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

Unexpected rare uterine carcinosarcoma with neuroendocrine differentiation: Reflections on clinical diagnosis and treatment of a case report

RATIONALE

Uterine carcinosarcoma (UCS) is a rare and highly invasive malignant tumor.It exhibits an ectopic growth pattern of the uterus,and its histological features are biphasic differentiation of malignant epithelial components (cancer) and malignant mesenchymal components (sarcoma). The pathological pattern of high-component neuroendocrine differentiation is extremely rare. Due to the inherent heterogeneity of tumors, it increases the difficulty of accurate identification and diagnosis. The author introduces a rare case of primary endometrial carcinosarcoma (heterologous) with small cell neuroendocrine carcinoma (SCNEC) components. There is limited literature on this rare pathological differentiation pattern and a lack of guidelines for the best treatment methods, which prompts reflection on the diagnosis, optimal treatment strategies, and how preoperative diagnosis can affect patient prognosis for endometrial carcinosarcoma with neuroendocrine differentiation.

PATIENT CONCERNS

The patient is an elderly woman who presents with abnormal vaginal bleeding after menopause. Transvaginal ultrasound examination shows that the uterus is slightly enlarged, and there is a lack of homogeneous echogenicity in the uterine cavity. Subsequently, a hysteroscopic curettage was performed, and a space-occupying lesion was observed on the anterior wall of the uterine cavity.

DIAGNOSES

Preoperative endometrial biopsy revealed SCNEC of the endometrium. The patient underwent radical hysterectomy, and the postoperative pathological results showed that UCS (heterologous) was accompanied by SCNEC components (about 80%).

INTERVENTION

The patient received radical hysterectomy, followed by adjuvant chemotherapy.

OUTCOME

After 7 months of follow-up, no tumor recurrence or metastasis was found at the time of writing this article.

LESSONS

The histological type of UCS (heterologous) with cell neuroendocrine carcinoma components is rare and highly invasive, with a high misdiagnosis rate in preoperative biopsy. There are currently no effective treatment guidelines for this type of case. The unusual appearance of SCNEC components in this case poses a challenge for both pathologists and surgeon. The rare differentiation pattern of this case exposes the complexity of its management and the necessity of prospective trials to determine the optimal treatment plan.

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

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

Carcinosarcoma of the nasal cavity and paranasal sinuses: Review of the national cancer database

Background

Carcinosarcomas are rare, aggressive malignancies that can arise in the nasal cavity and paranasal sinuses. There are limited outcome data available. Accordingly, we sought to use the National Cancer Database (NCDB) to characterize patient demographics and outcomes.

Method

A retrospective analysis of the NCDB from 2004 to 2016 for patients with sinonasal carcinosarcoma was conducted.

Results

Thirty patients were included. The patients were predominantly male (n = 20), white (n = 23), and privately insured (n = 15), with an average age of 62.4 years. The nasal cavity was the most common subsite (n = 14), followed by the maxillary sinus (n = 8). Most patient were treated with surgery followed by radiation (n = 23), with the remaining undergoing surgery alone (n = 4), radiation alone (n = 2), or no treatment (n = 1). One-third (n = 10) received adjuvant chemotherapy. The 1- and 5-year overall survival (OS) in the cohort were 79.2% and 43.3%, respectively. Univariate log-rank testing showed OS varied based on intervention (P < 0.029), sex (P < 0.042), and age (P < 0.025), while on multivariate analysis none of these factors independently predicted OS.

Conclusions

We describe the demographics and presenting features of a national cohort of sinonasal carcinosarcoma patients. Future research is needed to identify predictors of overall survival, and to assess the optimal roles for radiation and systemic chemotherapy.

Evaluation of chemotherapy and radiotherapy in the adjuvant management of uterine carcinosarcoma: a population-based analysis

PURPOSE

To evaluate the effects of adjuvant chemotherapy (CT) and radiotherapy (RT) on the survival of uterine carcinosarcoma (UCS) patients.

METHODS

We analyzed 3207 patients with uterine carcinosarcoma without distant metastasis after surgery from 2004 to 2015 by utilizing data from the Surveillance, Epidemiology, and End Results database. Generally, cancer-specific survival (CSS) and overall survival (OS) outcomes were analyzed by Kaplan-Meier and Cox proportional hazards regression models. Further subgroup survival analysis was performed for those receiving RT and chemoradiotherapy (CRT).

RESULTS

In general, both univariate and multivariate analyses showed that age, race, marital status, stage, lymph node metastasis, lymphadenectomy (LND), RT, and chemotherapy (CT) were associated with improved CSS and OS (P < 0.05). Further subgroup analysis showed that CRT exhibited a survival advantage over RT or CT alone in different groups. Various RT modalities, including brachytherapy (BT), external radiotherapy (EBRT), and EBRT + BT, were correlated with improved survival for patients aged 60-69 years with stage III-IV disease and lymph node metastasis. Patients with stage I-II disease aged > 70 years seemed to gain survival benefits from brachytherapy (BT) alone. BT with or without external radiotherapy was associated with improved survival for those who did not undergo lymphadenectomy.

CONCLUSION

For UCS without distant metastasis after surgery, CRT should be considered. Regarding RT, BT alone is efficient in improving survival, especially for patients with stage I-II disease aged > 70 years old. EBRT alone does not show results in survival improvement for patients who did not undergo LND and those with lymph node metastasis. However, considering the limitation of SEER database, further studies with more large sample size and strict study design are needed to confirm it.

Influence of Clinical and Surgical Factors on Uterine Carcinosarcoma Survival

BACKGROUND

The aim of this study was to assess the impact of prognostic factors on the survival of patients diagnosed with uterine carcinosarcoma.

METHODS

A sub-analysis of the SARCUT study, a multicentric retrospective European study, was carried out. We selected 283 cases of diagnosed uterine carcinosarcoma for the present study. Prognosis factors influencing survival were analyzed.

RESULTS

Significant prognostic factors for overall survival were: incomplete cytoreduction (HR = 4.02; 95%CI = 2.68-6.18), FIGO stages III and IV (HR = 3.21; 95%CI = 1.83-5.61), tumor persistence after any treatment (HR = 2.90; 95%CI = 1.97-4.27), presence of extrauterine disease (HR = 2.62; 95%CI = 1.75-3.92), a positive resection margin (HR = 1.56; 95%CI = 1.05-2.34), age (HR = 1.02; 95%CI = 1.00-1.05), and tumor size (HR = 1.01; 95%CI = 1.00-1.01). Significant prognostic factors for disease-free survival were: incomplete cytoreduction (HR = 3.00; 95%CI = 1.67-5.37), tumor persistence after any treatment (HR = 2.64; 95%CI = 1.81-3.86), FIGO stages III and IV (HR = 2.33; 95%CI = 1.59-3.41), presence of extrauterine disease (HR = 2.13; 95%CI = 1.44-3.17), administration of adjuvant chemotherapy (HR = 1.84; 95%CI = 1.27-2.67), a positive resection margin (HR = 1.65; 95%CI = 1.11-2.44), presence of LVSI (HR = 1.61; 95%CI = 1.02-2.55), and tumor size (HR = 1.00; 95%CI = 1.00-1.01).

CONCLUSIONS

Incomplete cytoreduction, presence of tumor residual after treatment, advanced FIGO stage, extrauterine disease, and tumor size are significant prognostic factors decreasing disease-free survival and overall survival of patients with uterine carcinosarcoma.

Endometrial carcinosarcoma

Endometrial carcinosarcoma is a rare and aggressive high-grade endometrial carcinoma with secondary sarcomatous trans-differentiation (conversion theory). The clinical presentation and diagnostic work-up roughly align with those of the more common endometrioid counterpart, although endometrial carcinosarcoma is more frequently diagnosed at an advanced stage. Endometrial carcinosarcoma is not a single entity but encompasses different histological subtypes, depending on the type of carcinomatous and sarcomatous elements. The majority of endometrial carcinosarcomas are characterized by p53 abnormalities. The proportion of POLE and microsatellite instablity-high (MSI-H) is directly related to the epithelial component, being approximately 25% and 3% in endometrioid and non-endometrioid components.The management of non-metastatic disease is based on a multimodal approach with optimal surgery followed by (concomitant or sequential) chemotherapy and radiotherapy, even for early stages. Palliative chemotherapy is recommended in the metastatic or recurrent setting, with carboplatin/paclitaxel doublet being the first-line regimen. Although the introduction of immunotherapy plus/minus a tyrosine kinase inhibitor shifted the paradigm of treatment of patients with recurrent endometrial cancer, patients with endometrial carcinosarcoma were excluded from most studies evaluating single-agent immunotherapy or the combination. However, the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) approved the use of pembrolizumab and lenvatinib in endometrial cancer (all histotypes) after progression on chemotherapy and single-agent immunotherapy in MSI-H cancers. In the era of precision medicine, emerging knowledge on molecular endometrial carcinosarcoma is opening new promising therapeutic options for more personalized treatment. The present review outlines state-of-the-art knowledge and future directions for patients with endometrial carcinosarcoma.

