancer Network study

Objective

Primary uterine leiomyosarcomas (ULMS) are rare, and the optimal treatment is controversial. We aimed to assess the outcome and prognostic factors in a multicenter population of women treated for primary ULMS.

Methods

We retrospectively collected data of 110 women treated in 19 institutions of the Rare Cancer Network (RCN). Inclusion criteria consisted of a pathology report confirming the diagnosis of ULMS, aged 18-80 years, complete International Federation of Gynecology and Obstetrics (FIGO) stage information, complete information on treatment, and a minimum follow-up of 6 months. Local control (LC) and locoregional control (LRC), overall survival (OS) and disease-free survival (DFS) rates were computed using the Kaplan-Meier method. Univariate analysis was implemented using the log rank test, and multivariate analysis using the Cox model.

Results

All patients underwent surgery. Seventy-five patients (68%) received adjuvant radiotherapy (RT), including brachytherapy in 18 (16%). Seventeen patients (15%) received adjuvant chemotherapy. Median follow-up was 58 (range, 6-240) months. Five-year OS and DFS rates were 50% and 34%, and LC and LRC rates were 88% and 72%, respectively. On multivariate analysis, independent favorable prognostic factors were younger age, FIGO stage I, small tumor size, previous uterine disease, and no vascular invasion for OS and DFS. FIGO stage was the only favorable factor influencing LRC. Adjuvant local or systemic treatments did not improve the outcomes. Eight patients treated with RT presented a grade 3 acute toxicity, and only one patient with grade 3 late toxicity.

Conclusions

In this large population of primary ULMS patients, we found good results in terms of LC and LRC. Nevertheless, OS remains poor, mainly due to the occurrence of distant metastases. An early diagnosis seemed to improve the prognosis of the patients. Adjuvant local or systemic treatments, or more aggressive surgical procedures such as the Wertheim procedure, did not seem to impact the outcome.

Laparoscopic surgery on broken points for uterine sarcoma in the early stage decrease prognosis

Uterine sarcoma, a rare solid tumor in uterus, is difficult to identify in the early stage from some benign uterine tumors, such as uterine fibroids. Hence, uterine sarcoma may be treated in the same way as uterine fibroids; and this may not be found until pathological diagnosis. Consequently, this can lead to tumor's abdominal spread, planting and local invasive growth, resulting in an early uterine sarcoma, an increased relapse rate after surgery and a decreased survival. Therefore, it's important to avoid these unintended and iatrogenic complications through an accurate diagnosis and an appropriate surgical approach. The surgical staging and a complete resection of the tumor are both important for patients' prognosis. In this review, we will discuss the laparoscopic surgery for uterine sarcoma in the early stage and patients' prognosis.

Effects of morcellation on long-term outcomes in patients with uterine leiomyosarcoma

OBJECTIVES

Clinical long-term outcomes of women with uterine leiomyosarcoma (ULMS) with different types of hysterectomy (open abdominal, vaginal, laparoscopic and switch from laparoscopic to open abdominal) were compared according to morcellation and other factors.

MATERIALS

The clinical cancer registry Regensburg (Germany) registered 64 patients between 2004 and 2013 with ULMS. A retrospective cohort analysis was performed using the Kaplan-Meier method to estimate 5-year overall survival (OAS), recurrence-free survival (RFS) and recurrence rates. To compare surgery with or without morcellation log rank test was used. To adjust for age, FIGO stage, grading and other factors multivariable Cox regression models were applied to estimate hazard ratios (HR).

RESULTS

In the cohort of 64 patients 15 underwent morcellation, preferably during laparoscopic surgery. Although numbers were small we performed analysis for OAS and RFS. Median OAS for morcellation was 10.6 vs. 6.4 years for non morcellation. 5y-OAS was 76.0 % for morcellation compared to 54.8 % in patients without morcellation (p = 0.115). Cox regression models rendered an unadjusted (univariable) HR 0.428 for morcellation vs. non-morcellation (p = 0.125) and an adjusted (multivariable) HR 0.644 (p = 0.406). 5y-RFR was 64.0 % compared to 42.8 % in patients without morcellation (p = 0.104; unadjusted HR 0.484, p = 0.111; adjusted HR 0.607, p = 0.306).

