Treatment of uterine sarcoma at the Royal Marsden Hospital from 1974 to 1998

Uterine Sarcomas: A Retrospective Analysis of a Cohort of 62 Patients

Background and objective

Uterine sarcomas are rare tumors, and they account for 4% of all uterine malignancies. These tumors are characterized by a great diversity of histological types, and current knowledge regarding their treatment is limited. The aim of our study was to analyze a cohort of patients with uterine sarcomas with respect to the histological types of their tumors, as well as their prognosis and treatment.

Materials and methods

This was a retrospective analysis involving patients diagnosed at a single center with uterine sarcoma between 2003 and 2017. 

Results

The study included 62 patients; the mean age of the patients was 62 ±13 years. Carcinosarcoma was identified in 44% of cases, leiomyosarcoma in 40%, and endometrial stromal sarcoma in 13%. Endometrial stromal sarcoma was found to occur in younger women compared to carcinosarcoma (52 ±13 vs. 66 ±12 years, p=0.016); 90% of patients underwent surgery, and medical treatment was implemented in 42%. The mean overall survival (OS) was 93 ±10.65 months, and the median progression-free survival (PFS) was 12 months. There was a significant association between the stage of the disease at diagnosis and the probability of survival: mean OS was 118 months for locoregional disease vs. 44 months for metastatic disease (p<0.001). The overall five-year survival rate was 39%.

Discussion and conclusions

Uterine sarcomas are rare cancers, and they are very heterogeneous. They are also associated with a high mortality rate. Further investigational studies are required so that a more effective treatment method and individualized treatment plans can be implemented for patients with uterine sarcoma.

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.

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.

Treatment of pure uterine sarcoma at the Institut Català D'Oncologia

AIM

The aim of this retrospective study was to investigate the clinical and histopathological characteristics of the disease and treatment outcome of patients with pure uterine sarcomas.

BACKGROUND

Uterine sarcomas are especially rare tumours, comprising only 3-5% of uterine cancers. They are characterized by histopathological diversity, rapid clinical progression, and poor prognosis. Optimal management consists of complete surgical removal and adjuvant radiotherapy may improve the prognosis.

MATERIALS AND METHODS

All patients with pure uterine sarcoma histology treated at our centre, the Institut Català D'Oncologia in Barcelona Spain, between 2002 and 2010 were reviewed.

RESULTS

Records of 17 patients treated at our hospital over an 8-year period were obtained. Nine patients (53%) had leiomyosarcoma, 7 (41%) had endometrial stromal sarcoma, and 1 patient had unclassified sarcoma. All patients were treated with external beam radiation after surgical excision. Mean age was 62 years (range, 51-69 years). Of the 17 patients, 13 (76%) presented with stage I disease, 2 (12%) were stage II, and 2 (12%) stage III. The overall actuarial 2-year survival estimate was 82.5%. Two patients experienced local relapse. The 2-year local control rate was 90%. A total of 5 patients experienced either local or metastatic relapse. The 2-year progression free survival rate was 58%.

CONCLUSION

In our experience, combined treatment (surgery and adjuvant radiation therapy) is effective with acceptable side effects. Larger and multicenter studies are needed to assess treatment outcome for pure uterine sarcoma histology.

Cyclooxygenase-2 Is an Independent Predictor of Poor Prognosis in Uterine Leiomyosarcomas

Introduction:

Cyclooxygenase-2 (COX-2) is a well-known enzyme that promotes tumor growth and metastasis. Cyclooxygenase-2 is upregulated in a number of human epithelial tumors, but data about the significance of COX-2 in mesenchymal tumors are lacking. The purpose of this study was to determine COX-2 expression in uterine sarcomas and whether a relationship exists between COX-2 expression and clinicopathologic outcomes.

Methods:

Immunohistochemical staining for COX-2 was performed on paraffin-embedded tissue blocks of 49 uterine sarcomas (30 leiomyosarcomas, 14 endometrial stromal sarcomas, and 5 carcinosarcomas). Positive staining was defined as moderate or strong staining in 5% or more of tumor cells.