Trends in Gynecologic Carcinosarcoma Based on Analysis of the Surveillance Epidemiology End Result (SEER) Database

Carcinosarcomas (malignant mixed Mullerian tumors) of a female genital organ are rare tumors associated with a poor survival. The purpose of this study was to identify site-specific differences in the incidence and prognosis in carcinosarcomas originating in the uterus, cervix, or ovary. The data of patients with gynecologic carcinosarcomas were extracted from the Surveillance, Epidemiology, and End Results (SEER) database between 2000 and 2016. The characteristics of gynecologic carcinosarcomas were compared using Pearson X2 and Fisher's exact tests. Kaplan-Meier models were used for cause-specific survival (CSS) analysis. The cohort included 7086 females, including 5731 cases of uterine carcinosarcoma, 161 cervical carcinosarcomas, and 1193 ovarian carcinosarcomas. The age-adjusted incidence rates of uterine, cervical, and ovarian carcinosarcoma were 3.9, 0.1, and 0.6 per 1,000,000, respectively. In the distribution of carcinosarcoma incidence by race, compared with the uterus or cervix, those originating from the ovary were unequally distributed in Caucasians (84.4% versus 69.6%, 67.7%; p < 0.001). The incidence of uterine carcinosarcoma steadily increased over time, from 2.2 in 2000 to 5.5 in 2016 (per 1,000,000), while cervical or ovarian carcinosarcoma showed no significant difference in incidence. The five-year CSS rates based on the site of origin (uterus, cervix, and ovary) were 39.9%, 33.1%, and 25.8%, respectively. The incidence rates of gynecologic carcinosarcoma, especially uterine carcinosarcoma, are gradually increasing. Although uterine carcinosarcoma is associated with a higher incidence than the others, it has a better prognosis compared with ovarian and cervical carcinosarcoma. The survival rates were worst in ovarian carcinosarcoma.

Radiation Therapy for Endometrial Cancer: An American Society for Radiation Oncology Clinical Practice Guideline

PURPOSE

With the results of several recently published clinical trials, this guideline informs on the use of adjuvant radiation therapy (RT) and systemic therapy in the treatment of endometrial cancer. Updated evidence-based recommendations provide indications for adjuvant RT and the associated techniques, the utilization and sequencing of adjuvant systemic therapies, and the effect of surgical staging techniques and molecular tumor profiling.

METHODS

The American Society for Radiation Oncology convened a multidisciplinary task force to address 6 key questions that focused on the adjuvant management of patients with endometrial cancer. The key questions emphasized the (1) indications for adjuvant RT, (2) RT techniques, target volumes, dose fractionation, and treatment planning aims, (3) indications for systemic therapy, (4) sequencing of systemic therapy with RT, (5) effect of lymph node assessment on utilization of adjuvant therapy, and (6) effect of molecular tumor profiling on utilization of adjuvant therapy. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for quality of evidence grading and strength of recommendation.

RESULTS

The task force recommends RT (either vaginal brachytherapy or external beam RT) be given based on the patient's clinical-pathologic risk factors to reduce risk of vaginal and/or pelvic recurrence. When external beam RT is delivered, intensity modulated RT with daily image guided RT is recommended to reduce acute and late toxicity. Chemotherapy is recommended for patients with International Federation of Gynecology and Obstetrics (FIGO) stage I to II with high-risk histologies and those with FIGO stage III to IVA with any histology. When sequencing chemotherapy and RT, there is no prospective data to support an optimal sequence. Sentinel lymph node mapping is recommended over pelvic lymphadenectomy for surgical nodal staging. Data on sentinel lymph node pathologic ultrastaging status supports that patients with isolated tumor cells be treated as node negative and adjuvant therapy based on uterine risk factors and patients with micrometastases be treated as node positive. The available data on molecular characterization of endometrial cancer are compelling and should be increasingly considered when making recommendations for adjuvant therapy.

CONCLUSIONS

These recommendations guide evidence-based best clinical practices on the use of adjuvant therapy for endometrial cancer.

Efficacy and safety of trabectedin for the treatment of advanced uterine or ovarian carcinosarcoma: Results of a phase II multicenter clinical trial (MITO-26)

OBJECTIVE

This open-label phase II clinical trial evaluated the antitumor activity and safety of trabectedin in patients with advanced ovarian (OC) or uterine carcinosarcomas (UC).

METHODS

Eligible patients were adults (≥18 years) with histologically proven recurrent OC/UC not amenable to surgery or radiotherapy who received up to two prior chemotherapy lines. Trabectedin 1.3 mg/m² was administered as a 3-h infusion every three weeks. The primary endpoint was objective response rate (ORR) as per RECIST v.1.1. If at least 8 of 43 patients (18.6%) achieve an objective response, trabectedin would be declared worthy for further investigations.

RESULTS

Forty-five patients with either OC (n = 32) or UC (n = 13) from seven MITO centers across Italy were enrolled. The ORR was 11.9% (90% CI: 6-23) and included two patients with a complete response and three with a partial response. Eight patients (19.0%) had disease stabilization for a disease control rate of 31.0% (90% CI: 20-44). Median progression-free survival was 2.01 months (95% CI: 1.78-2.30) and median overall survival was 4.64 months (95% CI: 3.19-8.29). Neutrophil count decreases (n = 8, 18.2%) and transaminase increases (n = 6, 13.6%) were the most common grade 3-5 adverse events related with trabectedin. Two patients died due to trabectedin-related grade 5 hematological toxicity.

CONCLUSION

Although trabectedin did not meet the prespecified activity criteria, it confers modest but clinically meaningful benefit to patients with advanced OC/UC as being as effective as any other available treatment for this indication. The toxicity profile appears in line with that previously reported for the drug.

Improved survival with combination chemotherapy and external beam radiation therapy in uterine carcinosarcoma

Objectives

To evaluate differences in survival and recurrence patterns in stage I–IV uterine carcinosarcoma patients treated with surgery followed by adjuvant chemotherapy alone, radiation alone, or a combination of both chemotherapy and radiation therapy.

Methods

A multicenter retrospective analysis of patients with surgically staged carcinosarcoma receiving adjuvant therapy from January 2000 to December 2019 was conducted. Inclusion criteria were patients with carcinosarcoma who had received primary surgical treatment, followed by adjuvant therapy with chemotherapy alone, radiation therapy alone, or a combination of chemoradiation. Patients were excluded for incomplete surgical staging data, adjuvant brachytherapy alone, adjuvant chemotherapy and brachytherapy without external beam radiation therapy, receipt of neoadjuvant chemotherapy and/or pre-operative pelvic radiation, and death due to non-cancer causes. Sites of recurrence were analyzed by adjuvant treatment modality using Pearson’s χ2 test. Progression-free and overall survival were calculated using Kaplan-Meier estimates. Multivariate analysis was performed using Cox proportional hazards model.

Results

Of 176 evaluable patients, 27% (n=47) had stage I, 14% (n=24) stage II, 37% (n=66) stage III, and 22% (n=39) stage IV disease. Among them, 33% (n=59) received chemotherapy alone, 17% (n=29) received radiation therapy alone, and 50% (n=88) received chemoradiation. Patients with stage I disease recurred less frequently (64%) versus stage II (83%), stage III (85%), and stage IV (90%) (p<0.001). Stage I disease demonstrated improved progression-free and overall survival relative to all other stages (p<0.01). Across all stages, patients receiving chemoradiation experienced superior progression-free (p=0.01) and overall survival (p=0.05) versus single modality therapy. However, when analyzed in a stage-specific manor, stage III disease derived the greatest survival benefit from chemoradiation versus all other stages (p<0.01). On multivariant analysis, only stage and receipt of chemoradiation were independent predictors of survival.

Conclusion

Stage I disease demonstrated improved survival compared with other stages regardless of adjuvant treatment modality. Chemoradiation was associated with improved survival and better distant and local disease control for all stages of disease. Patients with stage III disease derived the most benefit from chemoradiation.