CONCLUSION

In general, the prognosis of patients with ULMS is poor. In our cohort, women who underwent hysterectomy with morcellation had a better cumulative OAS and RFS than women without morcellation. Although we adjusted for differences between women with and without morcellation regarding age, grading and stage, there were no statistically significant differences between the groups.

Giant leiomyosarcoma: A case report

Introduction

Uterine leiomyosarcoma is a rare uterine malignancy. Most of the patients lack symptoms or present with a rapidly enlarging pelvic mass.

Presentation of case

We report on a very large leiomyosarcoma in a woman presenting with a 3 months history of rapidly growing adominal mass and fatigue. Laparotomy was performed and diagnosis was confirmed by pathologic and histologic analysis. Patient refused chemotherapy after surgery and died from recurrence at 4th postoperative month.

Discussion

Uterine leiomyosarcomas may follow a rapid clinical course with a doubling time of four weeks. There is no reliable method to distinguish uterine sarcoma from benign leiomyomas preoperatively.

Conclusion

This case represents the largest leiomyosarcoma reported in the literature.

Outcome and prognosis in uterine sarcoma and malignant mixed Mullerian tumor

PURPOSE

There is low evidence regarding the optimal treatment in patients with uterine sarcomas and malignant mixed Mullerian tumors (MMMTs). This study provides an overview of experience at our center with patients diagnosed with uterine sarcoma and MMMT, in relation to the clinical management and outcome.

METHODS

The medical records for 143 patients with low-grade endometrial stromal sarcoma (ESS), leiomyosarcoma (LMS), and high-grade (undifferentiated) endometrial sarcoma (UES) and MMMT were reviewed. All available clinical and pathological data were collected and analyzed. Putative prognostic factors were entered into a multivariate analysis using a Cox proportional hazards ratio model, and survival data were calculated.

RESULTS

The 5-year overall survival rates were significantly different between patients with ESS, LMS, and UES and MMMT (86 vs. 40 vs. 57 vs. 45 %; P < 0.001). The multivariate analysis showed that the patients' age, higher FIGO stage (III-IV), a history of smoking, prior pelvic radiation, diabetes, and residual tumor after surgery were associated with a poorer overall survival. Histological subtypes of LMS (HR 4.68; 95 % CI 1.35-16.17), UES (HR 1.21; 95 % CI 0.26-5.77) and MMMT (HR 1.63; 95 % CI 0.42-6.43) were also associated with a poorer overall survival than ESS (P = 0.008). Adjuvant therapies showed no associations with overall survival.

CONCLUSIONS

Adjuvant therapy has so far not shown any overall survival benefit, and the focus is therefore on primary surgery. In future studies, the entities should be investigated separately in relation to prognostic factors and effective therapeutic management.

Trends in the treatment of uterine leiomyosarcoma in the Medicare population

OBJECTIVE

Uterine leiomyosarcoma (LMS) is a relatively rare malignancy that is associated with a poor prognosis. The rarity of LMS has led to a lack of consensus regarding appropriate treatment. The goal of this study was to identify the role that chemotherapy and radiotherapy have played in the treatment of uterine LMS in the United States as well as the effectiveness of adjuvant treatment.

MATERIALS/METHODS

We used the SEER (Surveillance, Epidemiology, and End Results)-Medicare database to gather information on uterine LMS patients older than the age of 66 years diagnosed between 1992 and 2009. Basic demographic and clinical characteristics were collected. A logistic regression model analysis was performed to determine predictors of treatment. Cox proportional hazards models were used to identify clinical parameters and treatment strategies associated with survival differences.

