Chemotherapy in management of mixed mesodermal tumors of the ovary

Carcinosarcoma of the ovary—a case series

OBJECTIVE

To evaluate our experience with ovarian carcinosarcoma and identify prognostic factors.

METHODS

Thirty-one cases of ovarian carcinosarcoma were identified over a 6-year time period through tumor registry and pathology records. Fisher exact test and log rank using Kaplan-Meier method (P < 0.05) were used to compare variables with outcome.

RESULTS

All 31 patients underwent initial surgical treatment with an appropriate staging procedure. Stage distribution: 1 stage I, 6 stage II, 23 stage III, and 1 stage IV. The median follow-up was 28 months. The median survival for the entire group was 21 months. Early vs. advanced stage significantly influenced progression-free interval, P = 0.05. Nineteen patients were found to have stage IIIC disease and required debulking procedures. In patients with stage IIIC disease, presence of residual disease was associated with decreased overall survival, P = 0.03. 29 patients received adjuvant chemotherapy with 11 patients receiving ifosfamide/cisplatin and 16 patients receiving carboplatin/taxol. Progression-free interval was improved with the use of ifosfamide/cisplatin vs. carboplatin/taxol. The median PFI was 12 months in the carbo/taxol group and has not been reached in the ifos/cisplatin group (P = 0.005). The overall survival was also significantly improved with the use of ifosfamide/cisplatin, P = 0.03. In advanced stage patients, overall survival was not significantly influenced by type of adjuvant chemotherapy administered, P = 0.13.

CONCLUSIONS

Ovarian carcinosarcoma has a poor overall prognosis with median survival rates reported in the literature ranging from 7-10 months. Our series, although limited by a small number of patients, exhibits a more encouraging median survival of 21 months for the overall group. Aggressive debulking to eliminate residual disease and the use of ifosfamide/cisplatin chemotherapy seem to be factors in this improved outcome.

Clinicopathological features of ovarian carcinosarcomas: a single institution experience

OBJECTIVE

The aim of this study was to elucidate the clinicopathological and immunohistochemical prognostic factors of patients with ovarian carcinosarcoma treated with radical surgery and postoperative chemotherapy.

METHODS

During a 6-year period, nine patients with ovarian carcinosarcoma were referred to our institution. Tissue blocks were reviewed and sections containing both carcinomatous and sarcomatous elements were stained for epithelial membrane antigen (EMA), vimentin, vascular endothelial growth factor (VEGF), CD45RO, c-erbB-2, p53, CD34, Ki67, S100, estrogen, and progesterone receptors. Histological and immunohistochemical findings as well as clinical characteristics were then correlated with progression-free interval and overall survival.

RESULTS

There were four homologous and five heterologous carcinosarcomas. Five patients had early stage disease. Seven of the patients were optimally debulked. All patients were treated with anthracycline-based chemotherapy following surgery. With regard to immunohistochemistry, all specimens were negative for CD34, c-erbB-2, estrogen, and progesterone receptor expression. Five tumors overexpressed p53 and four specimens demonstrated a positive staining for Ki67. Reactivity for VEGF and CD45RO was observed in four and two tumor specimens, respectively. The median overall survival was 32.9 months with no statistical difference between early and advanced stages, while median time to progression was 13.5 months. p53 overexpression demonstrated a trend for better overall survival.

CONCLUSIONS

Only p53 overexpression seems to influence overall survival although, due to the small number of patients studied, no safe conclusions can be drawn. Despite the predominance of early stage patients that favorably influenced overall survival, aggressive surgical cytoreduction followed by anthracycline-based treatment were the cornerstone in our multimodality approach.