Uterine carcinosarcoma: A 10-year single institution experience

Objective

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

Design

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

Methods

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

Results

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

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

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

Conclusions

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

Randomized Phase III Trial of Paclitaxel and Carboplatin Versus Paclitaxel and Ifosfamide in Patients With Carcinosarcoma of the Uterus or Ovary: An NRG Oncology Trial

PURPOSE

This phase III randomized trial (NCT00954174) tested the null hypothesis that paclitaxel and carboplatin (PC) is inferior to paclitaxel and ifosfamide (PI) for treating uterine carcinosarcoma (UCS).

PATIENTS AND METHODS

Adults with chemotherapy-naïve UCS or ovarian carcinosarcoma (OCS) were randomly assigned to PC or PI with 3-week cycles for 6-10 cycles. With 264 events in patients with UCS, the power for an overall survival (OS) hybrid noninferiority design was 80% for a null hazard ratio (HR) of 1.2 against a 13% greater death rate on PI with a type I error of 5% for a one-tailed test.

RESULTS

The study enrolled 536 patients with UCS and 101 patients with OCS, with 449 and 90 eligible, respectively. Primary analysis was on patients with UCS, distributed as follows: 40% stage I, 6% stage II, 31% stage III, 15% stage IV, and 8% recurrent. Among eligible patients with UCS, PC was assigned to 228 and PI to 221. PC was not inferior to PI. The median OS was 37 versus 29 months (HR = 0.87; 90% CI, 0.70 to 1.075; P < .01 for noninferiority, P > .1 for superiority). The median progression-free survival was 16 versus 12 months (HR = 0.73; P = < 0.01 for noninferiority, P < .01 for superiority). Toxicities were similar, except that more patients in the PC arm had hematologic toxicity and more patients in the PI arm had confusion and genitourinary hemorrhage. Among 90 eligible patients with OCS, those in the PC arm had longer OS (30 v 25 months) and progression-free survival (15 v 10 months) than those in the PI arm, but with limited precision, these differences were not statistically significant.

CONCLUSION

PC was not inferior to the active regimen PI and should be standard treatment for UCS.

Therapeutic Challenges in Patients with Gynecologic Carcinosarcomas: Analysis of a Multicenter National Cohort Study from the French Prospective TMRG Network

BACKGROUND

Gynecological carcinosarcomas are rare and aggressive diseases, with a poor prognosis. The rarity of these tumors explains the lack of robust and specific data available in the literature. The objective of this study was to investigate the impact of initial adjuvant treatment and recurrent therapeutic strategies.

PATIENTS AND METHODS

A multicentric cohort study within the French national prospective Rare Malignant Gynecological Tumors (TMRG) network was conducted. Data from all included carcinosarcomas diagnosed between 2011 and 2018 were retrospectively collected.

RESULTS

425 cases of uterine and ovarian carcinosarcomas (n = 313 and n = 112, respectively) were collected and analyzed from 12 participating centers. At diagnosis, 140 patients (48%) had a FIGO stage III-IV uterine carcinosarcoma (UCS) and 88 patients (83%) had an advanced ovarian carcinosarcoma (OCS) (FIGO stage ≥ III). Two hundred sixty-seven patients (63%) received adjuvant chemotherapy, most preferably carboplatin-paclitaxel regimen (n = 227, 86%). After a median follow-up of 47.4 months, the median progression-free survival (mPFS) was 15.1 months (95% CI 12.3-20.6) and 14.8 months (95% CI 13.1-17.1) for OCS and UCS, respectively. The median overall survival for OCS and UCS was 37.1 months (95% CI 22.2-49.2) and 30.6 months (95% CI 24.1-40.9), respectively. With adjuvant chemotherapy followed by radiotherapy, mPFS was 41.0 months (95% CI 17.0-NR) and 18.9 months (95% CI 14.0-45.6) for UCS stages I-II and stages III-IV, respectively. In the early stage UCS subgroup (i.e., stage IA, n = 86, 30%), mPFS for patients treated with adjuvant chemotherapy (n = 24) was not reached (95% CI 22.2-NR), while mPFS for untreated patients (n = 62) was 19.9 months (95% IC 13.9-72.9) (HR 0.44 (0.20-0.95) p = 0.03). At the first relapse, median PFS for all patients was 4.2 months (95% CI 3.5-5.3). In the first relapse, mPFS was 6.7 months (95% CI 5.1-8.5) and 2.2 months (95% CI 1.9-2.9) with a combination of chemotherapy or monotherapy, respectively (p < 0.001).

CONCLUSIONS

Interestingly, this vast prospective cohort of gynecological carcinosarcoma patients from the French national Rare Malignant Gynecological Tumors network (i) highlights the positive impact of adjuvant CT on survival in all localized stages (including FIGO IA uterine carcinosarcomas), (ii) confirms the importance of platinum-based combination as an option for relapse setting, and (iii) reports median PFS for various therapeutic strategies in the relapse setting.

Is minimally invasive surgery for clinical stage I uterine carcinosarcoma safe?

Minimally invasive surgery (MIS) has been a mainstay of the surgical management of uterine cancer since the mid-2000s. We aim to determine the role and safety of MIS in women with uterine carcinosarcoma (UCS). An Institutional Review Board-approved study identified all patients with UCS between January 2011 and December 2017 at our institution. Demographic and outcome measures were abstracted from the medical records and tumor registry. Cox proportional hazard models, log rank tests, and comparisons of means were used to calculate significance (p < 0.05). 129 women with UCS were identified during the study period. 62 cases (48%) were open procedures and 67 cases (52%) were MIS with the majority of the MIS group having robotic surgery. 55% of the patients had pathological stage 1 disease. Thirty-eight percent of UCS tumors were heterologous. 93% of patients received adjuvant therapy in the form of chemotherapy and/or radiation therapy. There was no difference in the recurrence-free survival (RFS) or overall survival (OS) between the open surgery and the MIS groups as well as between the heterologous and homologous UCS groups (p > 0.05). UCS represents a rare and aggressive subtype of endometrial cancer. Our data suggest that MIS is a safe surgical approach for staging in women with UCS.

Increased incidence with improved survival of gynecologic carcinosarcoma: A population-based study

OBJECTIVE

To evaluate trends in the incidence and survival of gynecologic carcinosarcoma over the last 35 years and to explore ethnic disparities.

STUDY DESIGN

Using the Israeli National Cancer Registry database, all cases of gynecologic carcinosarcoma were included (1980-2014). Age at diagnosis, patient's ethnicity and anatomical site were extracted. Age-standardized incidence rates (ASRs) were calculated for 3 time periods (1980-1994, 1995-2004 and 2005-2014). Relative survival was calculated using the Pohar-Perme method.

RESULTS

Overall, 935 cases of gynecologic carcinosarcomas were diagnosed during 1980-2014. The most common gynecologic anatomical site was the uterus (83.4%). Most cases (66%) were diagnosed at ages 60-80, with median age of 69 years. There was a steady increase in ASRs from 5.6 to 8.2 per million women. Throughout 1980-1994 and 2005-2014, ASRs were significantly higher in the Jewish compared to the Arab population (5.8 vs. 3.1, p = 0.02 and 8.5 vs. 5.2, p = 0.002, respectively). Relative survival rates increased throughout the study period. No significant differences were noted in relative survival between the Jewish and Arab populations (p = 0.18).

CONCLUSION

The incidence of gynecologic carcinosarcoma increased significantly from 1980 through 2014. Nevertheless, survival rates increased during this time, with no difference in survival between the Jewish and Arab populations.

Adjuvant radiotherapy improves overall survival when added to surgery and chemotherapy for uterine carcinosarcoma: a surveillance, epidemiology, and end results analysis

BACKGROUND

Uterine carcinosarcoma (UCS) confers a high recurrence risk following surgery, and adjuvant chemotherapy (CHT) is typically administered in all stages. The benefit of radiation therapy (RT) in UCS, when added to adjuvant CHT, is unknown. We sought to analyze the Surveillance, Epidemiology, and End Results (SEER) database to ascertain whether RT improves overall survival (OS) when added to surgery and CHT for UCS.

METHODS

SEER 18 Custom Data registries (Nov 2018 submission) were queried for uterine (ICD10 C54.1-9, C55.9) carcinosarcoma (ICD-0-3 8980-3). Patients with stage I-III UCS who underwent surgery and CHT ± RT were analyzed with univariate analysis (UVA) and multivariable analysis (MVA) using Kaplan-Meier and Cox proportional hazards regression modeling. Propensity-score matched analysis with inverse probability of treatment weighting (IPTW) was performed to account for indication bias. Furthermore, conditional landmark analysis (minimum three-month follow-up) was performed to minimize immortal time bias.