RESULTS

Our final study group included 230 patients. We found that the rate of use of chemotherapy and radiotherapy in the treatment of patients with uterine LMS increased over the period investigated. However, we identified no significant survival advantage associated with either mode of therapy. The strongest predictor of survival was stage at diagnosis. The logistic regression model analysis revealed that age at diagnosis, treatment year, stage, and underlying health status were all independent predictors of chemotherapy. Age at diagnosis was also a predictor of radiation therapy.

CONCLUSIONS

The increasing rates of chemotherapy and radiotherapy use in this population seem to be unfounded given the lack of survival benefit. Further investigation into alternative treatment regimens is merited. The prognostic significance of stage at diagnosis indicates the importance of improving early detection of uterine LMS.

Vascular invasion in uterine sarcomas and its significance. A multi-institutional study

Although metastases and high-mortality are frequent in high-grade endometrial sarcomas (HGSs), these findings are less commonly seen in low-grade endometrial stromal sarcomas (LGESSs), even in cases with lymphovascular invasion (LVI). We hypothesized that the "bulging plugs" of tumor characteristic of LVI in LGESS are fundamentally different from LVI seen in HGS. We reviewed 70 uterine sarcomas: 42 HGSs (high-grade endometrial stromal sarcomas, undifferentiated uterine sarcoma, and leiomyosarcoma) and 28 LGESSs. All cases had LVI documented on the histologic slides. Immunostains for CD31, ERG, and D2-40 were performed. LGESS harbored cohesive intravascular tumor foci with direct communication from the main tumor and attached to the vessel wall. The intravascular foci included tumor cells and small arteriole-type vessels and were surrounded by a thin fibrous band. Vascular markers confirmed the LVI and highlighted positively stained endothelial cells separating intravascular tumor foci from the blood itself. In contrast, intravascular tumor foci in HGS were composed of discohesive cells clusters, lacking the features described in LGESS. Only 8 (30.8%) patients with LGESS had recurrence/metastases (6 with lung metastasis); only 1 patient died of disease. Thirty (77%) patients with HGS had recurrence/metastases, 27 (69%) patients had lung metastases, and 22 (56.4%) patients died of disease. We propose that in most LGESSs, LVI represents vascular intrusion; manipulation or trauma is potentially responsible for tumor cell detachment into the circulation increasing the chances of recurrence/metastases. Classic LVI features were identified in HGS. This important distinction may allow for better management of patients and avoid unnecessary treatment in LGESS, reducing morbidity.

CD146 as an adverse prognostic factor in uterine sarcoma

Background

Uterine sarcoma is an aggressive malignancy with a poor prognosis. This study aimed to determine the expression of CD146, P53, and Ki-67 in uterine sarcoma and to evaluate their prognostic significance.

Methods

We retrospectively analyzed the prognosis and clinicopathologic features of 68 patients with uterine sarcoma. Immunohistochemical analyses of CD146, P53, and Ki-67 were performed in tissue samples collected from these patients and their relationship with prognosis was investigated.

Results

The 5-year overall survival (OS) rate was 46 %. Endometrial stromal sarcoma (ESS) patients had a better prognosis than leiomyosarcoma (LMS) patients, with a 2-year survival rate of 82 %. The membrane and cytoplasm of tumor cells exhibited CD146 overexpression in 8 (32 %) ESS cases, which was less than the 25 (69.4 %) cases observed in LMS and 2 (28.6 %) in MMMT. CD146 overexpression in the membrane and cytoplasm of tumor cells was closely related to lymph node metastasis (P = 0.021) and Ki-67 overexpression (P = 0.0053); there was no significant correlation with age, tumor size, International Federation of Obstetrics and Gynecology stage, or P53 overexpression in LMS.

Conclusions

CD146, P53, and Ki-67 are overexpressed in uterine sarcoma. CD146 expression correlates with lymph node metastasis and is associated with poor OS in LMS; it may be a potential prognostic marker for LMS.

