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Shi Q, Wang L, Yao J. Unexpected rare uterine carcinosarcoma with neuroendocrine differentiation: Reflections on clinical diagnosis and treatment of a case report. Medicine (Baltimore) 2024; 103:e38800. [PMID: 38996113 PMCID: PMC11245266 DOI: 10.1097/md.0000000000038800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/12/2024] [Indexed: 07/14/2024] Open
Abstract
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.
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Affiliation(s)
- Qichong Shi
- Department of General Surgery, The Fifth People’s Hospital of Huaian, Yangzhou University Huaian, Jiangsu, China
| | - Longmei Wang
- Department of Pathology, The Fifth People’s Hospital of Huaian, Yangzhou University Huaian, Jiangsu, China
| | - Juan Yao
- Department of Pathology, The Fifth People’s Hospital of Huaian, Yangzhou University Huaian, Jiangsu, China
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Aroche Gutierrez LL, McIntire DD, Lea J, LoCoco S, Miller DS. Social determinants of health in uterine carcinosarcoma. Gynecol Oncol 2024; 184:117-122. [PMID: 38309028 DOI: 10.1016/j.ygyno.2024.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/26/2024] [Accepted: 01/28/2024] [Indexed: 02/05/2024]
Abstract
OBJECTIVE UCS survival outcome disparities by race have been reported. We aimed to investigate social determinants of health (SDOH) and their relation to survival outcomes in women at two affiliated high-volume institutions serving a racially and economically diverse population. METHODS Women diagnosed with stage I-IV UCS treated at St. Paul University Hospital, University of Texas Southwestern (UTSW) Zale Lipshy Pavilion-William P. Clements Jr. University Hospital, and Parkland Memorial Hospital between 1992 and 2022 were eligible. Patients were identified by the local tumor registries; a retrospective study was conducted. The Pearson chi-square test was utilized for categorical variables. OS and PFS were calculated using Kaplan-Meier estimates and compared with the log-rank test. Multivariate Cox models were used to identify independent prognostic factors. All statistical analyses were performed using SAS, version 9.4. RESULTS Over half of the 218 patients with UCS were NHB. 35% of the patients had stage IV disease. Most HSP and NHB patients had a lower median household income* than Asian/Pacific Islander (API) or NHW (p < 0.001). Stage at diagnosis significantly affected OS (p < 0.001) but not PFS (p = 0.46) in univariate analyses. Accounting for age at diagnosis, insurance, income*, hospital, distance between hospital and home, months from diagnosis to first treatment, stage, and adjuvant therapy, race was significant for OS (p = 0.03) and PFS (p = 0.04). *Median household income by ZIP Code. CONCLUSIONS Racial disparities were seen in median household income. Most SDOH independently analyzed in this study did not affect OS. The complex interaction between race and stage in UCS survival outcomes needs further investigation.
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Affiliation(s)
- Larissa L Aroche Gutierrez
- Department of Obstetrics & Gynecology, Division of General Obstetrics & Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Donald D McIntire
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Jayanthi Lea
- Department of Obstetrics & Gynecology, Division of Gynecologic Oncology, and Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Salvatore LoCoco
- Department of Obstetrics & Gynecology, Division of Gynecologic Oncology, and Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - David Scott Miller
- Department of Obstetrics & Gynecology, Division of Gynecologic Oncology, and Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, United States of America.
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Evaluation of chemotherapy and radiotherapy in the adjuvant management of uterine carcinosarcoma: a population-based analysis. Arch Gynecol Obstet 2023; 307:891-901. [PMID: 35708782 DOI: 10.1007/s00404-022-06589-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 03/20/2022] [Indexed: 11/02/2022]
Abstract
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.