Results:

Four of 30 leiomyosarcomas, 1 of 14 endometrial stromal sarcomas, and 2 of 5 carcinosarcomas were positive for COX-2 expression. In leiomyosarcomas, COX-2 expression correlated with tumor stage with marginal significance (P = 0.058). Patients with leiomyosarcoma positive for COX-2 expression had a lower overall survival rate than those without COX-2 expression (P = 0.025). In the multivariate Cox proportional hazards regression model, COX-2 expression, tumor stage, and mitotic count were independently associated with overall survival in leiomyosarcomas.

Conclusions:

Our data suggest that immunohistochemically determined COX-2 expression is an independent prognostic factor in uterine leiomyosarcomas. Assessment of COX-2 status might be useful for determining the prognosis in patients with uterine leiomyosarcomas.

Pelvic radiation improves local control after hysterectomy for uterine leiomyosarcoma: a 20-year experience

BACKGROUND

Uterine leiomyosarcoma (LMS) is associated with high rate of recurrence after surgical resection. The role of adjuvant radiation therapy in improving survival in women with uterine LMS is unclear.

METHODS

All cases of LMS treated from 1985 to 2005 at 11 regional medical centers were identified. Kaplan-Meier survival curves were constructed and compared with log-rank testing. Multivariate analysis was performed to account for the potential influence of confounding factors.

RESULTS

One hundred forty-seven patients with LMS were identified. The median age of diagnosis was 51 years with the stage distribution of stage I (n = 87), II (n = 9), III (n = 25), IV (n = 25), and unknown (n = 1). One hundred forty-three underwent total abdominal hysterectomy and bilateral salpingoophorectomy. Twenty-four (17%) of these patients received adjuvant pelvic irradiation, and 63 (44%) received adjuvant and/or palliative chemotherapy. With a median follow-up of 24 months (range, 1-249 months), the median survival for the entire group was 37 months. Cox proportional hazards modeling demonstrated the presence of high tumor grade and advanced stage adversely affected survival. Although the 5-year survival for patients who received adjuvant radiotherapy was significantly higher than those who did not (70% vs 35%), this survival advantage was not sustained as the curves crossed at 90-month follow-up. Pelvic recurrence rate was lower in the radiation group (18% vs 49%; P = 0.02).

CONCLUSIONS

Adjuvant radiation therapy was associated with decreased pelvic failure and a modest improvement in 5-year survival, but did not impact overall survival with extended follow-up.

Treatment of early uterine sarcomas: disentangling adjuvant modalities

Uterine sarcomas are a rare group of neoplasms with aggressive clinical course and poor prognosis. They are classified into four main histological subtypes in order of decreasing incidence: carcinosarcomas, leiomyosarcomas, endometrial stromal sarcomas and "other" sarcomas. The pathological subtype demands a tailored approach. Surgical resection is regarded as the mainstay of treatment. Total abdominal hysterectomy and bilateral salpingo-oophorectomy represents the standard treatment of uterine sarcomas. Pelvic and para-aortic lymph node dissection in carcinosarcomas is recommended, given their high incidence of lymph node metastases, and may have a role in endometrial stromal sarcomas. Adjuvant radiation therapy has historically been of little survival value, but it appears to improve local control and may delay recurrence. Regarding adjuvant chemotherapy, there is little evidence in the literature supporting its use except for carcinosarcomas. However, more trials are needed to address these issues, especially, their sequential application. Patients with uterine sarcomas should be referred to large academic centers for participation in clinical trials.

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

PURPOSE

Uterine sarcoma is a rare malignancy with the worst prognosis of all uterine cancers. This study evaluated the prognostic factors and treatment outcomes of patients with this disease.

METHODS

A retrospective analysis was performed on 127 patients with histologically verified uterine sarcoma who were treated and followed at the Asan Medical Center (Seoul, Korea) from 1989 to 2007.