Management Strategies in Advanced Uterine Leiomyosarcoma: Focus on Trabectedin

The treatment of advanced uterine leiomyosarcomas (U-LMS) represents a considerable challenge. Radiological diagnosis prior to hysterectomy is difficult, with the diagnosis frequently made postoperatively. Whilst a total abdominal hysterectomy is the cornerstone of management of early disease, the role of routine adjuvant pelvic radiotherapy and adjuvant chemotherapy is less clear, since they may improve local tumor control in high risk patients but are not associated with an overall survival benefit. For recurrent or disseminated U-LMS, cytotoxic chemotherapy remains the mainstay of treatment. There have been few active chemotherapy drugs approved for advanced disease, although newer drugs such as trabectedin with its pleiotropic mechanism of actions represent an important addition to the standard front-line systemic therapy with doxorubicin and ifosfamide. In this review, we outline the therapeutic potential and in particular the emerging evidence-based strategy of therapy with trabectedin in patients with advanced U-LMS.

FIGO staging for uterine sarcomas: can the revised 2008 staging system predict survival outcome better?

PURPOSE

The aim of this study was to compare survival of patients with uterine sarcomas using the 1988 and 2008 International Federation of Gynecologists and Obstetricians (FIGO) staging systems to determine if revised 2008 staging accurately predicts patient survival.

MATERIALS AND METHODS

A total of 83 patients with leiomyosarcoma and endometrial stromal sarcoma treated at Yonsei University Health System between March of 1989 and November of 2009 were reviewed. The prognostic validity of both FIGO staging systems, as well as other factors was analyzed.

RESULTS

Leiomyosarcoma and endometrial stromal sarcoma comprised 47.0% and 53.0% of this study population, respectively. Using the new staging system, 43 (67.2%) of 64 eligible patients were reclassified. Among those 64 patients, 45 (70.3%) patients with limited uterine corpus involvement were divided into stage IA (n=14) and IB (n=31). Univariate analysis demonstrated a significant difference between stages I and II and the other stages in both staging systems (p<0.001) with respect to progression-free survival and overall survival (OS). Age, menopausal status, tumor size, and cell type were significantly associated with OS (p=0.011, p=0.031, p=0.044, p=0.009, respectively). In multivariate analysis, revised FIGO stage greater than III was an independent poor prognostic factor with a hazard ratio of 9.06 [95% confidence interval (CI) 2.49-33.0, p=0.001].

CONCLUSION

The 2008 FIGO staging system is more valid than the previous FIGO staging system for uterine sarcomas with respect to its ability to distinguish early-stage patients from advanced-stage patients.

The expression and characterization of endoglin in uterine leiomyosarcoma

Endoglin (CD105), an accessory receptor of transforming growth factor-β, is expressed in vascular endothelial cells. Recently, it was reported that endoglin expression was significantly associated with poorer survival in several cancers. In this study, we evaluated the role of endoglin in uterine leiomyosarcoma. We examined the expression of endoglin in 22 uterine leiomyosarcomas and the association between their expression and the outcome. Additionally, to evaluate the function of endoglin, we used SKN cells, a human uterine leiomyosarcoma cell line. We generated SKN cells stably transfected with plasmids encompassing shRNA targeting endoglin (shEng cells), and compared the ability of proliferation, migration, and invasion to control shRNA-transfected cells (shCon cells). We compared the level of VEGF and matrix metalloproteinases (MMP) in culture supernatants of shEndoglin and shControl cells. Nine patients were endoglin-positive and 13 patients were -negative. The endoglin-positive group had a significantly poorer overall survival and progression-free survival than the endoglin-negative group. In an in vitro study, there was no difference in cell proliferation between shEng and shCon cells. On the other hand, shEng cells showed a lower ability for migration and invasion than shControl cells. The activity of MMP-9 and VEGF level in the supernatant from shEng cells were lower than in shCon cells. In uterine leiomyosarcoma, endoglin expression was associated with a poor prognosis. It was suggested that endoglin up-regulated invasion and VEGF secretion. The investigation of endoglin may lead to a new strategy in uterine leiomyosarcoma therapy.

Immunohistochemical Analysis for Therapeutic Targets and Prognostic Markers in Low-Grade Endometrial Stromal Sarcoma

Objective

To investigate potential therapeutic targets and prognostic markers for low-grade endometrial stromal sarcoma (LGESS).