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Bogani G, Ray-Coquard I, Concin N, Ngoi NYL, Morice P, Caruso G, Enomoto T, Takehara K, Denys H, Lorusso D, Coleman R, Vaughan MM, Takano M, Provencher DM, Sagae S, Wimberger P, Póka R, Segev Y, Kim SI, Kim JW, Candido Dos Reis FJ, Ramirez PT, Mariani A, Leitao M, Makker V, Abu-Rustum NR, Vergote I, Zannoni G, Tan D, McCormack M, Paolini B, Bini M, Raspagliesi F, Benedetti Panici P, Di Donato V, Muzii L, Colombo N, Pignata S, Scambia G, Monk BJ. Endometrial carcinosarcoma. Int J Gynecol Cancer 2023; 33:147-174. [PMID: 36585027 DOI: 10.1136/ijgc-2022-004073] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Giorgio Bogani
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | - Nicole Concin
- Department of Gynecology and Obstetrics; Innsbruck Medical Univeristy, Innsbruck, Austria
| | | | - Philippe Morice
- Department of Surgery, Institut Gustave RoussT, Villejuif, France
| | - Giuseppe Caruso
- Department of Maternal and Child Health and Urological Sciences, Policlinico Umberto I, Rome, Italy
| | - Takayuki Enomoto
- Department of Obstetrics and Gynecology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Belgium
| | - Kazuhiro Takehara
- Department of Gynecologic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan
| | - Hannelore Denys
- Department of Medical Oncology, University Hospital Ghent, Gent, Belgium
| | | | - Robert Coleman
- Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michelle M Vaughan
- Department of Medical Oncology, Canterbury Regional Cancer and Haematology Service, Christchurch, New Zealand
| | - Masashi Takano
- Department of Obstetrics and Gynecology, National Defense Medical College, Tokorozawa, Medical, Japan
| | | | | | - Pauline Wimberger
- Department of Gynecology and Obstetrics, Technische Universitat Dresden Medizinische Fakultat Carl Gustav Carus, Dresden, Germany
| | | | - Yakir Segev
- Department of Obstetrics and Gynecology, Carmel Hospital, Haifa, Israel
| | - Se Ik Kim
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea
| | - Jae-Weon Kim
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea
| | | | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Andrea Mariani
- Department of Gynecologic Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Mario Leitao
- Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Vicky Makker
- Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Nadeem R Abu-Rustum
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Ignace Vergote
- Department of Gynecology and Obstetrics, Gynecologic Oncology, Leuven Cancer Institute, Catholic University Leuven, Leuven, Belgium
| | - Gianfranco Zannoni
- Dipartimento Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - David Tan
- National University Cancer Institute, Singapore
| | - Mary McCormack
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Biagio Paolini
- Istituto Nazionale per lo Studio e la Cura dei Tumori, Milano, Italy
| | - Marta Bini
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Lombardia, Italy
| | | | | | - Violante Di Donato
- Department of Obstetrics and Gynecology, University Sapienza of Roma, Rome, Italy
| | - Ludovico Muzii
- Department of Maternal, Infantile, and Urological Sciences, Umberto I Hospital, Sapienza University of Rome, Roma, Italy
| | - Nicoletta Colombo
- Medical Gynecologic Oncology Unit; University of Milan Bicocca; Milan; Italy, European Institute of Oncology, Milano, Italy
| | - Sandro Pignata
- Department of Gynaecological Oncology, National Cancer Institute Napels, Naples, Italy
| | - Giovanni Scambia
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Bradley J Monk
- HonorHealth, University of Arizona, Creighton University, Phoenix, Arizona, USA
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Terblanche L, Botha MH. Uterine carcinosarcoma: A 10-year single institution experience. PLoS One 2022; 17:e0271526. [PMID: 35862371 PMCID: PMC9302809 DOI: 10.1371/journal.pone.0271526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 06/29/2022] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Leana Terblanche
- Department of Obstetrics and Gynaecology and Unit for Gynaecological Oncology, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
- * E-mail:
| | - Matthys H. Botha
- Department of Obstetrics and Gynaecology and Unit for Gynaecological Oncology, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
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van der Horst RL, van der Hel O, Lutgens L, van der Aa M, Slangen B, Kruitwagen R, Lalisang RI. The role of multimodal adjuvant therapy for FIGO I-II carcinosarcoma of the uterus: a systematic review. Crit Rev Oncol Hematol 2022; 175:103701. [PMID: 35533817 DOI: 10.1016/j.critrevonc.2022.103701] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/07/2022] [Accepted: 05/02/2022] [Indexed: 11/26/2022] Open
Abstract
The uterine carcinosarcoma (UCS) is a rare entity with poor prognosis. Treatment of FIGO I-II UCS usually consists of surgery with or without adjuvant treatment. Due to the high metastatic potential, aggressive combined modality adjuvant treatment approaches, consisting of chemo- and radiotherapy, have been of interest. Our systematic review aims to compare survival, disease control and toxicity profiles in patients receiving adjuvant chemoradiation to other adjuvant strategies (e.g.observation, chemotherapy or radiotherapy). A total of ten studies were included for a combined cohort size of 6,520 patients. Generally, the studies showed a trend towards improved disease control and survival in patients undergoing adjuvant multimodal treatment, although statistical significance was often not reached. Selection bias and non-randomized treatment allocation pose serious challenges to extrapolate these outcomes to clinical practice. We recommend additional prospective research on the role of adjuvant chemoradiation in FIGO I-II UCS.
