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Verma N, Laird JH, Moore NS, Hayman TJ, Housri N, Peters GW, Knowlton CA, Jairam V, Campbell AM, Park HS. Radioresistant Pulmonary Oligometastatic and Oligoprogressive Lesions From Nonlung Primaries: Impact of Histology and Dose-Fractionation on Local Control After Radiation Therapy. Adv Radiat Oncol 2024; 9:101500. [PMID: 38699671 PMCID: PMC11063223 DOI: 10.1016/j.adro.2024.101500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 03/07/2024] [Indexed: 05/05/2024] Open
Abstract
Purpose We investigated whether pulmonary metastases from historically considered radioresistant primaries would have inferior local control after radiation therapy than those from nonradioresistant nonlung primaries, and whether higher biologically effective dose assuming alpha/beta=10 (BED10) would be associated with superior local control. Methods and Materials We identified patients treated with radiation therapy for oligometastatic or oligoprogressive pulmonary disease to 1 to 5 lung metastases from nonlung primaries in 2013 to 2020 at a single health care system. Radioresistant primary cancers included colorectal carcinoma, endometrial carcinoma, renal cell carcinoma, melanoma, and sarcoma. Nonradioresistant primary cancers included breast, bladder, esophageal, pancreas, and head and neck carcinomas. The Kaplan-Meier estimator, log-rank test, and multivariable Cox proportional hazards regression were used to compare local recurrence-free survival (LRFS), new metastasis-free survival, progression-free survival, and overall survival. Results Among 114 patients, 73 had radioresistant primary cancers. The median total dose was 50 Gy (IQR, 50-54 Gy) and the median number of fractions was 5 (IQR, 3-5). Median follow-up time was 59.6 months. One of 41 (2.4%) patients with a nonradioresistant metastasis experienced local failure compared with 18 of 73 (24.7%) patients with radioresistant metastasis (log-rank P = .004). Among radioresistant metastases, 12 of 41 (29.2%) patients with colorectal carcinoma experienced local failure compared with 6 of 32 (18.8%) with other primaries (log-rank P = .018). BED10 ≥100 Gy was associated with decreased risk of local recurrence. On univariable analysis, BED10 ≥100 Gy (hazard ratio [HR], 0.263; 95% CI, 0.105-0.656; P = .004) was associated with higher LRFS, and colorectal primary (HR, 3.060; 95% CI, 1.204-7.777; P = .019) was associated with lower LRFS, though these were not statistically significant on multivariable analysis. Among colorectal primary patients, BED10 ≥100 Gy was associated with higher LRFS (HR, 0.266; 95% CI, 0.072-0.985; P = .047) on multivariable analysis. Conclusions Local control after radiation therapy was encouraging for pulmonary metastases from most nonlung primaries, even for many of those classically considered to be radioresistant. Those from colorectal primaries may benefit from testing additional strategies, such as resection or systemic treatment concurrent with radiation.
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Affiliation(s)
- Nipun Verma
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - James H. Laird
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Nicholas S. Moore
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Thomas J. Hayman
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Nadine Housri
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Gabrielle W. Peters
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Christin A. Knowlton
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Vikram Jairam
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Allison M. Campbell
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Henry S. Park
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
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Zadeh N, Bhatt A, Sripiparu V, Pasli M, Edwards G, Larkins MC, Peach MS. Malignant mixed mullerian tumors: a SEER database review of rurality and treatment modalities on disease outcome. Front Oncol 2024; 14:1296496. [PMID: 38390260 PMCID: PMC10881697 DOI: 10.3389/fonc.2024.1296496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
Introduction Malignant Mixed Mullerian Tumors (MMMT) are rare and poorly understood sarcomas with limited research on risk factors, pathogenesis, and optimal treatments. This study aimed to address this knowledge gap and explore the impact of community size, patient characteristics, disease characteristics, and treatment modalities on MMMT outcomes. Methods Using the Surveillance, Epidemiology, and End Results database (SEER), the largest SEER cohort to date of 3,352 MMMT patients was analyzed for demographic factors, treatment modalities, and histologic characteristics. Data was processed, including the removal of incomplete entries, and analyzed in Python 3.1 using packages scikit-learn, lifelines, and torch; log-rank analysis and Cox proportional hazards models were used to evaluate a number of demographic characteristics and disease characteristics for significance in regard to survival. Results Our study found adjuvant radiotherapy and chemotherapy significantly improved survival, with modest benefits from neoadjuvant chemotherapy. Our findings also suggest age at diagnosis, disease grade, and suburban versus rural geographic locations may play key roles in patient prognosis. On multivariable analysis both disease Grade and surgical treatment were significant factors. Discussion MMMTs remain challenging, but appropriate treatment appears to enhance survival. The present findings suggest opportunities for improved outcomes and treatment strategies for patients with MMMTs.