Prolonged survival of stage IV malignant mixed Müllerian tumor of the ovary after carboplatin, mesna, ifosfamide, and cis-platin chemotherapy: case report

Malignant mixed müllerian tumors (MMMT) of the ovary are rare, aggressive and rapidly progressive tumors. According to the available literature, the presence of metastatic disease rarely permits long term survival. We report on a 64-year old patient with stage IV ovarian MMMT who achieved a surgically-documented complete response (CR) after 6 cycles of carboplatin, mesna, ifosfamide, cis-platin. Pelvic recurrence was diagnosed 14 months later; the patient received 6 cycles of the same regimen used as first-line chemotherapy which resulted in a second complete response lasting for 4 months. The patient died 37 months after initial diagnosis due to intestinal occlusion. In the current case Ca 125 was significantly increased at clinical presentation of disease but not at the time of recurrence.

Malignant mixed mesodermal ovarian tumor treatment and prognosis: a 20-year experience

Mixed mesodermal sarcoma of the ovary is a rare clinical entity. To review the epidemiology, prognostic factors, and treatment results related to primary ovarian sarcoma at our center, a retrospective chart review of all patients referred for ovarian cancer was carried out from 1974 to 1994. Cases with confirmed pathologic diagnosis of primary mixed mesodermal ovarian sarcomas were selected, forming the present study group. Thirty-six charts were identified. The median age at presentation was 67.5 years. Findings at laparotomy demonstrated extraovarian metastasis in 33/35 patients. Total abdominal hysterectomy and bilateral salpingo-oophorectomy +/- omentectomy were performed in 34 patients, with 22 patients left with macroscopic residual disease after surgery. Follow-up adjuvant chemotherapy consisting of cisplatin and doxorubicin was administered to 29/36 patients. Follow-ups ranged from 1 to 11 years with a median of 2 years. As with epithelial ovarian cancer, residual disease after initial surgery is an important prognostic factor. Thirteen patients had a second-look laparotomy. Five patients were positive for disease. Eight patients, one of whom recurred, were histologically negative. The patients with positive second-look findings, as well as all those who recurred clinically, subsequently died within 12 months despite trials with different second-line chemotherapeutic agents. Survival analysis showed a median survival of 3 years among patients treated with combination cytotoxic chemotherapy. Primary ovarian sarcomas make up about 2-3% of all ovarian cancer cases seen in our center. These are often very aggressive tumors with widespread metastasis at the time of presentation, making optimal tumor debulking difficult. The combination of cisplatin and doxorubicin appears to have activity resulting in a survival of 35% at 5 years. Second-look surgery offers little helpful information on the management of these tumors.

Carcinosarcoma of the ovary: incidence, prognosis, treatment and survival of patients

BACKGROUND

Carcinosarcomas (also known as malignant mixed mullerian tumours) are rare malignant neoplasms that histologically contain both epithelial and stromal components.

METHODS AND MATERIALS

All cases of carcinosarcoma of the ovary presenting to the Royal Marsden Hospital from January 1975 to August 1993 were retrospectively analysed and the histological sections reviewed.

RESULTS

There were 37 cases of carcinosarcoma of the ovary representing 1.12% of the ovarian neoplasms seen at this institution. The median age of presentation was 65 years (range 26-85 years) and 70% of patients had advanced disease (FIGO stage III and IV). Clinical features at presentation were similar to those encountered in patients with epithelial ovarian cancer. The overall median survival was 247 days with 40% 1-year survival and 6% 5-year survival for all stages. Early FIGO stage was the only independent prognostic factor for survival. Histology (homologous/heterologous subtypes; grade, type or percentage of the epithelial component) had no significant impact on survival. Adjuvant radiotherapy may have a role and single agent platinum compounds are active, giving a response rate of 35%.

CONCLUSIONS

The management of this tumour is difficult and randomised trials are needed to accrue sufficient patient numbers to demonstrate optimal therapy.