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Affiliation(s)
- R L van der Horst
- Division Medical Oncology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht the Netherlands; GROW-School for Oncology and Reproduction, Maastricht University, the Netherlands; Maastricht UMC+ Comprehensive Cancer Center, Maastricht, the Netherlands
| | - O van der Hel
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | - L Lutgens
- GROW-School for Oncology and Reproduction, Maastricht University, the Netherlands; Department of Radiation Oncology, MAASTRO Clinic, Maastricht, the Netherlands; Maastricht UMC+ Comprehensive Cancer Center, Maastricht, the Netherlands
| | - M van der Aa
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | - B Slangen
- GROW-School for Oncology and Reproduction, Maastricht University, the Netherlands; Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, the Netherlands; Maastricht UMC+ Comprehensive Cancer Center, Maastricht, the Netherlands
| | - R Kruitwagen
- GROW-School for Oncology and Reproduction, Maastricht University, the Netherlands; Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, the Netherlands; Maastricht UMC+ Comprehensive Cancer Center, Maastricht, the Netherlands
| | - R I Lalisang
- Division Medical Oncology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht the Netherlands; GROW-School for Oncology and Reproduction, Maastricht University, the Netherlands; Maastricht UMC+ Comprehensive Cancer Center, Maastricht, the Netherlands
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Cory L, Brensinger C, Burger RA, Giuntoli RL, Morgan MA, Latif N, Lin LL, Ko EM. Patterns of adjuvant treatment and survival outcomes in stage I uterine carcinosarcoma. Gynecol Oncol Rep 2022; 39:100930. [PMID: 35111895 PMCID: PMC8790468 DOI: 10.1016/j.gore.2022.100930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 12/03/2022] Open
Abstract
5-year survival for stage I uterine carcinosarcoma without adjuvant therapy is 43%. Nationally 40% of stage I uterine carcinosarcoma do not receive adjuvant therapy. Adjuvant chemotherapy alone improved OS and CSS in stage I uterine carcinosarcoma.
Objective To determine patterns in type and sequence of adjuvant treatment and associated differences in overall survival among women with Stage I uterine carcinosarcoma (UCS). Methods Women with stage I UCS from 2000 to 2015 were identified through the National Cancer Institute’s Surveillance, Epidemiology and End Results database linked to Medicare-based claims follow-up data through 2016. Data including demographics, co-morbidities, surgical procedure, surgical pathology and type and sequence of adjuvant treatment were collected. The primary study outcome was overall survival (OS) by type and sequence of adjuvant therapy. Cancer specific survival was also analyzed. Results A total of 755 women with Stage I UCS were identified. Of these, 56.3% (n = 445) received adjuvant therapy, whereas 43.7% (n = 330) did not. In comparison to no adjuvant treatment, an overall survival benefit was noted with receipt of chemotherapy alone for women with Stage I disease (log rank p < 0.01). Pairwise comparisons did not show a benefit in OS of concurrent RT-chemo, sequential RT-chemo, or sequential chemo-RT, over chemotherapy alone (p > 0.05 for all). Likewise, radiation alone and no treatment were associated with worse OS compared to chemotherapy alone (p < 0.001 for both). Adjusted Cox regression models demonstrated an OS benefit only in the chemotherapy alone cohort for Stage I disease (HR 0.43 95% CI 0.32, 0.60, p < 0.0001), as well as for CSS (HR 0.41, 95 %CI 0.26, 0.62, p < 0.0001), compared to no treatment. Conclusions In comparison to no adjuvant therapy, an overall survival and cancer-specific survival benefit was noted with receipt of chemotherapy alone in Stage I UCS.
