Clinicopathologic analysis of uterine sarcomas from a single institution in the Canary Islands

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.

Uterine Sarcoma: Retrospective Study From A Single institute

Abstract

Uterine sarcomas are heterogeneous group of tumours comprising 1% of gynaecological malignancies. There is lack of concences on optimal treatment of uterine sarcomas. This is because of lack of randomised controlled trials due to rarity of these tumours. Surgical management without spill remains the standard primary treatment. Most of the times uterine sarcomas are diagnosed postoperatively from histopathology report of either myomectomy or hysterectomy. This retrospective study analysed the clinico pathological characteristics, prognostic factors, treatment details and survival outcome of different types of uterine sarcomas.

Materials and methods

This is a retrospective analysis of 59 patients of uterine sarcomas. All patients underwent surgery. Adjuvant chemotherapy or radiation treatment were given according to histopathological report and FIGO stage. Patients were followed up every three months for first two years and then every six months. Disease free survival (DFS) and Overall survival (OS) were calculated.

Statistical analysis

The data were summarized using descriptive statistics as mean, percent and range. Survival probabilities were estimated using Kaplan-Meier method and the significance of difference between the survival curves were calculate using log-rank test.

Results

Uterine sarcomas are rare and aggressive tumours of uterus. Majority of these tumours present in early stage. Surgery remains the main treatment modality. Role of adjuvant radiation treatment remains controversial. Tumour stage is the most important prognostic factor.

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.

Does iatrogenic tumor rupture during surgery have prognostic implications for the outcome of uterine sarcomas?

OBJECTIVE

Tumor rupture during surgery is a risk factor for recurrence of sarcomas in other locations. However, the independent impact of rupture on prognosis is uncertain in uterine sarcomas. The aim of this study was to evaluate whether uterine rupture impacts outcomes in patients with uterine sarcoma.

METHODS

A retrospective analysis was carried out of all consecutive patients with uterine sarcoma managed at the Department of Gynecology and Obstetrics of the Complejo Hospitalario Universitario Insular-Materno Infantil of the Canary Islands, Spain between January 1990 and December 2016. Inclusion criteria included all patients with histologically proven uterine sarcoma. Exclusion criteria included patients with endometrial carcinoma (non-sarcomatous) and carcinosarcomas. During this period, 1981 patients were diagnosed with a uterine malignancy; 1799 were excluded because of a diagnosis of endometrial carcinoma and 85 patients were excluded for a diagnosis of carcinosarcoma. Thus, the final sample included 97 patients with uterine sarcoma (4.9%). These included leiomyosarcoma, endometrial stromal sarcoma, adenosarcoma, and liposarcoma. Surgical resection was the primary treatment, including open, laparoscopic and vaginal surgery. Survival rates were analyzed using the Kaplan-Meier method.

RESULTS

The median age was 52 years (range 25-90); 49.5% (48) were pre-menopausal. Distribution per histological type was: 46.4% (45) leiomyosarcoma, 23.7% (23) high-grade endometrial stromal sarcoma, 17.5% (17) low-grade endometrial stromal sarcoma, 11.3% (11) adenosarcoma, and 1% (1) liposarcoma. Uterine leiomyoma was the most frequent pre-operatively suspected diagnosis (49.5%). Iatrogenic rupture of the tumor during surgery occurred in 25.3% of cases (23). International Federation of Gynecology and Obstetrics stages I-II and III-IV were identified in 74.2% (72) and 25.8% (25) of patients, respectively. The median tumor size was 8 cm (range 2-40). The recurrence rate was 47.8% (11) for patients with intra-operative tumor rupture and 25% (17) for patients without uterine rupture (p=0.03). Disease-free survival rates at 1, 2, and 5 years for patients with uterine rupture were 72.7%, 55.4%, and 13.9%, respectively, with a median time of 39 months (95% CI 2.9 to 75). For those patients without uterine rupture, disease-free survival rates at 1, 2, and 5 years were 84.8%, 76.1%, and 71.3%, respectively, with a mean time of 208.6 months (95% CI 169 to 248.3) (p=0.01). Multivariate analysis showed that stage, histological type, and iatrogenic tumor rupture during surgery were all independent prognostic factors for overall survival (OR 7.9, 95% CI 1.6 to 38.2, p=0.01); OR 5.3, 95% CI 2.1 to 13, p<0.0001; and OR 2.6, 95% CI 1.1 to 6.5, respectively, p=0.03).