RESULTS

All 1541 patients (1988-2016) underwent surgery and CHT and 54% received RT. On UVA, RT improved median and 5-year OS from 41 to 87 months and 43-55%, respectively (HR 0.65, 95% CI 0.56-0.77) (p < 0.001). After IPTW adjustment, RT improved median and 5-year OS from 46 to 65 months and 46-53%, respectively (HR 0.74, 95% CI 0.63-0.87) (p < 0.001). The benefit of RT remained on unadjusted and adjusted MVA and conditional landmark analysis.

CONCLUSION

In stage I-III UCS treated with surgery and CHT, receipt of RT is associated with OS benefit. Further prospective data are needed to investigate the RT's benefit in UCS.

Detection of PIK3CA E545A mutation in circulating tumor DNA of a patient affected by uterine carcinosarcoma

Uterine carcinosarcomas are biphasic neoplasms consisting of mixed epithelial and mesenchymal elements, representing less than 5% of all uterine malignancies. Carcinosarcomas are rare, although the most common cause of uterine cancer-specific death. Few information is available on the pathogenesis, and molecular characterization is poorly investigated. Consequently, the treatment has not changed over the last years and is far too being tailored, consisting of surgery and traditional chemotherapy and radiotherapy. Molecular characterization of liquid biopsy by circulating tumor DNA (ctDNA)/circulating cell-free DNA (ccfDNA) evaluation in a patient with uterine carcinosarcoma. Here, we describe a case report of an 83-year-old woman with carcinosarcomas, stage T3aN0M0. Cancer cells did not express estrogen nor progesterone receptors, while p53 and p16 were positive. Molecular characterization of ccfDNA and of ctDNA was performed by quantitative PCR, amplification-refractory mutation system technology. The presence of phosphatidylInositol-4,5-bisphosphate 3-Kinase catalytic subunit alpha p.E545A mutation was detected in plasma. This approach may suggest the use of liquid biopsy and the development of specific targeted therapy for precision personalized medicine even in rare carcinosarcomas.

Carcinosarcomas of the Uterus: Prognostic Factors and Impact of Adjuvant Treatment

Background

Uncertainties remain about the most effective treatment for uterine carcinosarcoma (UCS), a rare but aggressive uterine cancer, due to the limited scope for randomized trials. This study investigates whether nodal excision or adjuvant therapies after hysterectomy offer a survival benefit, using multi-institutional clinical registry data from South Australia.

Methods

Data for all consecutive cases of UCS from 1980 to 2019 were extracted from the Clinical Cancer Registry. Clinical and treatment-related factors associated with disease-specific mortality (DSM) and all-cause mortality (ACM) were determined using multivariable Cox proportional hazards regression, with subgroup analyses by stage.

Results

Median follow-up for the 140 eligible cases was 21 months. 94% underwent hysterectomy, and 72% had an additional pelvic lymph node dissection (PLND). Furthermore, 16% received adjuvant chemotherapy; 11% adjuvant radiotherapy and 16% multimodal chemoradiotherapy, with an increase in the latter two modalities over time. DSM was reduced among those who underwent PLND (HR: 0.41; 95%CI: 0.23–0.74), adjuvant chemotherapy (HR: 0.39; 95%CI: 0.18–0.84) or multimodality treatment (HR: 0.11; 95%CI: 0.06–0.30) compared with hysterectomy alone for the whole cohort and for late stage disease (FIGO III/IV) but not for earlier stage disease, except for reduced DSM with multimodal therapy. Findings were similar for ACM.

Conclusion

Our findings indicate better survival among those who received PLND, chemotherapy and multimodal adjuvant therapy, with the latter applying to early and late stage disease. However, cautious interpretation is warranted, due to potential “indication bias” and limited power. Further research into effective treatment modalities, ideally using prospective study designs, is needed.

Uterine carcinosarcoma: An overview

Uterine carcinosarcoma (UCS), also known as malignant mixed Müllerian tumor, is a rare gynecological malignancy characterized by poor prognosis. This "biphasic" neoplasm presents an admixture of epithelial and mesenchymal/sarcomatoid tumor cells which partially share their molecular signature and exhibit a typical epithelial-to-mesenchymal transition gene expression profile. Due to the rarity of this cancer, at present there is a scarcity of specific treatment guidelines. Surgical resection remains the best curative option for localized disease, whereas the addition of peri-operative radiotherapy, chemotherapy and chemoradiation has been shown to further improve disease outcomes. In the metastatic setting, palliative chemotherapy is currently the treatment of choice, although no consensus exists about the best regimen to be delivered. Besides standard treatment options for the advanced disease, mechanistic insights into UCS pathogenesis and identification of its histopathological and molecular features boosted the development of novel, and potentially more effective, therapeutic agents, that will be here discussed.

Adjuvant therapy and prognosis in uterine carcinosarcoma

PURPOSE

To investigate the prognostic factors and impact of adjuvant treatment on uterine carcinosarcoma (UCS).

METHODS

A retrospective review of UCS patients treated between 2005 and 2019 was conducted. International Federation of Gynecology and Obstetrics (FIGO) 2009 staging system was used. Multivariate stepwise Cox proportional hazard regression models were used to identify the independent predictors of overall survival (OS) and progression-free survival (PFS).

RESULTS

A total of 138 patients were eligible for descriptive analysis. Excluding 12 patients without surgery, 126 patients with adequate clinicopathologic data were included for prognostic analysis. The median follow-up for survivors was 51.8 months. 5-year OS and PFS rates for FIGO stage I, II, III, IV were 64.5% and 51.8%, 60.8% and 57.7%, 47.7% and 45.9%, 5.1% and 4.1%, respectively. By multivariate analysis, six models each for PFS and OS were formulated including highly correlated variables alternatively. Adjuvant chemoradiation was consistently selected as an independent prognostic factor for OS (hazard ratio [HR] 0.10-0.22, all p < 0.001) and PFS (HR 0.12-0.23, all p < 0.001), while adjuvant chemotherapy (HR 0.33-0.41), age≥58 years (HR 1.80-1.91), stage III/IV (HR 3.36-13.34), and adnexal metastasis (HR 2.06-5.02) in three to four of the six models for OS. Stratified analyses revealed that adjuvant chemoradiation significantly improved outcome compared with adjuvant chemotherapy for stage IA patients with lymphovascular space invasion and stage IB-IV, lymph node metastasis, and adnexal metastasis.

CONCLUSION

Adjuvant chemoradiation was confirmed as an independent good prognostic factor, while older age, stage III/IV, and adnexal metastasis were associated with poor outcome in UCS.

The Effect of Adjuvant Pelvic Radiotherapy on Distant Metastasis for Uterine Carcinosarcoma

BACKGROUND

Uterine carcinosarcomas (UCS) are rare tumors that carry a poor prognosis and high recurrence rate. Standard treatment consists of surgical resection and chemotherapy, though the benefit of adjuvant radiotherapy (RT) has yet to be determined. This study assessed survival rates between patients with UCS who underwent surgical resection alone and patients who underwent combinations of surgery, chemotherapy, and RT.

MATERIALS AND METHODS

We conducted a retrospective review of all patients who underwent surgical resection for UCS between 1993 and 2011 at a single institution. We assessed 3-year disease-free survival, locoregional recurrence-free survival, distant metastases-free survival (DMFS), and overall survival rates and utilized Kaplan-Meier modeling to analyze differences between UCS treatment modalities.

RESULTS

Twenty-four patients underwent UCS surgical resection between 1993 and 2011. The mean age was 61 (range: 39 to 75 y). Of these patients, 100% (n=24) underwent surgical resection, 25% (n=6) underwent surgery and adjuvant chemotherapy, 29% (n=7) underwent surgery and adjuvant RT, and 33% (n=8) underwent surgery and adjuvant chemotherapy and RT. At 3 years median follow, there was no significant difference in overall survival between treatment modalities. The addition of radiation therapy conferred increased DMFS in patients undergoing surgery irrespective of adjuvant chemotherapy (44% vs. 83%, P=0.0211).In patients receiving adjuvant chemotherapy, the significant increase in DMFS persisted with the addition of RT (P=0.0310). Lymph node involvement (n=8) was associated with a lower locoregional recurrence-free survival (38% vs. 92%, P=0.0029).

CONCLUSIONS

RT may offer a potential benefit in reducing the rate of distant metastases, though there were no statistically significant improvements in survival metrics.

Adjuvant vaginal interventional radiotherapy in early-stage non-endometrioid carcinoma of corpus uteri: a systematic review

Purpose

This systematic review focused on rare histological types of corpus uteri malignancy, including uterine carcinosarcoma (UCS), uterine clear cell carcinoma (UCCC), and uterine papillary serous carcinoma (UPSC), and it is proposed to assist with clinical decision-making. Adjuvant treatment decisions must be made based on available evidences. We mainly investigated the role of vaginal interventional radiotherapy (VIRt) in UCS, UCCC, and UPSC managements.