Materials and Methods

Thirty-nine patients with LGESS were included in this study. Using tissue microarrays, the immunohistochemical expression levels of 5 therapeutic targets (epidermal growth factor receptor, human epidermal growth factor 2, vascular endothelial growth factor receptor, platelet-derived growth factor receptor [PDGFR], and c-kit) and 3 proteins involved in cell proliferation (p16, p53, and ki67) were investigated. The associations between these targets, markers, other clinicopathological factors, disease-free survival (DFS), and overall survival (OS) were analyzed.

Results

Epidermal growth factor receptor and human epidermal growth factor 2 were not expressed in these 39 patients. Vascular endothelial growth factor receptor, PDGFR, c-kit, p16, p53, and ki67 were expressed in 10 (25.6%), 28 (71.8%), 32 (82.1%), 18 (46.2%), 4 (10.3%), and 21 (53.8%) patients, respectively. The expression of each marker was not significantly associated with other clinicopathological factors. On multivariate analysis, p53 and ki67 were associated with significantly poorer DFS and OS. The 5-year DFS rates were 88%, 46%, and 0% for the p53(−)/ki67(−) group (n = 18), p53(−)/ki67(+) group (n = 17), and p53(+)/ki67(+) group (n = 4) (P = 0.002), respectively; the 5-year OS rates were 100%, 71%, and 0%, respectively (P < 0.001). The time to recurrence was longer (P = 0.123), and more patients had distant recurrence in the p53(+)/ki67(+) group (P = 0.063).

Conclusions

In patients with LGESS, c-kit and PDGFR were expressed in higher portions of patients, suggesting that imatinib mesylate should be investigated as a potential targeting agent. Both p53 and ki67 demonstrated strong prognostic implications, suggesting that further evaluation using these markers is required.

Reproductive outcome after uterine-sparing surgery for endometrial stromal sarcoma

► This is the second report of pregnancy following endometrial stromal sarcoma (ESS). ► The role of adnexectomy is controversial in stage I ESS. ► Adnexectomy does not appear to affect survival in stage I ESS.

Diagnosis and treatment of sarcoma of the uterus. A review

BACKGROUND

The histopathological classification and staging system for uterine sarcoma (US) were revised in 2003 and 2009, respectively. However, there is currently no consensus on the significance of various prognostic factors. Therefore the available clinicopathological data on US are summarized in this review.

METHODS

Articles on uterine sarcoma published in English from 1970 to 2011 were identified systematically by computer-based searches in Medline and the Cochrane Library.

RESULTS

Prognosis of US is poor, with a five-year survival rate as low as 30%. The most common histological types are leiomyosarcoma (LMS, 63%), endometrial stromal sarcoma (ESS, 21%), adenosarcoma (6%), undifferentiated sarcoma (5%) and other types (5%). Carcinosarcoma is a mixed tumor, which is today regarded as a subset of endometrial carcinoma. Disease stage is the most important prognostic factor for all types of US. However, the prognosis of stage I LMS is also significantly related to tumor size and mitotic index (MI), and stage I ESS is related to MI and tumor cell necrosis (TCN). In adenosarcoma, TCN is the only significant histopathological prognostic factor. Information on the use of preoperative imaging for staging purposes is lacking. Total hysterectomy is the cornerstone of US treatment. The ovary can be preserved in premenopausal women with early-stage LMS and ESS, and routine lymphadenectomy is not necessary unless enlarged lymph nodes are present. As tumor-free resection margins at primary surgery are the most important prognostic factor for survival, sarcoma surgery should be centralized. Adjuvant treatment has changed from radiation therapy to chemotherapy over the last decades, without any change in survival.

CONCLUSION

There are differences in survival between histological types of US. LMS and ESS can be divided into different prognostic groups and should be treated separately.