CONCLUSION

Considering that uterine sarcomas, especially leiomyosarcomas, often occur in pre-menopausal women as bulky tumors requiring laparotomy and that they are rarely diagnosed pre-operatively, efforts should be made to avoid iatrogenic uterine rupture during surgery as it impairs patient survival.

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.

Uterine and Cervical Adenosarcoma: A Retrospective Study of Overall Oncologic Outcomes and Fertility Preservation in Early-Stage Disease

BACKGROUND

The management of adenosarcoma is based on the limited available data. This study aimed to explore the characteristics and oncologic outcomes of patients with uterine and cervical adenosarcoma.

MATERIALS AND METHODS

A total of 21 and 32 cases of cervical and uterine adenosarcoma, respectively, were retrospectively reviewed in Peking Union Medical College Hospital between April 2006 and March 2019.

RESULTS

The median follow-up time was 37.5 months (range, 1-153 months). The disease progression rate (DPR) was significantly higher in patients with uterine adenosarcoma compared with those with cervical adenosarcoma (28.1% vs. 4.8%). The curve of progression-free survival significantly differed. For those with cervical adenosarcoma, the presence of a tumor stalk was a protective factor, whereas heterologous elements (HE) presented a risk factor for disease progression. For those with uterine adenosarcoma, the presence of a tumor stalk was an independent protective factor, whereas lymphovascular space invasion (LVSI) was an independent risk factor for disease progression. Moreover, HE was an independent risk factor for mortality. Fertility-sparing surgery (FSS) was performed in four and five patients with cervical and uterine adenosarcoma, respectively. Regarding FSS, combined with cases in previous studies, the DPR of patients with uterine adenosarcoma was relatively higher compared with those with cervical adenosarcoma.

CONCLUSION

We found that cervical adenosarcoma had a better prognosis than uterine adenosarcoma. The presence of a tumor stalk was a protective factor, whereas HE and LVSI were risk factors for prognosis. For those with uterine adenosarcoma, if FSS was administered, robust evaluation would be necessary. The small sample size limits the ability to make any strong conclusions about FSS.

IMPLICATIONS FOR PRACTICE

Uterine cervical adenosarcoma had a better prognosis than uterine adenosarcoma. For patients with cervical adenosarcoma, the presence of a tumor stalk was a protective factor and the presence of heterologous elements (HE) was a risk factor for disease progression. For those with uterine adenosarcoma, the presence of a tumor stalk was a protective factor and lymphovascular space invasion was a risk factor for disease progression. Moreover, HE was a risk factor for mortality. Regarding fertility-sparing surgery (FSS), the disease progression rate was higher in patients with uterine adenosarcoma compared with those with cervical adenosarcoma. For patients with uterine adenosarcoma, if FSS was administered, hysteroscopy and robust imaging evaluation would be necessary.

Uterine Adenosarcoma: A Retrospective 12-Year Single-Center Study

Synopsis: Lymphovascular space invasion is an independent risk factor for disease progression and presence of tumor stalk an independent protective factor. Fertility sparing surgery may be acceptable in cases whose tumors present with stalks and without high risk factors.

Objectives: The aim of the present study was to investigate the potential prognostic factors of uterine adenosarcoma.

Methods: A total of 49 cases of uterine adenosarcoma were retrospectively reviewed at our institution between April 2006 and October 2018.