Material and methods

A systematic research using PubMed and Cochrane library was conducted to identify full articles evaluating the efficacy of VIRt in early-stage UPSC, UCCC, and UCS. A search in ClinicalTrials.gov was performed in order to detect ongoing or recently completed trials as well as in PROSPERO for ongoing or recently completed systematic reviews. Survival outcomes and toxicity rates were obtained.

Results

All studies were retrospective. For UCS, the number of evaluated patients was 432. The 2- to 5-year average local control (LC) was 91% (range, 74.2-96%), disease-free survival (DFS) 88% (range, 82-94%), overall survival (OS) 79% (range, 53.8-84.3%), the average 5-year cancer-specific survival (CSS) was 70% (range, 70-94%), and G3-G4 toxicity was 0%. For UCCC, the number of investigated patients was 335 (UCCC – 124, mixed – 211), with an average 5-year LC of 100%, DFS of 83% (range, 82-90%), OS of 93% (range, 83-100%), and G3-G4 toxicity of 0%. For UPSC, the number of examined patients was 1,092 (UPSC – 866, mixed – 226). The average 5-year LC was 97% (range, 87.1-100%), DFS 84% (range, 74.7-95.6%), OS 93% (range, 71.9-100%), CSS 89% (range, 78.9-94%), and G3-G4 toxicity was 0%.

Conclusions

These data suggest that in adequately selected early-stage UPSC and UCCC patients, VIRt alone may be suitable in women who underwent surgical staging and received adjuvant chemotherapy. In early-stage UCS, a multidisciplinary therapeutic approach has to be planned, considering high-rate of pelvic and distant relapses.

HDAC Inhibition Induces Cell Cycle Arrest and Mesenchymal-Epithelial Transition in a Novel Pleural-Effusion Derived Uterine Carcinosarcoma Cell Line

Objective: Uterine carcinosarcoma (UCS) is a rare but highly aggressive malignancy with biphasic growth pattern. This morphology can be attributed to epithelial-mesenchymal transition (EMT) that often associates with tumor invasion and metastasis. Accordingly, we analyzed a novel patient-derived preclinical model to explore whether EMT is a potential target in UCS.

Methods: A novel UCS cell line (PF338) was established from the malignant pleural effusion of a 59-year-old patient at time of disease progression. Immunohistochemistry was performed in primary and metastatic tumor lesions. Oncogenic mutations were identified by next-generation sequencing. Viability assays and cell cycle analyses were used to test in vitro sensitivity to different standard and novel treatments. E-cadherin, β-catenin and pSMAD2 expressions were measured by immunoblot.

Results: Whereas immunohistochemistry of the metastatic tumor showed a predominantly sarcomatous vimentin positive tumor that has lost E-cadherin expression, PF338 cells demonstrated biphasic growth and carried mutations in KRAS, PIK3CA, PTEN and ARID1A. PF338 tumor cells were resistant to MEK- and TGF-β signaling-inhibition but sensitive to PIK3CA- and PARP-inhibition and first-line chemotherapeutics. Strikingly, histone deacetylase (HDAC) inhibition markedly reduced cell viability by inducing a dose-dependent G0/1 arrest and led to mesenchymal-epithelial transition as evidenced by morphological change and increased E-cadherin and β-catenin expression.

Conclusions: Our data suggest that HDAC inhibition is effective in a novel UCS cell line by interfering with both viability and differentiation. These findings emphasize the dynamic manner of EMT/MET and epigenetics and the importance of molecular profiling to pave the way for novel therapies in UCS.

Endometrial cancer: A society of gynecologic oncology evidence-based review and recommendations

INTRODUCTION

In 2014, the Society of Gynecologic Oncology's Clinical Practice Committee published a clinical update reviewing the treatment of women with endometrial cancer. At that time, there had been significant advances in the diagnosis, work-up, surgical management, and available treatment options allowing for more optimal care of affected women. Despite these advances, the incidence of endometrial cancer as well as the deaths attributable to the disease have continued to rise; from 1987 to 2014 there has been a 75% increase in cases and almost 300% increase in endometrial cancer deaths. Fortunately, since then, there has been progress in the treatment of patients with endometrial cancer with increased utilization of molecular pathology, greater understanding of genetic predisposition, enhanced methods for lymph node assessment, a broader understanding of the efficacy of radiation and chemotherapy, and a more efficient approach to survivorship and surveillance. The purpose of this document is to present a comprehensive review of this progress.

MANUSCRIPT DEVELOPMENT PROCESS

The authors reviewed the available evidence, contributed to the development of this manuscript, provided critical review of the guidelines, and finalized the manuscript recommendations. The review was also presented to and approved by the Society of Gynecologic Oncology (SGO) Clinical Practice Committee, SGO Publications Committee, and the SGO board members prior to submission for publication. The recommendations for this manuscript were developed by a panel of gynecologic oncologists who were members of the SGO Clinical Practice and Education Committees. Panelists reviewed and considered evidence from current uterine cancer literature. The terminology used in these guidelines was adopted from the ASCCP management guidelines [1] using a two-part rating system to grade the strength of recommendation and quality of evidence (Table 1). The rating for each recommendation is given in parentheses.

Stereotactic Body Radiation Therapy: A Versatile, Well-Tolerated, and Effective Treatment Option for Extracranial Metastases From Primary Ovarian and Uterine Cancer

Purpose

Single extracranial metastases from ovarian and uterine malignancies have historically been treated with surgery or conventional radiation. We report mature local control (LC), overall survival (OS), progression free survival (PFS), and toxicity for patients who completed 5-fraction stereotactic body radiation therapy (SBRT).

Methods

Patients with biopsy-proven, single extracranial metastases from primary ovarian and uterine malignancies treated with 5-fraction SBRT were included. Patients were stratified based on tumor volume (small < 50 cc or large ≥ 50 cc) and dose (low dose < 35 Gy or high ≥ 35 Gy). Kaplan–Meier method was used to estimate LC, OS, and PFS.

Results

Between July 2007 and July 2012, 20 patients underwent SBRT to a single extracranial metastasis. Primary site was divided evenly between ovarian and uterine (n = 10 each). Metastases involved the liver (30%), abdominal lymph nodes (25%), lung (20%), pelvic lymph nodes (10%), spine (10%), and extremity (5%). The median gross tumor volume (GTV) was 42.5 cc (range, 5–273 cc) and the median dose to the GTV was 35 Gy (range, 30–50 Gy). At a median follow-up of 56 months, the 5-year LC and OS estimates were 73 and 46%. When stratified by tumor volume, the 5-year LC and OS for small tumors were significantly better at 100% (p < 0.01) and 65% (p < 0.02). When stratified by dose, the 5-year LC was 87.5% with high dose and 53.6% with low dose (p = 0.035). The 5-year PFS for the entire cohort was 20%. Four patients with small metastases who had complete response remained disease free at study completion and were considered cured (median PFS > 10 years). Treatment was generally well tolerated, and only one patient experienced a late grade III musculoskeletal SBRT related toxicity.

Conclusions

SBRT is a versatile, well-tolerated, and effective treatment option for single extracranial metastases from ovarian and uterine primary tumors. 35 Gy in five fractions appears to be a practical minimum effective dose. Four patients with small metastases were disease free at the study completion and considered cured. However, patients with larger metastases (≥50 cc) may require higher SBRT dosing or alternative treatments.

The Role of Postoperative Radiotherapy for Carcinosarcoma of the Uterus

Simple Summary

The role of radiotherapy on carcinosarcoma, a rare malignant tumor, of the uterus is unclear. We reviewed data published from 2010 on the effects of radiotherapy on tumor control and survival in this patient group. Available data were mainly from cancer registries and suggested that radiotherapy, given either as vaginal brachytherapy (contact radiotherapy of the vagina) or external-beam radiotherapy or a combination of both, reduces the risk of recurrence and improves survival in patients with all stages of carcinosarcoma of the uterus without metastases in other organs.