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Affiliation(s)
- Lori Cory
- University of Pennsylvania Health System, Division of Gynecologic Oncology, Philadelphia, PA 19104, United States
- Corresponding author at: 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Colleen Brensinger
- University of Pennsylvania, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Robert A. Burger
- University of Pennsylvania Health System, Division of Gynecologic Oncology, Philadelphia, PA 19104, United States
| | - Robert L. Giuntoli
- University of Pennsylvania Health System, Division of Gynecologic Oncology, Philadelphia, PA 19104, United States
| | - Mark A. Morgan
- University of Pennsylvania Health System, Division of Gynecologic Oncology, Philadelphia, PA 19104, United States
| | - Nawar Latif
- University of Pennsylvania Health System, Division of Gynecologic Oncology, Philadelphia, PA 19104, United States
- University of Pennsylvania, Leonard Davis Institute of Health Economics, United States
| | - Lilie L. Lin
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology. Houston, TX 77030, United States
| | - Emily M. Ko
- University of Pennsylvania Health System, Division of Gynecologic Oncology, Philadelphia, PA 19104, United States
- University of Pennsylvania, Penn Center for Cancer Care Innovation, Abramson Cancer Center, United States
- University of Pennsylvania, Leonard Davis Institute of Health Economics, United States
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8
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Yahya JB, Zhu S, Burmeister C, Hijaz MY, Elshaikh MA. Matched-pair Analysis for Survival Endpoints Between Women With Early-stage Uterine Carcinosarcoma and Uterine Serous Carcinoma. Am J Clin Oncol 2021; 44:463-468. [PMID: 34265785 DOI: 10.1097/coc.0000000000000851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to compare survival endpoints between women with uterine carcinosarcoma and those with uterine serous carcinoma utilizing matching analysis. METHODS Patients with stages I to II who underwent hysterectomy at our institution were included in this analysis. Patients with carcinosarcoma were then matched to patients with serous carcinoma based on stage, and adjuvant management received (observation, radiation treatment alone, chemotherapy alone, or combined modality with radiotherapy and chemotherapy. Recurrence-free survival, disease-specific survival, and overall survival were calculated for the 2 groups. RESULTS A total of 134 women were included (67 women with carcinosarcoma and 67 with serous carcinoma, matched 1:1). There was no statistically significant difference between the 2 groups regarding 5-year recurrence-free survival (59% vs. 62%), disease-specific survival (66% vs. 67%), or overall survival (53% vs. 57%), respectively. The only independent predictor of shorter recurrence-free survival for the entire cohort was the lack of adjuvant combined modality therapy, while lower uterine segment involvement was the only independent predictor for shorter disease-specific survival. Lack of lymph node dissection and lack of adjuvant combined modality therapy were independent predictors of shorter overall survival. DISCUSSION When matched based on stage and adjuvant treatment, our study suggests that there is no statistically significant difference in survival endpoints between women with early-stage carcinosarcoma and serous carcinoma. Adjuvant combined modality treatment is an independent predictor of longer recurrence-free survival and overall survival.
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Affiliation(s)
| | | | | | - Miriana Y Hijaz
- Division of Gynecologic Oncology, Henry Ford Cancer Institute
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Beckmann K, Selva-Nayagam S, Olver I, Miller C, Buckley ES, Powell K, Buranyi-Trevarton D, Gowda R, Roder D, Oehler MK. Carcinosarcomas of the Uterus: Prognostic Factors and Impact of Adjuvant Treatment. Cancer Manag Res 2021; 13:4633-4645. [PMID: 34140809 PMCID: PMC8203298 DOI: 10.2147/cmar.s309551] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/15/2021] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Kerri Beckmann
- Cancer Epidemiology and Population Health Research, University of South Australia, Adelaide, Australia
| | | | - Ian Olver
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Caroline Miller
- South Australian Health and Medical Research Institute, Adelaide, Australia.,School of Public Health, University of Adelaide, Adelaide, Australia
| | - Elizabeth S Buckley
- Cancer Epidemiology and Population Health Research, University of South Australia, Adelaide, Australia
| | - Kate Powell
- South Australian Health and Medical Research Institute, Adelaide, Australia
| | | | - Raghu Gowda
- Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia
| | - David Roder
- Cancer Epidemiology and Population Health Research, University of South Australia, Adelaide, Australia
| | - Martin K Oehler
- Gynaecological Oncology, Royal Adelaide Hospital, Adelaide, Australia
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10
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Toboni MD, Crane EK, Brown J, Shushkevich A, Chiang S, Slomovitz BM, Levine DA, Dowdy SC, Klopp A, Powell MA, Thaker PH. Uterine carcinosarcomas: From pathology to practice. Gynecol Oncol 2021; 162:235-241. [PMID: 34030871 DOI: 10.1016/j.ygyno.2021.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/05/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Uterine carcinosarcoma (UCS) is a rare but aggressive cancer. In early-stage disease data guiding treatment is sparse. The purpose of this review is to summarize the findings from the 2019 NRG oncology group summer symposium meeting as well as a review of the current literature, with a particular focus on molecular targets, ongoing clinical trials, and treatment of early and advanced/recurrent disease. METHODS A combination of expert presentations and an extensive literature search was undertaken to summarize the literature in this review. MEDLINE was queried for peer-reviewed publications on UCS. This search was not limited by year or study design, but was limited to English language publications. ClinicalTrials.gov was queried for ongoing trials in UCS. RESULTS UCS is a rare cancer that is biphasic, with the carcinomatous component driving its aggressive nature. Level 3 evidence regarding early stage disease is lacking, but retrospective data suggests adjuvant therapy is warranted. The recent results of GOG 261 have contributed valuable information towards treatment strategy, including use of paclitaxel and carboplatin for UCS. Clinical trials are ongoing to investigate new targeted agents in UCS. CONCLUSION Ongoing endometrial cancer clinical trials now include UCS patients. In combination with advances in molecular profiling, this will provide patients with UCS improved therapeutic options. Until that time, surgical resection and traditional cytotoxic chemotherapy remains standard of care.