Results: Median follow-up time was 34 months (range: 1–148). Median age was 47.50 years (19–75). Nineteen (38.9%) patients were uterine cervical adenosarcoma and 30 (61.22%) patients were uterine corpus adenosarcoma. Twenty-nine (59.2%) patients were polypoid with a stalk to the uterine cervix or corpus. Twenty-six (38.8%) patients were stage IA. Fifteen (30.6%) patients showed sarcomatous overgrowth. Six (12.2%) patients displayed lymphovascular space invasion (LVSI). Four (8.16%) patients had heterologous elements. In univariate analysis, Disease-free-survival (DFS) was associated with tumor location, presence of tumor stalk, heterologous elements, LVSI. In multivariate analysis, presence of tumor stalk remained an independently protective factor for recurrence (HR = 0.088, P = 0.005), and LVSI a risk factor for recurrence (HR = 11.953, P = 0.002). Fertility-sparing surgery (FSS) was performed in seven stage IA patients. When patients of stage IA analyzed separately, FSS was not significant with the DFS or OS.

Conclusions: Presence of tumor stalk remained an independently protective factor for recurrence. Along with adequate counseling, FSS may be acceptable in cases whose tumors present with stalks and without high risk factors.

Prognostic factors for uterine adenosarcoma: a review

INTRODUCTION

Uterine adenosarcoma is a rare tumor with both epithelial and stromal components. Standard treatment is total abdominal hysterectomy and bilateral salpingo-oophorectomy. There is no defined role for adjuvant or neoadjuvant chemotherapy or radiation. There is a misconception that this is an indolent, low-grade sarcoma. In fact, at least 50% of patients will develop disease recurrence. Establishing prognostic factors is of paramount importance. Areas covered: This article reviews the current literature regarding adenosarcoma prognostic factors from case reports, case series, and retrospective series. An extensive review of the literature was undertaken via PubMed and Medline searches, relevant articles are included in this review. Expert commentary: The most important prognostic factors of uterine adenosarcoma are age, presence of sarcomatous overgrowth, presence of myometrial invasion, presence of lymphovascular invasion, and lymph node involvement. These factors can be used to accurately prognosticate for uterine adenosarcoma patients. Patients at low risk of disease recurrence can be identified. These patients require observation alone. Patients at high risk of disease recurrence can be identified and are candidates for aggressive therapy with adjuvant chemotherapy to reduce the risk of disease recurrence.

The Importance of Lymphovascular Invasion in Uterine Adenosarcomas: Analysis of Clinical, Prognostic, and Treatment Outcomes

Objective

This retrospective study examined the clinicopathologic features of adenosarcoma patients to determine potential prognostic factors and retrospectively evaluated overall survival (OS), disease-free survival (DFS), and local recurrence-free survival (LRFS) after primary treatment of adenosarcoma including surgery, radiation, and chemotherapy.

Methods

One hundred sixty-five patients with adenosarcoma were identified from the MD Anderson Cancer Center tumor registry between 1982 and 2014. Clinical data were collected retrospectively. Pathologic characteristics were examined by sarcoma pathologists. We used the Kaplan-Meier method to estimate OS, DFS, and LRFS. The log-rank test was performed to test the difference in survival between groups. Multivariate regression analyses of survival data were conducted using the Cox proportional hazards model.

Results

Median OS and DFS for all patients were 8.5 and 4.7 years, respectively. Pathologic characteristics that influence OS and DFS were sarcomatous overgrowth (SO), myometrial invasion (MI), lymphovascular invasion (LVI), tumor size, number of mitosis, estrogen receptor, progesterone receptor, International Federation of Gynecology and Obstetrics (FIGO) stage, age, and resection status. Median OS for adenosarcoma patients with SO was 5.2 versus 14.5 years for patients without SO (P < 0.0001). Median OS for adenosarcoma patients with MI was 5.8 years versus not reached for patients without MI (P = 0.0005). Median OS for adenosarcoma patients with LVI was 1.0 versus 8.9 years for patients without LVI (P = 0.0021). On Cox analysis for OS and DFS and LRFS, only SO, MI, LVI, age, resection status, and FIGO stage remained significant. There was no difference in OS or LRFS for adjuvant radiation versus no adjuvant radiation (P = 0.17, P = 0.076).