Clinical Characteristics, Surgical Management and Adjuvant Therapy of Patients with Uterine Leiomyosarcoma: 27 Years of Experience

Purpose: To review a single-center experience over a 27-year period in the management of uterine leiomyosarcoma (LMS) for insight into surgical practice, adjuvant therapy and clinical outcome. Material and Methods: This was a retrospective study of women with histologically proven uterine LMS who were treated at the Department of Obstetrics and Gynecology, University of Tuebingen, Germany, between 1983 and 2010. Inpatient and ambulatory records were reviewed; follow-up and survival data were ascertained. Results: The study sample comprised 32 patients with uterine LMS. Primary surgical treatment consisted of total abdominal hysterectomy in 28 patients (88 %) and laparoscopic total hysterectomy in 4 patients (12 %). Lymph nodes were dissected and evaluated in 17 women (53 %); positive lymph nodes were present in 1 patient (6 %). A total of 17 patients (53 %) received adjuvant therapy. Median follow-up for disease-free survival (DFS) was 35.6 months and median DFS was 27.0 months for all patients. The median follow-up for overall survival (OS) was 51.3 months and the median OS was 28.0 months for our study group. The 5-year survival rate was 30 %. There was no significant difference in DFS (p = 0.76) and OS (p = 0.51) between patients who received adjuvant therapy and those who did not. Conclusion: Uterine LMS are rare and aggressive uterine neoplasms with high recurrence rates and metastatic potential. Surgery consisting of total hysterectomy with or without bilateral salpingo-oophorectomy is the most important treatment-element in patients with uterine LMS. Lymphadenectomy should be reserved for patients with clinically suspicious nodes.

Staging of uterine sarcomas

Uterine sarcomas comprise leiomyosarcoma, endometrial stromal sarcoma, adenosarcoma, undifferentiated endometrial sarcoma, and their variants. Carcinosarcoma is historically classified as sarcoma, but it is now regarded as a metaplastic carcinoma. Uterine sarcomas are rare, and are traditionally staged in the same way as endometrial carcinoma. Because of their different clinical and biological behaviours, the International Federation of Gynecology and Obstetrics introduced a new staging system in 2009 for leiomyosarcoma, endometrial stromal sarcoma and adenosarcoma, and carcinosarcoma, respectively. Following an extensive literature review no good evidence was found to support the modification of the staging system. This is mainly because of the rarity of the sarcomas and the heterogeneity of the reports, the different diagnostic criteria and treatments changing over the decades the retrospective nature and small sample size in most studies, and the lack of uniform pathological review even in large studies. Currently, evidence is still lacking about the use of preoperative imaging for staging purpose, and uterine sarcomas remain to be surgically staged. Total hysterectomy is the cornerstone for both staging and treatment. Newer evidence shows that routine lymphadenectomy and bilateral salpingo-oophorectomy may not be necessary, unless in the presence of extra-uterine spread, suspicious ovaries or lymph nodes, and certain poor histological types, such as undifferentiated endometrial sarcoma and adenosarcoma with sarcomatous overgrowth. More research and data collection are definitely needed in order to verify and further revise the current staging systems.

The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma

OBJECTIVE

Uterine leiomyosarcoma (LMS) is usually diagnosed after surgery for leiomyoma; thus tumor morcellation frequently occurs. We evaluated the impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine LMS.

METHODS

Outcomes were retrospectively compared between patients who underwent total abdominal hysterectomy without tumor morcellation and those who underwent surgery that included abdominal, vaginal or laparoscopic tumor morcellation.