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Affiliation(s)
- Neusha Zadeh
- Jerry M. Wallace School of Osteopathic Medicine, Campbell University, Buies Creek, NC, United States
| | - Arjun Bhatt
- Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - Vaishnavi Sripiparu
- Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - Melisa Pasli
- Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - George Edwards
- Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - Michael C Larkins
- Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - M Sean Peach
- Department of Radiation Oncology, Brody School of Medicine, East Carolina University, Greenville, NC, United States
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Morcet-Delattre R, Espenel S, Tas P, Chargari C, Escande A. Role of radiotherapy in the management of rare gynaecological cancers. Cancer Radiother 2023; 27:778-788. [PMID: 37925347 DOI: 10.1016/j.canrad.2023.08.006] [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: 08/16/2023] [Accepted: 08/22/2023] [Indexed: 11/06/2023]
Abstract
There are a large number of gynaecological cancers with rare histologies, for which the available data are limited and usually retrospective. Because of their rarity and poor prognosis, the management of these cancers must be centralized in expert centres, for both histological diagnosis and treatment. With the exception of sarcomas, most endometrial or cervical cancers with rare histologies respond to the same radiation treatment modalities than cancers with more common histologies, although there are some specificities regarding treatments such as neuroendocrine carcinomas (chemotherapy with platinum and etoposide, major role of surgery). For localized or locally advanced ovarian cancer, external beam radiotherapy has a role in the management of hypercalcaemic small cell carcinoma of the ovary. This article summarizes the current role of external beam radiotherapy and brachytherapy in the management of cancers of the uterine cervix, uterine corpus and ovaries, with rare or very rare histologies, and with localized or locally advanced stages.
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Affiliation(s)
- R Morcet-Delattre
- Radiation oncology department, centre Eugène-Marquis, Rennes, France.
| | - S Espenel
- Radiation oncology department, Gustave-Roussy Cancer Campus, Villejuif, France
| | - P Tas
- Anatomopathology department, Ouest pathologie, Rennes, France
| | - C Chargari
- Radiation oncology department, groupe hospitalier Pitié-Salpêtrière, Paris, France
| | - A Escande
- Radiation oncology department, centre Léonard-de-Vinci, Dechy, France; Laboratoire CRIStAL UMR9189, université de Lille, CNRS, Lille, France
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4
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Collet L, González López AM, Romeo C, Méeus P, Chopin N, Rossi L, Rowinski E, Serre AA, Rannou C, Buisson A, Treilleux I, Ray-Coquard I. Gynecological carcinosarcomas: Overview and future perspectives. Bull Cancer 2023; 110:1215-1226. [PMID: 37679206 DOI: 10.1016/j.bulcan.2023.07.005] [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: 03/18/2023] [Revised: 06/28/2023] [Accepted: 07/09/2023] [Indexed: 09/09/2023]
Abstract
Gynecologic carcinosarcoma (CS) are rare and aggressive tumors composed of high-grade carcinoma and sarcoma. Carcinosarcoma account for less than 5% of uterine and ovarian carcinoma and patients have poor outcome with a 5-year overall survival of less than 30%. In early-stage setting, the treatment mainstay is surgery and adjuvant chemoradiotherapy or adjuvant chemotherapy in uterine (UCS) and ovarian CS (OCS), respectively. In metastatic or advanced stage disease, chemotherapy is the rule with a lower response rate and poorer prognosis compared to other high-grade carcinomas. Although very few treatment options are available, CS are often excluded from the clinical trials precluding therapeutic improvement. However, recent molecular advances are paving the way for new therapeutic strategies. In the current proposal, we extensively review the uterine and ovarian carcinosarcomas including epidemiology, pathology, genomic landscape, as well as current therapies and future perspectives.