Complete response of carcinosarcoma of the ovary to therapy with doxorubicin, ifosfamide, and dacarbazine

Although carcinosarcoma occurs in various locations throughout the body, it rarely originates in the ovary. Chemotherapy has been minimally beneficial. This case describes a patient with carcinosarcoma of the ovary who responded minimally to chemotherapy used for epithelial carcinomas but had a complete response after receiving chemotherapy used for sarcomas. The patient relapsed within 1 year after receiving cisplatin therapy. She was treated with mesna, ifosfamide, Adriamycin, and dacarbazine (MAID) chemotherapy and after one cycle of chemotherapy she had no evidence of tumor. She has received six cycles of chemotherapy without evidence of progression 13+ months since beginning MAID therapy. MAID chemotherapy may be useful in the treatment of carcinosarcoma of the ovary.

Clinical features of advanced ovarian mixed mesodermal tumors and treatment with doxorubicin- and cis-platinum-based chemotherapy

Records of 15 patients with stage III and IV malignant mixed mesodermal tumors of the ovary treated between 1977 and 1988 were reviewed. All patients had primary surgery; 13 were given postoperative chemotherapy including doxorubicin and cis-platinum. Median survival for patients receiving chemotherapy is 16 months; 62% were alive at 12 months and 31% at 24 months. Progression-free responses were seen in 85% of treated patients and 55% of these recurred. All recurrences involved the pelvis and were predominantly mesenchymal. Serum CA-125 values accurately reflected tumor presence in 82% of tested patients. Cytoreductive surgery followed by treatment including doxorubicin- and cis-platinum-based chemotherapy is effective in treatment of disseminated ovarian mixed mesodermal tumors, but additional components must be added to achieve durable responses and consistently prolonged survivals.

Platinum-based combination chemotherapy for malignant mixed mesodermal tumors of the ovary

Although considerable clinical data are available to guide treatment decisions for patients with ovarian epithelial malignancies, therapy for the rare malignant mixed mesodermal (mullerian) tumor (MMMT) of the ovary is poorly studied. Ten untreated patients diagnosed with primary ovarian MMMT were managed with cis-platinum-based combination chemotherapy from 1980 to 1985. Six of the 10 patients were stage III suboptimal with evaluable residual disease; 4 of these 6 had CRs with a median duration of response of 13 months. The remaining 2 patients had PRs, of 2 and 11 months duration. Four patients had stage III optimal disease; 1 progressed at 7 months, 1 progressed at 16 months and the other 2 patients have no clinical evidence of disease at 12+ and 22+ months. Despite impressive initial response rates, survival overall was poor, with a median survival for all 10 patients of 16+ months.

Clinicopathologic features of ovarian mixed mesodermal tumors and carcinosarcomas

Over a 27-year period there were 15 patients treated at the University of Michigan Medical center for carcinosarcomas or mixed mesodermal tumors of the ovary. Overall median survival was 11 months. Median survival was 4 months in patients with carcinosarcomas and 13 months in patients with mixed mesodermal tumors (P = 0.066). Patients with a chondrosarcomatous element had a significantly longer median survival than patients with mixed mesodermal tumors lacking cartilaginous differentiation (P = 0.031). The presence of a rhabdomyosarcomatous element did not affect survival. The size of the primary tumor, presence of ascites, FIGO stage, and degree of initial resection (optimal versus suboptimal) did not affect survival. There was no difference in survival between patients receiving postoperative chemotherapy and patients undergoing postoperative irradiation.

Mixed mesodermal sarcoma of the ovary. Treatment with combination radiation therapy and chemotherapy

Twenty patients with mixed mesodermal sarcoma of the ovary treated at the M. D. Anderson Hospital and Tumor Institute in Houston, Texas are reviewed. This report focuses on 12 patients treated post-operatively with combination radiation therapy and chemotherapy with vincristine, dactinomycin, and cyclophosphamide (VAC). There were 4 patients achieving complete tumor control, including one who is alive without disease beyond 5 years and 3 who died of unrelated causes without disease at autopsy. One other patient had a significant disease-free interval of 18 months. Compared to previous reports, combination radiation and VAC chemotherapy appears effective in this disease. Due to the observed myelosuppression and gastrointestinal and neurologic toxicities, however, treatment modifications have been recommended.