RESULTS

Histological analyses revealed that 37 patients had endometrial stromal sarcoma, 44 had malignant mixed mullerian tumors and 46 had leiomyosarcoma. Surgical stages, as defined by the International Federation of Gynecology and Obstetrics (FIGO) system, were I in 82 patients, II in 6 patients, III in 18 patients and IV in 19 patients. All patients underwent surgical treatment and 72 patients received adjuvant therapy. The 10-year disease-free survival (DFS) rate was 30% and the 10-year overall survival (OS) rate was 48%, with a mean follow-up time of 38 months (ranging from 1 to 212 months). Adjuvant radiation and chemotherapy had limited impact on the outcome of early-stage disease. However, patients with advanced-stage disease who received adjuvant chemotherapy had significantly longer OS times. A multivariate analysis revealed that FIGO stage (P = 0.025), depth of myometrial invasion (P = 0.004), and complete cytoreduction (P = 0.030) were significantly associated with DFS, while menopausal status (P = 0.044), FIGO stage (P = 0.016), depth of myometrial invasion (P = 0.029), and lymph-vascular space invasion (LVSI) (P = 0.020) were significantly associated with OS.

CONCLUSIONS

This study suggests that complete cytoreduction is important and adjuvant chemotherapy can help achieve favorable prognoses in patients with advanced stage disease. However, postmenopausal status, advanced FIGO stage, deep myometrial invasion, and positive LVSI were associated with poor prognosis.

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.

Dermatomyositis as a paraneoplastic syndrome in carcinosarcoma of uterine origin

Paraneoplastic syndromes are a collection of disorders affecting an organ or tissue caused by cancer but occurring at a site distant from the primary or metastases. Dermatomyositis can occur in association with malignancy as a paraneoplastic phenomenon. We present a case of a patient presenting simultaneously with an advanced carcinosarcoma of the uterus and dermatomyositis. The diagnoses, pathophysiology and treatment of these two conditions are discussed and current published studies reviewed.

Prognostic factors and outcome in women with uterine sarcoma

OBJECTIVES

A retrospective analysis of patients with uterine sarcoma was undertaken to assess prognostic factors and treatment related outcomes.

PATIENTS AND METHODS

Ninety-four patients (median age: 60years, range: 20-93years) with a histologically verified uterine sarcoma treated at the McGill University Health Centre (MUHC) between 1989 and 2004 were identified from the tumor registry and pathology database.

RESULTS

Twenty-eight patients had an endometrial stromal sarcoma (ESS), 30 had a leiomyosarcoma (LMS), and 36 had mixed muellerian tumors (MMT). According to FIGO classification, Stage I, II, III, and IV tumors were identified in 49, 7, 20, and 18 patients, respectively. At the time of analysis, 55.5% of patients (52/94) were dead due to progressive sarcoma disease; 8.5% of the patients (8/94) were alive with disease recurrence, and 36.2% (34/94) were alive without disease recurrence, with a median survival of 35months. Univariate analysis demonstrated a statistically significant association between overall survival and histology in favor of patients with ESS (p<0.001). Analyzing each of the histological subtypes separately, adjuvant treatment with chemotherapy and/or hormonal treatment had no demonstrable impact on overall survival. In multivariate analysis age and advanced stage, remained a significant predictor for overall survival in patients with LMS and MMT, but not in patients with ESS. Regarding adjuvant treatment, radiotherapy had a significant impact on overall survival only in patients with MMT (p=0.002).

CONCLUSIONS

In patients with uterine sarcoma, in comparison to LMS and MMT, ESS tends to present as a less aggressive disease with a favorable outcome. Furthermore, reflected by an improved overall survival after radiotherapy only in patients with MMT, it seems to be mandatory to differentiate between these histological subtypes.

Sarcomes utérins : aspects cliniques et thérapeutiques

PURPOSE

Uterine sarcomas are rare tumours characterized by clinical and histopathological diversity and poor prognosis. We analyzed diagnostic, prognostic and therapeutic difficulties encountered with these tumors by insisting on the importance of early diagnosis.

PATIENTS AND METHODS

From 1997 to 2004 ten patients with uterine sarcoma who underwent surgery in the obstetrics and gynecology unit at the Tunis maternity center were included in this retrospective study. The tumors were classified at the time of diagnosis using the FIGO staging system. The histological diagnosis was based on the WHO classification.