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Affiliation(s)
- Laetitia Collet
- Institut Jules-Bordet, Breast Cancer Translational Research Laboratory, Bruxelles, Belgium; Institut Jules-Bordet, Department of Medical Oncology, Bruxelles, Belgium; Centre Leon-Berard, Department of Medical Oncology, Lyon, France.
| | | | - Clémence Romeo
- Centre Leon-Berard, Department of Medical Oncology, Lyon, France
| | - Pierre Méeus
- Centre Leon-Berard, Department of Surgery, Lyon, France
| | | | - Léa Rossi
- Centre Leon-Berard, Department of Surgery, Lyon, France
| | - Elise Rowinski
- Centre Leon-Berard, Department of Medical Oncology, Lyon, France
| | | | | | - Adrien Buisson
- Centre Leon-Berard, Department of Biology molecular, Lyon, France
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5
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Pérez-Fidalgo JA, Ortega E, Ponce J, Redondo A, Sevilla I, Valverde C, Isern Verdum J, de Alava E, Galera López M, Marquina G, Sebio A. Uterine sarcomas: clinical practice guidelines for diagnosis, treatment, and follow-up, by Spanish group for research on sarcomas (GEIS). Ther Adv Med Oncol 2023; 15:17588359231157645. [PMID: 37007636 PMCID: PMC10052607 DOI: 10.1177/17588359231157645] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 01/30/2023] [Indexed: 03/30/2023] Open
Abstract
Uterine sarcomas are very infrequent and heterogeneous entities. Due to its rarity, pathological diagnosis, surgical management, and systemic treatment are challenging. Treatment decision process in these tumors should be taken in a multidisciplinary tumor board. Available evidence is low and, in many cases, based on case series or clinical trials in which these tumors have been included with other soft tissue sarcoma. In these guidelines, we have tried to summarize the most relevant evidence in the diagnosis, staging, pathological disparities, surgical management, systemic treatment, and follow-up of uterine sarcomas.
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Affiliation(s)
| | - Eugenia Ortega
- Medical Oncology Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Jordi Ponce
- Gynecology Department, Hospital Universitario de Bellvitge. IDIBELL. Universidad de Barcelona, Barcelona, Spain
| | - Andres Redondo
- Medical Oncology Department, Hospital Universitario La Paz-IdiPAZ, Madrid, Spain
| | - Isabel Sevilla
- Clinical and Translational Research in Cancer/Instituto de Investigaciones Biomédicas de Málaga (IBIMA)/Hospitales Universitarios Regional and Virgen de la Victoria de Málaga, Málaga, Spain
| | - Claudia Valverde
- Medical Oncology Department, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Josep Isern Verdum
- Radiotherapy Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Enrique de Alava
- Institute of Biomedicine of Sevilla (IBiS), Virgen del Rocio University Hospital /CSIC/University of Sevilla/CIBERONC, Sevilla, Spain
- Department of Normal and Pathological Cytology and Histology, School of Medicine, University of Seville, Seville, Spain
| | - Mar Galera López
- Medical Oncology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Gloria Marquina
- Department of Medical Oncology, Hospital Clinico San Carlos, Madrid, IdISSC, Spain
- Department of Medicine, School of Medicine, Complutense University (UCM), Madrid, IdISSC, Spain
| | - Ana Sebio
- Medical Oncology Department, Hospital de la Santa Creu i Sant Pau, Barcelona
- Universitat Autònoma de Barcelona, Barcelona, Spain
- Institut de Recerca Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain
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6
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Tuan HX, Duc NM, Tri CM, Quyen HTD, Dung PX. Carcinosarcoma of uterus. Radiol Case Rep 2023; 18:1297-1301. [PMID: 36684637 PMCID: PMC9851838 DOI: 10.1016/j.radcr.2022.12.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 12/27/2022] [Accepted: 12/30/2022] [Indexed: 01/16/2023] Open
Abstract
Uterine carcinosarcoma, which is categorized as high-grade endometrial cancer, is an uncommon kind of malignant gynecological neoplasms. Clinically, this tumor frequently affects menopausal women and the main symptom is abnormally postmenopausal vaginal bleeding. Surgery continues to be the main treatment for carcinosarcoma. In this study, we wanted to discuss 2 cases of uterine carcinosarcoma in 2 women who were in menopause and who had been evaluated by ultrasound and magnetic resonance imaging.