RESULTS

We assessed 56 consecutive patients with stage I and II uterine LMS between 1989 and 2010, 25 with and 31 without tumor morcellation. There were no significant between group differences in age, parity, menopausal status, body mass index, stage, mitotic count, tumor grade, lymph node dissection, adjuvant therapy, and follow-up duration. However, tumor size was significantly smaller (9.8 cm vs. 7.3 cm, P=0.022) and ovarian tissue was more frequently preserved (38.7% vs. 72%, P=0.013) in patients with tumor morcellation. In univariate analysis, only tumor morcellation was significantly associated with poorer disease-free survival (DFS) (odds ratio [OR], 2.59; 95% confidence interval [CI], 1.03-6.50; P=0.043), and higher stage (I vs. II; (OR, 19.12; 95% CI, 1.19-307.11; P=0.037)) and tumor morcellation (OR, 3.07; 95% CI, 1.05-8.93; P=0.040) were significantly associated with poorer overall survival (OS). In multivariate analysis, higher stage (OR, 20.34; 95% CI, 1.27-325.58; P=0.033) and tumor morcellation (OR, 3.11; 95% CI, 1.07-9.06; P=0.038) were significantly associated with poorer OS. The percentage of patients with abdomino-pelvic dissemination, as shown by peritoneal sarcomatosis or vaginal apex recurrence, was significantly greater in patients with than without tumor morcellation (44% vs. 12.9%, P=0.032).

CONCLUSION

Tumor morcellation during surgery increased the rate of abdomino-pelvic dissemination and adversely affected DFS and OS in patients with apparently early uterine LMS.

The impact of tumor morcellation during surgery on the outcomes of patients with apparently early low-grade endometrial stromal sarcoma of the uterus

BACKGROUND

The purpose of this study was to evaluate the impact of tumor morcellation on the outcomes of patients with apparently early low-grade endometrial stromal sarcoma (LGESS).

METHODS

Outcomes were retrospectively compared between patients with apparently early LGESS who did not (group A, n=27) or did (group B, n=23) undergo tumor morcellation.

RESULTS

There were no between-group differences in age, menopausal status, parity, body mass index, and preoperative presumptive diagnosis, nor were there between-group differences in tumor stage, tumor size, myometrial invasion, lymphovascular space invasion, frequency of ovarian preservation, adjuvant therapy, or follow-up time. More patients in group A underwent lymph node dissection (51.9 vs. 21.7%; P=0.029). Only 1 patient in each group had distant recurrence. There were 2 patients (7.4%) in group A and 7 (31.4%) in group B who had abdominopelvic recurrence. The risk of abdominopelvic recurrence was significantly higher in group B than in group A (odds ratio [OR], 5.47; 95% confidence interval [95% CI], 1.04-29.70; P=0.035). The 5-year disease-free survival (DFS) rates were 84% for group A and 55% for group B (P=0.028) and the 5-year abdominopelvic DFS rates were 89 and 58% (P=0.023), respectively. Multivariate analysis showed that tumor morcellation were significantly associated with poorer DFS (OR, 4.03; 95% CI, 1.06-15.30; P=0.040) and abdominopelvic DFS (OR, 5.06; 95% CI, 1.02-25.04; P=0.047).

CONCLUSIONS

Inadvertent tumor morcellation during surgery has an adverse impact on the outcomes of patients with early LGESS.

Uterine sarcomas--recent progress and future challenges

Uterine sarcomas are a group of rare tumours that provide considerable challenges in their treatment. Radiological diagnosis prior to hysterectomy is difficult, with the diagnosis frequently made post-operatively. Current staging systems have been unsatisfactory, although a new FIGO staging system specifically for uterine sarcomas has now been introduced, and may allow better grouping of patients according to expected prognosis. While the mainstay of treatment of early disease is a total abdominal hysterectomy, it is less clear whether routine oophorectomy or lymphadenectomy is necessary. Adjuvant pelvic radiotherapy may improve local tumour control in high risk patients, but is not associated with an overall survival benefit. Similarly there is no good evidence for the routine use of adjuvant chemotherapy. For advanced leiomyosarcoma, newer chemotherapy agents including gemcitabine and docetaxel, and trabectedin, offer some promise, while hormonal therapies appear to be more useful in endometrial stromal sarcoma. Novel targeted agents are now being introduced for sarcomas, and uterine sarcomas, and show some indications of activity. Non-pharmacological treatments, including surgical metastatectomy, radiofrequency ablation, and CyberKnife(®) radiotherapy, are important additions to systemic therapy for advanced metastatic disease.