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Affiliation(s)
- Michael D Toboni
- Washington University School of Medicine and Siteman Cancer Center, St. Louis, MO, United States.
| | - Erin K Crane
- Levine Cancer Institute, Atrium Health, Charlotte, NC, United States
| | - Jubilee Brown
- Levine Cancer Institute, Atrium Health, Charlotte, NC, United States
| | | | - Sarah Chiang
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | | | - Douglas A Levine
- Perlmutter Cancer Center, NYU Langone Health, New York, NY, United States
| | | | - Ann Klopp
- The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Matthew A Powell
- Washington University School of Medicine and Siteman Cancer Center, St. Louis, MO, United States
| | - Premal H Thaker
- Washington University School of Medicine and Siteman Cancer Center, St. Louis, MO, United States
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11
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Zhao F, Tan P, Wang C, Ji X, Chen A. Effect of adjuvant therapy on the prognosis in stage I/II uterine carcinosarcoma: A meta-analysis. J Obstet Gynaecol Res 2021; 47:2473-2480. [PMID: 33913222 DOI: 10.1111/jog.14800] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 03/16/2021] [Accepted: 04/02/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION To assess the efficacy of adjuvant chemotherapy, radiotherapy, or both following the primary surgery on the progression-free survival and 5-year overall survival in patients with stage I/II uterine carcinosarcoma. METHODS A preliminary investigation was conducted using PubMed and Embase databases to identify relevant studies published up to March, 2020. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated by Revman 5.3 software to analysis outcomes. RESULTS Six retrospective cohort studies were involved in the analysis, including 1516 patients in observation group, 956 patients in chemotherapy group, 750 patients in radiotherapy group, and 1082 patients in raidochemotherapy group. The results indicated that chemotherapy alone (HR = 0.59, 95% CI = 0.38-0.91, p < 0.05) and radiochemotherapy (HR = 0.35, 95% CI: 0.24-0.53, p < 0.001) were associated with improved progression-free survival in patients. Similarly, pooled results suggested chemotherapy (HR = 0.49, 95% CI = 0.34-0.71, p < 0.001) and radiochemotherapy (HR = 0.46, 95% CI = 0.29-0.72, p < 0.001) promoted the 5-year overall survival compared with observation. However, radiotherapy alone had no statistical significance in improving progression-free survival (HR = 0.80, 95% CI = 0.49-1.29, p = 0.36) and 5-year overall survival (HR = 0.65, 95% CI = 0.38-1.12, p = 0.12). DISCUSSION Chemotherapy and radiochemotherapy appeared to be prognostic beneficial to early-stage uterine carcinosarcoma.
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Affiliation(s)
- Fei Zhao
- Department of Gynecology and Obstetrics, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ping Tan
- Department of Gynecology and Obstetrics, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chang Wang
- Department of Gynecology and Obstetrics, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xuechao Ji
- Department of Gynecology and Obstetrics, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Aiping Chen
- Department of Gynecology and Obstetrics, The Affiliated Hospital of Qingdao University, Qingdao, China
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12
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Kahramanoglu I, Demirkiran F, Turan H, Bese T, Cebi S, Ilvan S, Arvas M. Adjuvant Treatment Modalities, Prognostic Factors, and Outcome of the Uterine Carcinosarcoma. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 43:34-42. [PMID: 33041218 DOI: 10.1016/j.jogc.2020.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/20/2020] [Accepted: 06/24/2020] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Ilker Kahramanoglu
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey.
| | - Fuat Demirkiran
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Hasan Turan
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Tugan Bese
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sukru Cebi
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sennur Ilvan
- Department of Pathology, Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Macit Arvas
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Elshaikh MA, Modh A, Jhingran A, Biagioli MC, Coleman RL, Gaffney DK, Harkenrider MM, Heskett K, Jolly S, Kidd E, Lee LJ, Li L, Portelance L, Sherertz T, Venkatessan AM, Wahl AO, Yashar CM, Small W. Executive summary of the American Radium Society® Appropriate Use Criteria for management of uterine carcinosarcoma. Gynecol Oncol 2020; 158:460-466. [PMID: 32475772 DOI: 10.1016/j.ygyno.2020.04.683] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/08/2020] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
| | - Ankit Modh
- Henry Ford Cancer Institute, Detroit, MI, United States of America
| | - Anuja Jhingran
- University of Texas, MD Anderson Cancer Center, Houston, TX, United States of America
| | | | - Robert L Coleman
- University of Texas, MD Anderson Cancer Center, Houston, TX, United States of America
| | - David K Gaffney
- University of Utah Medical Center, Salt Lake City, UT, United States of America
| | | | - Karen Heskett
- University of California San Diego, San Diego, CA, United States of America
| | - Shruti Jolly
- University of Michigan Health System, Ann Arbor, MI, United States of America
| | | | - Larissa J Lee
- Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Linna Li
- Main Line Health System, United States of America
| | - Lorraine Portelance
- Miller School of Medicine University of Miami, Miami, FL, United States of America
| | - Tracy Sherertz
- Washington Permanente Medical Group, Kaiser Capitol Hill, Seattle, WA, United States of America
| | | | - Andrew O Wahl
- University of Nebraska Medical Center, Omaha, NE, United States of America
| | - Catheryn M Yashar
- University of California San Diego, San Diego, CA, United States of America
| | - William Small
- Stritch School of Medicine, Loyola University Chicago, IL, United States of America
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14
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Hapsari K, Bhugwandass C, van Rijn GWJ, van der Wurff AAM, van ‘t Veer M, Boll D, Vos MC, Pijlman B, Kok A, Piek JMJ. Treatment and Outcome of Patients with Uterine Carcinosarcoma in a Comprehensive Cancer Network. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2020. [DOI: 10.1007/s40944-019-0362-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Abstract
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.