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Affiliation(s)
- Ho Xuan Tuan
- Department of Medical Imaging, Da Nang University of Medical Technology and Pharmacy, Da Nang, Vietnam
| | - Nguyen Minh Duc
- Department of Radiology, Ho Chi Minh City Oncology Hospital, Ho Chi Minh City, Vietnam,Department of Radiology, Pham Ngoc Thach University of Medicine, 2 Duong Quang Trung Ward 12 District 10, Ho Chi Minh City, Vietnam,Corresponding author.
| | - Cao Minh Tri
- Department of Radiology, Ho Chi Minh City Oncology Hospital, Ho Chi Minh City, Vietnam
| | - Huynh-Thi Do Quyen
- Department of Radiology, Ho Chi Minh City Oncology Hospital, Ho Chi Minh City, Vietnam
| | - Pham Xuan Dung
- Director Board, Ho Chi Minh City Oncology Hospital, Ho Chi Minh City, Vietnam
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de Almeida BC, dos Anjos LG, Dobroff AS, Baracat EC, Yang Q, Al-Hendy A, Carvalho KC. Epigenetic Features in Uterine Leiomyosarcoma and Endometrial Stromal Sarcomas: An Overview of the Literature. Biomedicines 2022; 10:biomedicines10102567. [PMID: 36289829 PMCID: PMC9599831 DOI: 10.3390/biomedicines10102567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/16/2022] Open
Abstract
There is a consensus that epigenetic alterations play a key role in cancer initiation and its biology. Studies evaluating the modification in the DNA methylation and chromatin remodeling patterns, as well as gene regulation profile by non-coding RNAs (ncRNAs) have led to the development of novel therapeutic approaches to treat several tumor types. Indeed, despite clinical and translational challenges, combinatorial therapies employing agents targeting epigenetic modifications with conventional approaches have shown encouraging results. However, for rare neoplasia such as uterine leiomyosarcomas (LMS) and endometrial stromal sarcomas (ESS), treatment options are still limited. LMS has high chromosomal instability and molecular derangements, while ESS can present a specific gene fusion signature. Although they are the most frequent types of “pure” uterine sarcomas, these tumors are difficult to diagnose, have high rates of recurrence, and frequently develop resistance to current treatment options. The challenges involving the management of these tumors arise from the fact that the molecular mechanisms governing their progression have not been entirely elucidated. Hence, to fill this gap and highlight the importance of ongoing and future studies, we have cross-referenced the literature on uterine LMS and ESS and compiled the most relevant epigenetic studies, published between 2009 and 2022.
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Affiliation(s)
- Bruna Cristine de Almeida
- Laboratório de Ginecologia Estrutural e Molecular (LIM 58), Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo (HCFMUSP), São Paulo 05403-010, Brazil
| | - Laura Gonzalez dos Anjos
- Laboratório de Ginecologia Estrutural e Molecular (LIM 58), Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo (HCFMUSP), São Paulo 05403-010, Brazil
| | - Andrey Senos Dobroff
- UNM Comprehensive Cancer Center (UNMCCC), University of New Mexico, Albuquerque, NM 87131, USA
- Division of Molecular Medicine, Department of Internal Medicine, (UNM) School of Medicine, UNM Health Sciences Center, 1 University of New Mexico, Albuquerque, NM 87131, USA
| | - Edmund Chada Baracat
- Laboratório de Ginecologia Estrutural e Molecular (LIM 58), Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo (HCFMUSP), São Paulo 05403-010, Brazil
| | - Qiwei Yang
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL 60637, USA
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL 60637, USA
| | - Katia Candido Carvalho
- Laboratório de Ginecologia Estrutural e Molecular (LIM 58), Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo (HCFMUSP), São Paulo 05403-010, Brazil
- Correspondence: ; Tel.: +55-011-3061-7486
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8