Abstract

The role of postoperative radiotherapy delivered as external-beam radiotherapy (EBRT), vaginal brachytherapy (VBT) or a combination of both, in the management of carcinosarcoma of the uterus is not clearly defined, as only limited randomized trial data are available, indicating a reduction in locoregional recurrences after EBRT. We performed a structured review of data published from 2010. Although no relevant new data from prospective trials or meta-analyses were identified, 14 analyses of cancer registry data from the United States or Europe, focusing predominantly on the endpoint for overall survival, were identified, four of them using propensity-score matching to compare subgroups treated with vs. without radiotherapy. Although stage-by-stage data are rare, the registry analyses support the idea of a beneficial effect, especially of VBT, on overall survival in International Federation of Gynecology and Obstetrics (FIGO) stage IA patients (to a lesser extent in stage IB). For stages II to III, the data sets indicate the largest effects on overall survival for the combination of EBRT and VBT. In all stages, survival effects of radiotherapy apparently persist when given in addition to chemotherapy. Whereas some studies see the strongest survival effects in patients with positive lymph nodes, propensity-score matched data indicate an overall survival effect of radiotherapy (EBRT + VBT or VBT alone) in FIGO stages I to III regardless of lymph node surgery.

Management of stage II endometrial cancer and subsequent oncologic outcomes: a National Cancer Database study

Objective

The management of stage II endometrial cancer (EC) is challenging due to the wide variation in surgical practice and adjuvant treatment recommendations. We sought to describe the treatment patterns for patients with stage II EC and to evaluate the association between surgical management and adjuvant therapy on survival outcomes in a large cohort of patients with stage II EC.

Methods

Using data from the National Cancer Database, we identified 9,690 women with stage II EC. We used logistic regression to identify association of sociodemographic and tumor characteristics with surgery type and receipt of adjuvant therapy. We used Cox proportional hazards regression models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between adjuvant therapy, hysterectomy type, and overall survival.

Results

Almost 11% of the cohort underwent radical hysterectomy; however, there was no difference in survival between surgical types even when adjusted for adjuvant therapy (HR=0.94; 95% CI=0.82–1.07). Compared to no adjuvant treatment, radiation only (HR=0.66; 95% CI=0.61–0.73) and combination radiation and chemotherapy (HR=0.53; 95% CI=0.45–0.62) were associated with lower risk of death. There was no survival benefit of chemotherapy alone even when separated by histologic subtype (HR range, 0.55–1.46).

Conclusions

Women with stage II EC do not appear to benefit from routine radical hysterectomy though all patients appear to benefit from receipt of radiation therapy (RT), regardless of modality. Additionally, there may be an added survival benefit with the combination of computed tomography and RT in patients with non-endometrioid, high-risk histologies.

Four versus six chemotherapy cycles in endometrial carcinoma with a high risk of recurrence: a retrospective study

OBJECTIVE

This study compared the survival outcomes and the incidence of chemotherapy-related adverse events in endometrial cancer patients who received four and six cycles of adjuvant chemotherapy to examine the optimal number of adjuvant chemotherapy cycles.

METHODS

A total of 112 patients with endometrial cancer with a high risk of recurrence were retrospectively enrolled; 46 patients received four cycles and 66 received six cycles of adjuvant chemotherapy. Between-group differences of overall survival, disease-free survival, hematological and non-hematological toxicities were analyzed. Baseline patient's background differences were assessed with inverse probability of treatment weighting using propensity score.

RESULTS

Overall and disease-free survivals between the two groups were not significantly different. Paclitaxel + carboplatin, every 3-4 weeks was the most frequently used chemotherapy regimen in both groups. Patients in the six-cycle chemotherapy group developed neutropenia G4 or febrile neutropenia more frequently than those in the four-cycle group; odds ratio (95% confidence interval) is 4.07 (1.51-10.96). Peripheral sensory neuropathy was the most frequently observed non-hematological toxicity; the incidence of peripheral sensory neuropathy was not significantly different between four- and six-cycle chemotherapy group, P = 0.832. The result was same in the subgroup analysis in patients who received TC regimen, P = 0.455.

CONCLUSION

This study implies a possible benefit of fewer cycles of adjuvant chemotherapy in endometrial cancer patients with a high risk of recurrence because of the lower incidence of hematological toxicities without impairing survival outcomes.

Comparison of minimally invasive versus open surgery in the treatment of endometrial carcinosarcoma

OBJECTIVE

The aim of this study was to compare perioperative and oncologic outcomes between minimally invasive and open surgery in the treatment of endometrial carcinosarcoma.

METHODS

We retrospectively identified all patients with newly diagnosed endometrial carcinosarcoma who underwent primary surgery via any approach at our institution from January 2009 to January 2018. Patients with known bulky disease identified on preoperative imaging were excluded. The χ² and Mann-Whitney U tests were used to compare categorical and continuous variables, respectively. Kaplan-Meier curves were used to estimate survival, and compared using the log rank test.

RESULTS

We identified 147 eligible patients, of whom 37 (25%) underwent an open approach and 110 (75%) underwent minimally invasive surgery. Within the minimally invasive group, 92 (84%) of 110 patients underwent a robotic procedure and 14 (13%) underwent a laparoscopic procedure. Four minimally invasive cases (4%) were converted to open procedures. Median age, body mass index, operative time, stage, complication grade, and use of adjuvant treatment were clinically and statistically similar between groups. Median length of hospital stay in the open group was 4 days (range 3-21) compared with 1 day (range 0-6) in the minimally invasive group (p<0.001). The rates of any 30-day complication were 46% in the open and 8% in the minimally invasive group (p<0.001). The rates of grade 3 or higher complications were 5.4% and 1.8%, respectively (p=0.53). Median follow-up for the entire cohort was 30 months (range 0.4-121). Two-year progression-free survival rates were 52.8% (SE±8.4) in the open group and 58.5% (SE±5.1) in the minimally invasive group (p=0.7). Two-year disease-specific survival rates were 66.1% (SE±8.0) and 81.4% (SE±4.1), respectively (p=0.8).

CONCLUSIONS

In patients with clinical stage I endometrial carcinosarcoma, minimally invasive compared with open surgery was not associated with poor oncologic outcomes, but with a shorter length of hospital stay and a lower rate of overall complications.

Adjuvant Treatment Modalities, Prognostic Factors, and Outcome of the Uterine Carcinosarcoma

OBJECTIVE

To determine the impact of adjuvant therapy and other factors associated with the recurrence and survival of patients with uterine carcinosarcoma (UCS).

METHODS

A total of 102 patients who underwhent surgery for UCS from 1998 to 2017 were included in the analysis. Data were analyzed using Kaplan-Meier methods and Cox proportional hazards regression.

RESULTS

At 240 months, the actuarial recurrence rate was 34.3%. Distant recurrence was the most common recurrence pattern. Patients with higher CA 125 levels, sarcoma dominance, cervical involvement, advanced stage, no lymphadenectomy, and residual tumour had a significiantly higher risk of recurrence. Five-year disease-free survival (DFS) and overall survival (OS) were 67% and 77%, respectively. FIGO stage was found to be an independent prognostic factor for DFS and OS. Sarcoma dominance was independently associated with decreased OS.

CONCLUSION

Sarcoma dominance is associated with poor survival in UCS. Adjuvant treatment was not found to affect recurrence or survival. Given this finding, more effective postoperative strategies are needed.

The current clinical approach to newly diagnosed uterine cancer

INTRODUCTION

Uterine cancer is the most common gynecologic malignancy, although fortunately, 75% of women present with early-stage disease. A major area of controversy regarding the management of the disease concerns postoperative therapy for both women with early- and advanced-stage endometrial carcinoma. Here, we review landmark evidence that can help guide clinical decision-making in the treatment of women diagnosed with endometrial cancer.

AREAS COVERED

In this review, we present the latest data driving decisions for both surgical management and postoperative therapy for women with endometrial carcinoma. Areas discussed include surgical staging, with a specific discussion on the role of sentinel lymph node mapping, and postoperative therapy, ranging from the data supporting observation for women with early-stage, low-risk disease to combination therapy for women with advanced disease. Less common histologies, such as serous and clear cell carcinoma, as well as carcinosarcoma, will also be covered. Furthermore, a section of the paper is dedicated to the current state of fertility-sparing surgery.

EXPERT OPINION

We suggest several approaches for deciding on adjuvant therapy, based on stage and histology, after comprehensive surgical staging. The role that endometrial cancer molecular subtypes will play on postoperative therapy remains to be fully investigated.

Administration sequence for multi-agent oncolytic regimens

Purpose

The existence of a multitude of oncolytics regimens containing two or more agents (combination) outlines the need to define their most adequate sequence of administration. However, limited resources are currently available to specify a particular sequence, presenting challenges potentially impacting on patient safety, and Pharmacy & Infusion Nursing workflows.

Methods

A comprehensive literature search was performed leading to the compilation of a document containing drug administration sequencing instructions for our Nursing, Pharmacy, and Oncology providers to follow. Regimens prioritized in our literature review represented regimens selected as part of our approved Clinical Pathways, regimens inquiries from Pharmacy or Nursing, as well as less frequently used regimens. We stratified the regimens by tumor type and arranged them alphabetically by indication.