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Rojas C, Tian C, Powell MA, Chan JK, Bateman NW, Conrads TP, Rocconi RP, Jones NL, Shriver CD, Hamilton CA, Maxwell GL, Casablanca Y, Darcy KM. Racial disparities in uterine and ovarian carcinosarcoma: A population-based analysis of treatment and survival. Gynecol Oncol 2020; 157:67-77. [PMID: 32029291 DOI: 10.1016/j.ygyno.2020.01.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/31/2019] [Accepted: 01/07/2020] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Christine Rojas
- Gynecologic Cancer Center of Excellence, Department of Obstetrics & Gynecology, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA.
| | - Chunqiao Tian
- Gynecologic Cancer Center of Excellence, Department of Obstetrics & Gynecology, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Henry M Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA.
| | - Matthew A Powell
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Siteman Cancer Center, Washington University School of Medicine in St. Louis, St. Louis, MO, 63110, USA.
| | - John K Chan
- Palo Alto Medical Foundation, California Pacific Medical Center, Sutter Health, San Francisco, CA, USA.
| | - Nicholas W Bateman
- Gynecologic Cancer Center of Excellence, Department of Obstetrics & Gynecology, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Henry M Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA; John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA.
| | - Thomas P Conrads
- Gynecologic Cancer Center of Excellence, Department of Obstetrics & Gynecology, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, VA, USA.
| | - Rodney P Rocconi
- Mitchell Cancer Institute, University of South Alabama, Mobile, AL, USA.
| | - Nathaniel L Jones
- Mitchell Cancer Institute, University of South Alabama, Mobile, AL, USA.
| | - Craig D Shriver
- John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA.
| | - Chad A Hamilton
- Gynecologic Cancer Center of Excellence, Department of Obstetrics & Gynecology, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, VA, USA; Inova Schar Cancer Institute, Inova Center for Personalized Health, Falls Church, VA, USA.
| | - G Larry Maxwell
- Gynecologic Cancer Center of Excellence, Department of Obstetrics & Gynecology, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, VA, USA; Inova Schar Cancer Institute, Inova Center for Personalized Health, Falls Church, VA, USA.
| | - Yovanni Casablanca
- Gynecologic Cancer Center of Excellence, Department of Obstetrics & Gynecology, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA.
| | - Kathleen M Darcy
- Gynecologic Cancer Center of Excellence, Department of Obstetrics & Gynecology, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA; Henry M Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA; John P Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD, USA.
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Gómez-Raposo C, Merino Salvador M, Aguayo Zamora C, Casado Saenz E. Adjuvant chemotherapy in endometrial cancer. Cancer Chemother Pharmacol 2020; 85:477-486. [PMID: 31950214 DOI: 10.1007/s00280-019-04027-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 12/28/2019] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- César Gómez-Raposo
- Medical Oncology Department, Hospital Universitario Infanta Sofía, Avenida de Europa 34, 28702, San Sebastián de Los Reyes, Madrid, Spain.