Conclusions

This study highlights the importance of LVI as a prognostic factor and confirms the prognostic significance of SO, MI, age, resection status, and FIGO stage for adenosarcoma. Furthermore, this study suggests that there is no additional benefit to adjuvant radiation. The standard-of-care treatment for adenosarcoma should remain total abdominal hysterectomy bilateral salpingo-oophorectomy +/− lymphadenectomy and no adjuvant radiation.

Treatment of Recurrent or Metastatic Uterine Adenosarcoma

Purpose

This study retrospectively evaluated overall survival (OS) by treatment of recurrent or metastatic uterine adenosarcoma including surgery, radiation, chemotherapy, and hormonal therapy and evaluated OS and progression-free survival (PFS) after 1st line systemic chemotherapy.

Methods

78 patients with recurrent or metastatic adenosarcoma comprised the study population. The Kaplan-Meier method was used to estimate OS and PFS. The log-rank test was performed to test the difference in survival between groups.

Results

Median OS from diagnosis of recurrent or metastatic disease was 1.8 yrs. OS was influenced by pathology on recurrence, p=0.035. Median OS differed by surgery for 1st recurrence 26.3 months versus 15.1 months. OS was not influenced by chemotherapy, p=0.58, palliative radiation, p=0.58, or hormonal therapy, p=0.15. The response rate (CR + PR) per RECIST 1.1 for chemotherapy was 31.2% for doxorubicin-based regimens and 14.3% for gemcitabine/docetaxel. OS since 1st line chemotherapy was not significantly different among chemotherapy regimens. However, the median PFS was superior for doxorubicin/ifosfamide (15.4 months) compared to gemcitabine/docetaxel (5.0 months), platinum-based regimens (5.7 mo), or other doxorubicin-based regimens (6.5 months).

Conclusion

These results suggest that surgery is an important treatment modality for recurrent or metastatic uterine adenosarcoma, and the most effective chemotherapeutics are doxorubicin/ifosfamide and gemcitabine/docetaxel.

Elevated levels of serum MiR-152 and miR-24 in uterine sarcoma: potential for inducing autophagy via SIRT1 and deacetylated LC3

BACKGROUND

MiRNAs may be associated with the risk of uterine sarcoma and related molecular mechanism remains unclear.

METHODS

A total of 101 patients with uterine sarcoma (cases) and 54 healthy subjects (controls) were enrolled. The levels of serum miR-152, miR-205, miR-222, miR-24, miR-150 and sirtuin 1 (SIRT1, an NAD +-dependent class III histone deacetylase) were measured by qRT-PCR. HeLa cells were transfected with the mimics of miR-152 and miR-24. The autophagic rates, and the levels of SIRT1 and acetylation of microtubule-associated protein 1A/1B-light chain 3 (LC3) were measured.

RESULTS

Levels of miR-152, miR-24 and SIRT1 decreased while the levels of miR-205, miR-222 and miR-150 increased in cases vs. controls (all P < 0.05). All miRNAs were linked with stage of the cases' sarcoma (all P = 0.001). Kaplan-Meier analysis demonstrated uterine sarcoma patients have better survival rates with high-level miR-152 and miR-24, with a five-year overall survival of 21.8% and 67.5%, respectively (P  =  0.003 and 0.004). The mimics of miR-152 and miR-24 induced autophagy by increasing the level of SIRT1, which deacetylated LC3.

CONCLUSION

Present findings demonstrate altered miRNA species in uterine sarcoma that are linked to disease stage, and a new molecular mechanism, by which miR-152 and miR-24 promote autophagy by activating SIRT1 and deacetylating LC3.