Results

A table was compiled containing all the supporting literature for the recommended drug administration sequences. If, in certain instances, no literature support was identified outlining rationale such as enhanced management of adverse effects, a specific institutional decision was made by our enterprise Medical Oncology Committee with recommendations from Pharmacy experts. The primary guiding principles for outlining our recommendations were the following: administration of vesicant agents first; administration of biologic agents first; administration of taxanes prior to platinum agents; and duration of infusion (shorter infusions prioritized).

Conclusion

This guideline is not exhaustive. The compilation provided here is intended to be utilized as guidance for oncolytics administration sequence. We will continue to review and incorporate treatment sequencing recommendations for additional regimens.

Executive summary of the American Radium Society® Appropriate Use Criteria for management of uterine carcinosarcoma

OBJECTIVE

Uterine carcinosarcomas (UCS) represent a rare but aggressive subset of endometrial cancers, comprising <5% of uterine malignancies. To date, limited prospective trials exist from which evidence-based management of this rare malignancy can be developed.

METHODS

The American Radium Society Appropriate Use Criteria presented in this manuscript are evidence-based guidelines developed by a multidisciplinary expert panel for management of women with UCS. An extensive analysis of current medical literature from peer-reviewed journals was performed. A well-established methodology (modified Delphi) was used to rate the appropriate use of imaging and treatment procedures for the management of UCS. These guidelines are intended for the use of all practitioners who desire information about the management of UCS.

RESULTS

The majority of patients with UCS will present with advanced extra uterine disease, with 10% presenting with metastatic disease. They have worse survival outcomes when compared to uterine high-grade endometrioid adenocarcinomas. The primary treatment for non-metastatic UCS is complete surgical staging with total hysterectomy, salpingo-oophorectomy and lymph node staging. Patients with UCS appear to benefit from adjuvant multimodality therapy to reduce the chance of tumor recurrence with the potential to improve overall survival.

CONCLUSION

Women diagnosed with uterine UCS should undergo complete surgical staging. Adjuvant multimodality therapies should be considered in the treatment of both early- and advanced stage patients. Long-term surveillance is indicated as many of these women may recur. Prospective clinical studies of women with UCS are necessary for optimal management.

Multimodality adjuvant therapy and survival outcomes in stage I–IV uterine carcinosarcoma

Objectives

Uterine carcinosarcoma is a rare, aggressive form of uterine cancer with a high recurrence rate and poor survival at all stages. We sought to evaluate the outcomes of patients treated with chemotherapy versus a combination of chemotherapy and radiation (chemoradiation) to determine survival.

Methods

A multicenter retrospective analysis of patients with stage I–IV carcinosarcoma was conducted from January 2000 to December 2017. Inclusion criteria were primary surgical management, defined as hysterectomy ± salpingo-oophorectomy, comprehensive surgical staging and/or tumor debulking, followed by adjuvant chemotherapy or chemoradiation. Differences in the frequencies of stage, cytoreduction status, treatment delays and sites of disease recurrence were identified using Pearson’s χ2 test. Progression-free and overall survival rates were calculated using Kaplan-Meier estimates.

Results

Final analysis included 148 patients; 40.5% (n=60) chemotherapy and 59.5% (n=88) chemoradiation. The mean age was 67 years (range 39–89). Stage distribution included 24.3% stage I, 12.2% stage II, 37.2% stage III, and 26.3% stage IV. There was no difference in the frequency of stage (p=0.81), cytoreduction status (p=0.61), treatment delays (p=0.57), or location of recurrence (p=0.97) between cohorts. The most frequent location of recurrence was the abdomen (50.0%). The median progression-free survival favored chemoradiation over chemotherapy (15 vs 11 months, respectively), as did the median overall survival (26 vs 20 months, respectively). Chemoradiation was associated with a statistically significant improvement in 2 year progression-free survival (22.5% vs 13.6%; p=0.006) and 2 year overall survival (50.0% vs 35.6%; p=0.018) compared with chemotherapy alone. On subanalysis of patients receiving chemoradiation, ‘sandwich sequencing’ (chemotherapy–radiation–chemotherapy) was associated with superior overall survival compared with alternate therapy sequences (chemotherapy–radiation and radiation–chemotherapy) (34 months vs 14 months and 14 months, respectively) (p=0.038).

Conclusions

Chemoradiation was associated with improvement in both progression-free and overall survival for all stages of carcinosarcoma compared with chemotherapy alone.

Should MMMT still be treated with adjuvant taxane-based combination chemotherapy?

BACKGROUND

Malignant mixed Mullerian tumors of endometrial (MMMT-E) and ovarian (MMMT-O) origin are associated with poor prognosis. Suggestively epithelial-driven tumors, their treatment has shifted from anthracycline or ifosfamide-based towards taxane-based chemotherapy. It remains unclear whether this change associates with better outcomes.

PATIENTS AND METHODS

A conjoined Australian and Swiss patient cohort of MMMT-E (N = 103) and MMMT-O (N = 17) was compared to patients with adenocarcinoma of the endometrium (EC, N = 172) and ovary (OC, N = 189). Clinicopathological characteristics, FIGO stage, first-line treatment, and patient outcomes were analyzed. The generated hypothesis was verified in an US-American cohort with high-grade serous ovarian cancer (HGSOC, N = 1290) and MMMT-O (N = 450) using immunohistochemistry and next-generation sequencing.

RESULTS

Early stage I/II MMMT-E showed a survival plateau after 2.5 years, with no recurrence or death observed afterwards. Relapse-free survival was significantly worse in MMMT-E treated with platinum/taxanes (P = 0.024) compared to non-taxane regimen. Hypothesizing that also MMMT-O might benefit from an adjuvant non-paclitaxel regimen, a second independent cohort of MMMT-O and HGSOC patients was examined. p53 mutations dominated in both cancers with comparable frequency. PI3KCA and KRAS mutations were less frequent: they were more frequent in MMMT-O than in HGSOC (P = 0.015 and P = 0.018, respectively). MMMT-O responded better to a combination of carboplatin with anthracyclines than with taxanes (73.9% vs. 39.4%).

CONCLUSION

Early stage I/II MMMT-E patients have excellent prognosis if no recurrence has appeared within the first 2.5 years. In MMMT-E, platinum/anthracycline or ifosfamide regimen associated with better outcomes than platinum/taxanes regimens. This might also apply to MMMT-O.

Treatment and Outcome of Patients with Uterine Carcinosarcoma in a Comprehensive Cancer Network

Aim

To determine clinical characteristics, treatment modalities and survival of uterine carcinosarcoma (UCS).

Methods

Data on treatment of UCS patients in the Comprehensive Cancer Network south region in the Netherlands between 2004 and 2014 were retrospectively evaluated.

Results

Data of 62 patients with UCS were retrieved. Mean age at diagnosis was 69.2 years (45–95 years). Data of six patients were excluded because they did not receive any treatment. Of the 56 patients included in this study, 57.1% presented with early-stage (FIGO I–II) disease and 42.9% with late-stage (FIGO III–IV) disease. 46.9% of the patients with FIGO early-stage disease received only surgical treatment, whereas 9.4% received adjuvant chemotherapy and 43.8% received adjuvant radiotherapy. Median DFS in patients with early-stage disease was 47.0 months (17.5–72.0). Adjuvant therapy did not seem to alter prognosis (p = 0.261). 16.7% of the patients with late-stage disease received only surgical treatment, 12.5% received only chemotherapy, whereas 50% received adjuvant chemotherapy and 20.8% adjuvant radiotherapy after surgery. Median DFS in late-stage disease was 8.5 months (2.5–23.5). Adjuvant therapy did not seem to alter prognosis (p = 0.30).

Conclusion

UCS with both FIGO stages I–II and III–IV has a dismal prognosis. The addition of adjuvant treatment did not seem to increase survival.

Racial disparities in uterine and ovarian carcinosarcoma: A population-based analysis of treatment and survival

OBJECTIVE

To investigate racial disparities in uterine carcinosarcoma (UCS) and ovarian carcinosarcoma (OCS) in Commission on Cancer®-accredited facilities.

METHODS

Non-Hispanic Black (NHB) and non-Hispanic White (NHW) women in the National Cancer Database diagnosed with stage I-IV UCS or OCS between 2004 and 2014 were eligible. Differences by disease site or race were compared using Chi-square test and multivariate Cox analysis.