| | - María Merino Salvador
- Medical Oncology Department, Hospital Universitario Infanta Sofía, Avenida de Europa 34, 28702, San Sebastián de Los Reyes, Madrid, Spain
| | - Cristina Aguayo Zamora
- Medical Oncology Department, Hospital Universitario Infanta Sofía, Avenida de Europa 34, 28702, San Sebastián de Los Reyes, Madrid, Spain
| | - Enrique Casado Saenz
- Medical Oncology Department, Hospital Universitario Infanta Sofía, Avenida de Europa 34, 28702, San Sebastián de Los Reyes, Madrid, Spain
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Abstract
OBJECTIVE To provide a modern overview for radiologists of the unique radiological, pathological, and clinical features of uterine carcinosarcoma (UCS). RESULTS UCS is a unique gynecological malignancy that continues to present diagnostic and therapeutic challenges to the field of oncology. The classification and clinical understanding of this malignancy have evolved in recent years, yielding a modern conceptualization of a neoplastic entity that has been well studied but incompletely understood. As UCS causes a significant proportion of deaths secondary to uterine cancer, developing a familiarity with the imaging and clinical features of this entity is critical. In addition to summarizing the modern understanding of this tumor variant, an overview of the common imaging features of UCS will be presented. The role of radiological staging, imaging findings on presentation and follow-up imaging, and modern treatment paradigms will be discussed. Lastly, the current treatment paradigms and surveillance recommendations for UCS will be summarized. CONCLUSION Knowledge of the modern understanding of uterine carcinosarcoma, including its relevant imaging and clinical features, is critical for radiologists.
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Mills KA, Lopez H, Sun L, Cripe JC, Litz T, Thaker PH, Powell MA, Mutch DG, Fuh KC. Type II endometrial cancers with minimal, non-invasive residual disease on final pathology: What should we do next? Gynecol Oncol Rep 2019; 29:20-24. [PMID: 31193699 PMCID: PMC6541758 DOI: 10.1016/j.gore.2019.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/13/2019] [Accepted: 05/16/2019] [Indexed: 01/01/2023] Open
Abstract
There are minimal data regarding the management of high risk endometrial cancer histologies lacking invasive disease on the final pathology specimen. This study examines a cohort of these patients and assesses outcomes including time to recurrence and risk of death after management with and without adjuvant therapies. Endometrial cancer patients with minimal or no remaining invasive disease on final pathologic specimen from 1995 to 2010 were included. Surgical procedure was at the discretion of the operating physician. Electronic medical records were used to abstract relevant clinicopathologic data and standard statistical methods were employed. 70 patients met inclusion criteria, of which 26 were high grade histologies. Adjuvant therapies were given in 12 of 26 patients. 6/26 patients recurred, of which 50% were salvaged with therapy at time of recurrence. Overall deaths occurred in 3 of 26 patients in the high risk cohort. Less than half of the high risk cohort received adjuvant therapies after surgical management. No histologic type was found to increase risk of recurrence, and treatment with initial adjuvant therapy did not significantly reduce recurrence risk. Large scale prospective trials are needed to aid in management of this unique endometrial cancer population. This series describes a cohort of high risk with minimal remaining disease on final pathology specimen. Patients with clear cell histology who went on to recur did so quickly and were salvageable. Treatment with adjuvant therapy after primary surgery did not significantly improve risk of recurrence.
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Affiliation(s)
- Kathryn A Mills
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Heather Lopez
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Lulu Sun
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - James C Cripe
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Taylor Litz
- Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Premal H Thaker
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Matthew A Powell
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - David G Mutch
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Katherine C Fuh
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States of America
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19
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Prognostic factors impacting survival in early stage uterine carcinosarcoma. Gynecol Oncol 2018; 152:31-37. [PMID: 30414738 DOI: 10.1016/j.ygyno.2018.10.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Evaluate the impact of clinicopathologic characteristics and adjuvant treatment on survival outcomes in early stage uterine carcinosarcoma patients. METHODS We performed a retrospective cohort study of women with stage I or II uterine carcinosarcoma at our institution between March 1990 and June 2016. All pathology had been reviewed and confirmed by gynecologic pathologists. Data were extracted from the electronic medical record. Descriptive and comparative statistics were used to compare clinicopathologic characteristics. Univariable and multivariable analyses were performed for survival outcomes. RESULTS 140 patients were identified. Median age was 67 years (range: 36-91). Median follow-up was 39.1 months (2.9-297.4). The majority of patients had stage IA (67%) versus stage IB (21%) or stage II (11%) disease. The majority of patients (63%) received adjuvant treatment: vaginal brachytherapy only (14%); whole pelvic radiation therapy only (16%); chemotherapy only (n = 13, 9%); combination chemotherapy and vaginal brachytherapy (15%); combination chemotherapy and whole pelvic radiation (9%). 52 patients (37%) received no adjuvant therapy. Median overall survival (OS) was 48.0 months (95% CI 32.7-80.9). On multivariable analysis for OS, advancing age (HR 1.05, 95% CI 1.03-1.08, p < 0.001), higher stage (stage IB: HR 1.64, 95% CI 0.91-2.95, p = 0.10; stage II: HR 3.04, 95% CI 1.51-6.13, p = 0.002), and the presence of a rhabdomyosarcoma component (HR 1.66, 95% CI 1.02-2.70, p = 0.04) were significantly associated with worse OS. CONCLUSIONS Advancing age, stage, and the presence of a rhabdomyosarcoma component were all associated with worse OS in patients with early stage uterine carcinosarcoma. New treatment algorithms should incorporate factors aside from stage alone.