RESULTS

There were 5 cases of leiomyosarcoma, 2 cases of carcinosarcoma, 2 cases of endometrial stromal sarcoma and 1 adenosarcoma. There were four cases of stage I, two cases of stage II, two cases of stage III and two of stage IV tumors. The diagnosis of uterine sarcoma was strongly suspected and proved before the initial operation in 20% of cases and during this operation in 60% of cases. Diagnosis was only established at the histological exam in two cases. Total hysterectomy with bilateral salpingo-oophorectomy was performed in 90% of patients. Radiation therapy was performed in four. Chemotherapy was delivered in two patients. After an average of four years five patients were in remission, three had died and two were lost to follow-up.

CONCLUSION

Early preoperative or intra-operative diagnosis is essential while awaiting for more effective chemotherapy protocols or therapeutic strategies.

The expression of Ki-67, p53, estrogen and progesterone receptors affecting survival in uterine leiomyosarcomas. A clinicopathologic study

OBJECTIVES

To evaluate the level of expression of estrogen receptor (ER), progesterone receptor (PR), p53 and Ki-67 in patients with leiomyosarcoma and to investigate the effect of these and to identify the clinical parameters on prognosis.

MATERIALS AND METHODS

Twenty-four patients operated for LMS of uterine origin between 1994 and 2003 at Istanbul Medical School, Department of Obstetrics and Gynecology and Division of Gynecologic Oncology constituted our study group. The data of all patients were updated via mail or phone. The effects of stage, grade, chemotherapy, radiotherapy, number of mitoses, presence of necrosis, Ki-67 and p53 expression, presence of estrogen and progesterone receptors on survival were evaluated.

RESULTS

The mean follow-up period of patients is 30.42 +/- 25.15 months. The mean overall survival for all LMS patients was estimated to be 48.4 +/- 10.38 months. The cumulative survival ratio in the 33rd month was 33.08. Age, menopausal status, history of prior radiotherapy, number of mitoses had no statistically significant effect on overall survival in our study although stage had a significant effect. Finding of greater than 10% steroid receptor expression has a positive effect on survival ([ER P = 0.019; log rank = 5.49] and [PR P = 0.023; log rank = 5.14]). The median value of Ki-67 was calculated to be 30. There was a survival advantage in patients with Ki-67 expression (P = 0.034; log rank = 4.49) below the median value. p53 levels had no significant effect on survival (P = 0.336; log rank = 0.92).

CONCLUSION

Surgical staging is an important prognostic factor in LMS patients, while number of mitoses and grade of the tumor also seem to affect prognosis. Contrary to the current literature, our findings suggest that estrogen and progesterone receptor positivity greater than 10% may be associated with a better prognosis.

The role of surgery and treatment trends in uterine sarcoma

AIMS

To report a series of uterine sarcomas treated in one institution.

METHODS

We report 72 cases of uterine sarcomas treated in a single institution, comparing the periods 1966-1989 and 1990-2001. The parameters studied were histological type, tumour stage and treatment. The control of pelvic, local and/or metastatic disease were also studied.

RESULTS

The histological types consisted in 34 leiomyosarcomas, 25 mixte mullerian tumours, 12 endometrial stromal sarcoma and one angiosarcoma. The median age at diagnosis was 60.5 years. The presenting symptoms were genital bleeding, pelvic or abdominal pain. The proportion, of stage I was lower in 1966-1989 than in 1990-2002. During the 1966-1989 period, surgery was systematically used. The percentage of second-line surgery (post-radiotherapy or -chemotherapy) rose from 2.2% in 1966-1989 to 19.2% in 1990-2002. Radiotherapy was administered in 55.5% of cases. There was no difference between the two periods. Chemotherapy was administered in 37.5% of cases with also no difference between the two periods. The overall 2-year survival was 54.6% and the 5-year survival 36.1%. The median survival was 32.3 months (3 days-25 years). The overall 5-year survival by stage was 47.5% for stage I, 60.6% for stage II and 15.0% for stages III and IV. The median duration of pelvic disease control was 19.2 months. The 5-year pelvic disease control by FIGO stage was 66.6% for stage I, 62.5% for stage II and 18% for the more advanced stages.

CONCLUSION

Surgery remains the reference treatment. Local and regional disease control, as adjuvant therapies do not seem to decrease the risk of metastatic spread or increase survival.