Uterine Adenosarcoma: a Review

Adenosarcomas are rare malignancies of the female genital tract, accounting for approximately 5 % of uterine sarcomas. Occasionally, adenosarcoma occurs in the ovaries or in extra-uterine tissue, which may be related to endometriosis. These tumors are characterized by benign epithelial elements and a malignant mesenchymal component. Pathologic diagnosis is dependent on the identification of the characteristic morphologic features. The most common immunohistochemical markers for adenosarcoma are CD10 and WT1, but these are not specific. The most frequent presenting symptom is abnormal uterine bleeding. The majority of patients present with stage I disease, with a 5-year overall survival of 60 to 80 %. Survival is influenced by the presence of myometrial invasion, sarcomatous overgrowth, lymphovascular invasion, necrosis, and the presence of heterologous elements including rhabdomyoblastic differentiation. Patients with sarcomatous overgrowth have significantly increased risk of recurrence 23 versus 77 % and decreased 5-year overall survival 50 to 60 %. Standard of care treatment is total hysterectomy with bilateral salpingo-oophorectomy without lymphadenectomy, as the incidence of lymph node metastasis is rare. Retrospective data does not support the use of adjuvant pelvic radiotherapy in uterine adenosarcomas as no survival benefit is seen. Insufficient data exists to recommend routinely neoadjuvant or adjuvant chemotherapy for uterine adenosarcomas. Limited evidence exists for the role of hormonal therapy in uterine adenosarcomas. The PIK3/AKT/PTEN pathway is mutated in ∼70 % of adenosarcomas, and this may represent a possible therapeutic target. This article reviews the current state of knowledge concerning uterine adenosarcoma and discusses the management of this rare tumor.

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.

Clinicopathological characteristics, treatment and outcomes in uterine carcinosarcoma and grade 3 endometrial cancer patients: a comparative study

Objective

Uterine carcinosarcoma (UCS) shared the same staging system with endometrial carcinoma in the International Federation of Gynecology and Obstetrics 2009. The aim of the present study was to compare the clinicopathological and prognostic characteristics between UCS and grade 3 endometrioid endometrial carcinoma (G3EC).

Methods

A retrospective analysis of 60 UCS and 115 G3EC patients with initial treatment at the Department of Gynecology in the Fudan University Shanghai Cancer Center between February 2006 and August 2013. Chi-square analysis was used to compare differences between variables. Prognostic factors were determined using univariate/multivariate analysis, and the survival rates were assessed using the Kaplan-Meier method. The Cox regression model was used to assess the independent prognostic factor.

Results

UCS had significantly worse overall survival (OS) compared with G3EC. Carcinosarcoma subtype was an independent factor (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.0 to 5.8; p=0.039), stratified based on stage. Compared with G3EC, UCS patients had a greater incidence of ascites fluid (55.0% vs. 15.7%, p<0.001) and adnexal involvement (20.0% vs. 8.7%, p=0.048) and larger median tumor volume (4.6 cm vs. 4.0 cm, p=0.046). Subgroup analysis of the prognostic factors revealed that UCS patients exhibited worse OS than G3EC patients in such specific subgroups as patients at younger ages, with postmenopausal status, without ascites fluid, with early stage diseases, without vagina invasion, without lymph node metastases and receiving adjuvant chemo/radiotherapy. Adjuvant radiotherapy with chemotherapy was predictive of better survival in UCS patients compared with chemotherapy or radiotherapy alone (5-year OS, 71.0% vs. 35.8%, p=0.028). Multivariate Cox regression revealed that tumor mesenchymal component (HR, 4.6; 95% CI, 1.4 to 15.8; p=0.014) was an independent prognostic factor for UCS, whereas advanced stages (HR, 5.9; 95% CI, 1.0 to 33.9; p=0.046) and ascites fluid (HR, 5.1; 95% CI, 1.1 to 22.7; p=0.032) were independently correlated with poor prognosis for G3EC patients.

Conclusion

The distinctions in both clinicopathological and prognostic characteristics between UCS and G3EC suggest that this subtype should be treated separately from high-risk epithelial endometrial carcinoma.

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.

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.