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Patterns of Adjuvant Therapy Utilization in Uterine Carcinosarcoma Stages I to III. Am J Clin Oncol 2018; 41:927-932. [DOI: 10.1097/coc.0000000000000396] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Use of Adjuvant Chemotherapy, Radiation Therapy, or Combined Modality Therapy and the Impact on Survival for Uterine Carcinosarcoma Limited to the Pelvis. Int J Gynecol Cancer 2017; 27:1171-1177. [DOI: 10.1097/igc.0000000000001014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
ObjectiveClinical outcomes for patients with uterine carcinosarcoma are poor after surgical management alone. Adjuvant therapies including chemotherapy (CT) and/or radiation therapy (RT) have been previously investigated, but the optimal management of this disease remains controversial. The purposes of this study were to analyze the patterns of use of adjuvant CT and RT and to assess the impact on survival of each of these treatment regimens using the National Cancer Data Base.Methods/MaterialsThe National Cancer Data Base was queried for patients given a diagnosis of uterine carcinosarcoma confined to the pelvis who underwent total hysterectomy/bilateral salpingo-oophorectomy between 2004 and 2011. Patients were excluded if they survived less than 4 months after diagnosis. Data regarding CT and RT use were collected. Overall survival (OS) was analyzed using the Kaplan-Meier method. Multivariable Cox regression analysis was performed to evaluate the effect of covariates on OS.ResultsA total of 4906 patients were included in this study. Median age was 67 years (interquartile range, 60–75 years). Median follow-up was 28.9 months (interquartile range, 15.4–52.9 months). There were 1777 patients (36.2%) who received no adjuvant treatment, 971 (19.8%) who received CT alone, 1060 (21.6%) who received RT alone, and 1098 (22.4%) who received both RT and CT. The 5-year OS for patients receiving no adjuvant therapy, adjuvant RT alone, adjuvant CT alone, and combined CT and RT were 44.9%, 47.1%, 47.5%, and 62.9%, respectively. On pairwise analysis, combined CT and RT was associated with improved survival compared with all other subgroups (P < 0.001). On multivariable Cox regression analysis, combined CT and RT (hazard ratio, 0.50; 95% confidence interval, 0.44–0.57; P < 0.001) and CT alone (hazard ratio, 0.78; 95% confidence interval, 0.69–0.88; P < 0.001) were significantly associated with improved OS, whereas RT alone was not.ConclusionsCombination therapy with CT and RT was associated with significantly improved 5-year OS compared with no further therapy, RT alone, or CT alone.
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Yen MS, Chen JR, Wang PH, Wen KC, Chen YJ, Ng HT. Uterine sarcoma part III-Targeted therapy: The Taiwan Association of Gynecology (TAG) systematic review. Taiwan J Obstet Gynecol 2017; 55:625-634. [PMID: 27751406 DOI: 10.1016/j.tjog.2016.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2016] [Indexed: 12/29/2022] Open
Abstract
Uterine sarcoma is a very aggressive and highly lethal disease. Even after a comprehensive staging surgery or en block cytoreduction surgery followed by multimodality therapy (often chemotherapy and/or radiation therapy), many patients relapse or present with distant metastases, and finally die of diseases. The worst outcome of uterine sarcomas is partly because of their rarity, unknown etiology, and highly divergent genetic aberration. Uterine sarcomas are often classified into four distinct subtypes, including uterine leiomyosarcoma, low-grade uterine endometrial stromal sarcoma, high-grade uterine endometrial stromal sarcoma, and undifferentiated uterine sarcoma. Currently, evidence from tumor biology found that these tumors showed alternation and/or mutation of genomes and the intracellular signal pathway. In addition, some preclinical studies showed promising results for targeting receptor tyrosine kinase signaling, phosphatidylinositol 3-kinase/AKT/mammalian target of rapamycin pathway, various kinds of growth factor pathways, Wnt/beta-catenin signaling pathway, transforming growth factor β/bone morphogenetic protein signal pathway, aurora kinase A, MDM2 proto-oncogene, histone deacetylases, sex hormone receptors, certain types of oncoproteins, and/or loss of tumor suppressor genes. The current review is attempted to summarize the recurrent advance of targeted therapy for uterine sarcomas.
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Affiliation(s)
- Ming-Shyen Yen
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taipei, Taiwan; Foundation of Female Cancer, Taipei, Taiwan
| | - Jen-Ruei Chen
- Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan.
| | - Kuo-Chang Wen
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Yi-Jen Chen
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Heung-Tat Ng
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taipei, Taiwan; Foundation of Female Cancer, Taipei, Taiwan
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