RESULTS

There were 2830 NHBs and 7366 NHWs with UCS, and 280 NHBs and 2586 NHWs with OCS. Diagnosis of UCS was more common in NHBs (11.5%) vs. NHWs (3.7%) and increased with age (P < .0001). OCS diagnosis remained <5% in both races and all ages. NHBs with UCS or OCS were more common in the South and more likely to have a comorbidity score ≥ 1, low neighborhood income and Medicaid or no insurance (P < .0001). Diagnosis at stage II-IV was more common in NHBs than NHWs with UCS but not OCS. NHBs with both UCS and OCS were less likely to undergo surgery and to achieve no gross residual disease with surgery (P = .002). Risk of death in NHB vs. NHW patients with UCS was 1.38 after adjustment for demographic factors and dropped after sequential adjustment for comorbidity score, neighborhood income, insurance status, stage and treatment by 4%, 16%, 7%, 19% and 10%, respectively, leaving 43.5% of the racial disparity in survival unexplained. In contrast, risk of death in NHBs vs. NHWs with OCS was 1.19 after adjustment for demographic factors and became insignificant after adjustment for comorbidity. Race was an independent prognostic factor in UCS but not in OCS.

CONCLUSIONS

Racial disparities exist in characteristics, treatment and survival in UCS and OCS with distinctions that merit additional research.

Adjuvant chemotherapy in endometrial cancer

The role of adjuvant chemotherapy (CT) is controversial in endometrial carcinoma (EC). Surgery alone is usually curative for women who are at a low risk of disease recurrence. The treatment of EC following surgical staging is based on the risk of relapse, which is defined by the cancer stage at diagnosis, histology of the tumor and other prognostic factors such as grade differentiation, the presence of substantial lymphovascular invasion (LVSI), or depth of myometrial invasion (MI). External beam radiotherapy (EBRT) and/or vaginal brachytherapy (VBT) improved local control and are used as adjuvant treatment for early-stage disease. The role of adjuvant CT is controversial in early-stage EC, and there is no uniform approach to the treatment of women with stage III EC or early-staged non-endometrioid EC. Available evidence did not support the indication of adjuvant CT in stage I-II endometroid EC. In those cases at higher risk of relapse, defined as grade 3 tumors with substantial (no focal) LVSI, specifically with deep MI or cervical involvement, could be considered. Adjuvant CT should be administered to stage III EC patients. When RT is indicated (extensive lymph node involvement or deep MI), sequential treatment with RT or "sandwich" regimen may be considered rather than concurrent CRT. The patients with stage IA MI or IB USC may be offered adjuvant CT alone or in combination with VBT, whereas in stage II uterine serous carcinoma patients adding EBRT may be reasonable. Management approach for patients with stage IA without MI USC who underwent a comprehensive surgery remains controversial, and surveillance alone or CT plus VBT is an appropriate option. Early-stage clear-cell carcinoma patients might not benefit for adjuvant CT, but stage III patients might benefit from the combination of CT and EBRT. Stage I-III uterine carcinosarcoma patients might be offered adjuvant CT followed by RT or as a "sandwich" régimen.

A multi-institutional analysis of sequential versus 'sandwich' adjuvant chemotherapy and radiotherapy for stage IIIC endometrial carcinoma

Objective

To analyze the outcomes of sequential or sandwich chemotherapy (ChT) and radiotherapy (RT) in patients with node-positive endometrial cancer (EC).

Methods

Data from 4 centers were collected retrospectively for 179 patients with stage IIIC EC treated with postoperative RT and ChT (paclitaxel and carboplatin). Patients were either treated with 6 cycles of ChT followed by RT (sequential arm; 96 patients) or with 3 cycles of ChT, RT, and an additional 3 cycles of ChT (sandwich arm; 83 patients). Prognostic factors affecting overall survival (OS) and progression-free survival (PFS) were analyzed.

Results

The 5-year OS and PFS rates were 64% and 59%, respectively, with a median follow-up of 41 months (range, 5–167 months). The 5-year OS rates were significantly higher in the sandwich than sequential arms (74% vs. 56%; p=0.03) and the difference for 5-year PFS rates was nearly significant (65% vs. 54%; p=0.05). In univariate analysis, treatment strategy, age, International Federation of Gynecology and Obstetrics (FIGO) stage, pathology, rate of myometrial invasion, and grade were prognostic factors for OS and PFS. In multivariate analysis, non-endometrioid histology, advanced FIGO stage, and adjuvant sequential ChT and RT were negative predictors for OS, whereas only non-endometrioid histology was a prognostic factor for PFS.

Conclusion

Postoperative adjuvant ChT and RT for stage IIIC EC patients, either given sequentially or sandwiched, offers excellent clinical efficacy and acceptably low toxicity. Our data support the superiority of the sandwich regimen compared to the sequential strategy in stage IIIC EC patients for OS.

Hypofractionated Accelerated Chemo-radiotherapy (Chemo-HypoAR) With Cisplatin and Liposomal Doxorubicin for the Treatment of Patients With Uterine Sarcomas

BACKGROUND/AIM

Uterine sarcoma is an aggressive tumor associated with poor survival, compared to endometrioid carcinoma. Postoperative local radiotherapy and chemotherapy are controversial.

PATIENTS AND METHODS

We report a retrospective analysis of 14 patients with uterine homologous type carcinosarcoma (9 patients) or leiomyosarcoma (5 patients), treated with postoperative 3D-conformal accelerated hypofractionated radiotherapy (2.7 Gy/fraction for 14 fractions followed by one fraction of 6-8 Gy dose to the vagina). Chemotherapy with cisplatin (50 mg/m2) and liposomal doxorubicin (20 mg/m2), was also administered bi-weekly for two cycles before and for three cycles during radiotherapy.

RESULTS

Chemotherapy induced only grade 1 neutropenia or anemia in 4/14 (28.5%) and 5/14 (35.7%) of patients, respectively. Two patients (2/14, 14.2%) interrupted their radiotherapy for one and two weeks, respectively, due to grade II persistent diarrhea. Within a median of 58 months (range=8-137 months) of follow-up, none of the patients presented with loco-regional relapse. Two patients developed distant metastasis.

CONCLUSION

Concurrent hypofractionated and accelerated chemo-radiotherapy (chemo-HypoAR) is feasible and provides excellent survival figures.

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.

Patterns of Failures and Clinical Outcome of Patients with Early-Stage, High-Risk, Node-Negative Endometrial Cancer Treated with Surgery Followed by Adjuvant Platinum-Based Chemotherapy and Vaginal Brachytherapy

OBJECTIVE

To assess the clinical outcome of patients with high-risk early-stage endometrial cancer and negative pelvic nodes who received adjuvant platinum-based chemotherapy plus vaginal brachytherapy (VBT).

METHODS

This investigation assessed 80 patients who underwent hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy for stage Ib-II, grade 2-3 endometrioid (n = 43) or stage Ia-II nonendometrioid (n = 37) endometrial cancer.

RESULTS

Five-year local control rate, 5-year disease-free survival, and 5-year overall survival were 97, 87, and 97%, respectively, for endometrioid carcinoma, and 66, 50, and 72%, respectively, for nonendometrioid carcinoma.

CONCLUSIONS

This retrospective study appears to show that adjuvant platinum-based chemotherapy plus VBT achieve very good results in endometrioid carcinoma. This combined treatment seems to be less effective in nonendometrioid carcinoma.

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

Background:

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

Aims:

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

Study Design:

Cross-sectional study.

Methods:

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

Results:

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

Conclusion:

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

Primary leiomyosarcoma of the fallopian tube: Three case reports and review of the literature

OBJECTIVE

Leiomyosarcoma of the fallopian tube is a rare malignant gynecologic neoplasm with poor prognosis. It is important to share experience and to collect more cases to improve the understanding of the disease.

CASE REPORT

We reported three patients with leiomyosarcoma of the fallopian tube who were treated in Fudan University Shanghai Cancer Center (Shanghai, China) from 2012 to 2016. Although the three cases shared the same diagnosis, they varied in the presentations, treatments, and outcomes.

CONCLUSION

Leiomyosarcoma of the fallopian tube seems to have some particularities in imaging manifestations and immunohistochemical results. It has a progressive course with limited therapeutic options such as surgery, chemotherapy or radiotherapy.

Uterine Carcinosarcomas - Diagnosis and Management

Uterine carcinosarcomas are rare tumors that account for less than 5% of all uterine malignancies. These tumors (previously called malignant mixed Müllerian tumors) are dedifferentiated carcinomas that comprise carcinomatous and sarcomatous elements and arise from a single malignant clone. They are considered a high-risk variant of endometrial adenocarcinoma because carcinosarcomas share more similarities in epidemiology, risk factors, and clinical behavior with endometrial carcinoma than with uterine sarcomas. The clinical features, diagnosis, staging, and treatment of uterine carcinosarcoma will be discussed in this review.