The value of perioperative imaging in patients with uterine sarcomas

High grade undifferentiated uterine sarcoma: surgery, treatment, and survival outcomes

OBJECTIVES

High grade undifferentiated uterine sarcomas (HGUS) are rare, aggressive malignancies. Data regarding management are limited. We aimed to describe disease stage, response to treatment, and survival outcomes among patients with HGUS at our institution.

METHODS

We identified all patients with HGUS who received treatment at our institution from 1/2000 to 3/2011. Demographics, surgical procedures, disease stage, treatment response, and survival outcomes were abstracted from the medical records.

RESULTS

Twenty-one patients were identified. FIGO 2008 stage distribution was: I-7 (33%), II-1 (5%), III-2 (10%), IV-11 (52%). Eighteen of 21 patients (86%) undergoing primary surgical resection achieved a complete gross resection; however, progression within the abdominal cavity was identified in 11 patients (61%) by the time they underwent postoperative imaging. Of 13 patients who received first-line chemotherapy for measurable disease, the overall response rate was 62%. Responses were observed in patients treated with gemcitabine/docetaxel (6 of 8) and doxorubicin-based regimens (2 of 5). Progression-free and overall survivals for the entire cohort were 7.3 months and 11.8 months, respectively. In 14 patients with measurable disease at the time of treatment, 1-year survival was 35.7% versus 80% in 5 patients without measurable disease at time of treatment (P=0.112). Nine patients received second- or additional chemotherapy for progressive disease, with response rate of 19%. Time to progression was short among responders.

CONCLUSIONS

HGUS represents a distinct histologic subtype of uterine sarcoma with poor outcomes regardless of stage at diagnosis. A majority rapidly develops distant metastases despite surgical resection. Gemcitabine-docetaxel and doxorubicin-based treatment achieved objective, but short-lived, responses in patients with measurable disease.

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.

Can MRI predict the diagnosis of endometrial carcinosarcoma?

AIM

To ascertain whether magnetic resonance imaging (MRI) can be used to suggest a diagnosis of endometrial carcinosarcoma.

MATERIALS AND METHODS

A retrospective imaging review was performed of the MRI images of 39 patients with endometrial carcinosarcoma. Anteroposterior and longitudinal dimensions of the uterus and measurement of the endometrial thickness were taken in the sagittal plane. The ratio of antero-posterior measurement to endometrial thickness was calculated. The same measurements were taken on 50 patients with endometrial adenocarcinoma. A two-tailed t-test and receiver operator characteristic analysis were performed on these measurements for both patient groups.

RESULTS

There was a statistically significant difference between the longitudinal (p=0.0084) and anteroposterior (p=0.00036) dimensions of the uterus of the two groups. There was also a statistically significant difference between the ratios of anteroposterior dimension to endometrial thickness (p=0.00018). The optimal cut-off ratio above which the radiologist should be alerted to a potential diagnosis of endometrial carcinosarcoma was shown to be 0.63.

CONCLUSION

MRI can be helpful in suggesting a diagnosis of endometrial carcinosarcoma with the help of some simple measurements.

Present and future of PET and PET/CT in gynaecologic malignancies

OBJECTIVES

To review the published data in literature on patients affected by gynaecological malignancies to establish the role of (18)F-FDG positron emission tomography (PET) and PET/CT in comparison to conventional imaging (CI).

MATERIALS AND METHODS

All papers specifically addressed to the role of (18)F-FDG PET and PET/CT in gynaecological malignancies published on PubMed/Medline, in abstracts from the principal international congresses, in the guidelines from national Societies that had appeared in literature until November 2009 were considered for the purpose of the present study.

RESULTS AND CONCLUSIONS

The use of (18)F-FDG PET, and even more of (18)F-FDG PET/CT, is increasing in the follow up of patients with gynaecologic malignancies and suspected recurrent disease: there is evidence in the literature that (18)F-FDG PET/CT has a higher sensitivity than CI in depicting occult metastatic spread. An interesting issue is represented by patients with ovarian cancer with an increase of the specific biomarker, CA-125, and negative/inconclusive findings at CI. The use of (18)F-FDG PET in differential diagnosis and staging is more controversial, but there is some evidence that a baseline PET examination performed before commencing therapy, for staging purpose, is also useful to evaluate the response to chemoradiation treatment. In several papers it has been suggested a relevant role of (18)F-FDG PET/CT in evaluating the entity of response to treatment and therefore to plan the subsequent therapeutic strategy.