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Li YJ, Lyu J, Li C, He HR, Wang JF, Wang YL, Fang J, Ji J. A novel nomogram for predicting cancer-specific survival in women with uterine sarcoma: a large population-based study. BMC Womens Health 2022; 22:175. [PMID: 35568940 PMCID: PMC9107666 DOI: 10.1186/s12905-022-01739-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 04/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Uterine sarcoma (US) is a rare malignant uterine tumor with aggressive behavior and rapid progression. The purpose of this study was to constructa comprehensive nomogram to predict cancer-specific survival (CSS) of patients with US-based on the Surveillance, Epidemiology, and End Results (SEER) database. Methods A retrospective population-based study was conducted using data from patients with US between 2010 and 2015 from the SEER database. They were randomly divided into a training cohort and a validation cohort ata 7-to-3 ratio. Multivariate Cox analysis was performed to identify independent prognostic factors. Subsequently, a nomogram was established to predict patient CSS. The discrimination and calibration of the nomogram were evaluated by the concordance index (C-index) and the area under the curve (AUC). Finally, net reclassification improvement (NRI), integrated discrimination improvement (IDI), calibration plotting, and decision-curve analysis (DCA) were used to evaluate the benefits of the new prediction model. Results A total of 3861 patients with US were included in our study. As revealed in multivariate Cox analysis, age at diagnosis, race, marital status, insurance record, tumor size, pathology grade, histological type, SEER stage, AJCC stage, surgery status, radiotherapy status, and chemotherapy status were found to be independent prognostic factors. In our nomogram, pathology grade had strongest correlation with CSS, followed by age at diagnosis and surgery status. Compared to the AJCC staging system, the new nomogram showed better predictive discrimination with a higher C-index in the training and validation cohorts (0.796 and 0.767 vs. 0.706 and 0.713, respectively). Furthermore, the AUC value, calibration plotting, NRI, IDI, and DCA also demonstrated better performance than the traditional system. Conclusion Our study validated the first comprehensive nomogram for US, which could provide more accurate and individualized survival predictions for US patients in clinical practice.
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Affiliation(s)
- Yuan-Jie Li
- Department of Human Anatomy, Histology and Embryology, School of Basic Medical Sciences, Xi'an Jiao Tong University Health Science Center, Xi'an, Shaanxi, China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Chen Li
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Hai-Rong He
- Department of Clinical Research Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Jin-Feng Wang
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Yue-Ling Wang
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Jing Fang
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Jing Ji
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China.
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Chantharasamee J, Wong K, Potivongsajarn P, Qorbani A, Motamed N, Brackert S, Cohen J, Chmielowski B, Kalbasi A, Rao J, Nelson S, Singh A. Retrospective analysis of adjuvant treatment for localized, operable uterine leiomyosarcoma. Cancer Med 2022; 11:2906-2912. [PMID: 35307963 PMCID: PMC9359871 DOI: 10.1002/cam4.4665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 01/31/2022] [Accepted: 02/25/2022] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE Currently, there is no standard adjuvant treatment protocol for localized uterine leiomyosarcoma (uLMS) as clinical trials to address this question have been retrospective, underpowered, or undermined by slow accrual rates. The aim of this study is to determine the benefit of adjuvant chemotherapy for uLMS. METHODS We reviewed the medical records of localized uLMS patients who had underwent adjuvant therapy after upfront surgery between 2000 and 2020. The cases were blinded for review. We evaluated the influence of various clinical characteristics and different types of adjuvant therapies on specific outcomes. RESULTS Sixty-eight patients (median age: 50 years) were included for analysis. Forty of 68 (58.8%) patients received adjuvant chemotherapy +/- radiation therapy and 25 patients (38.6%) did not receive any adjuvant therapy. At a median follow-up time of 43.3 months, 45 patients (66.1%) had relapsed disease. The median disease-free survival (mDFS) for all patients was 23.1 months. Patients who received any adjuvant treatment (chemotherapy and/or radiation) trended toward a longer mDFS compared with those who did not receive any adjuvant therapy (29.7 vs. 14.1 months, p = 0.26). Patients who received adjuvant chemotherapy alone had a longer, but nonstatistically significant mDFS compared with those who did not receive any adjuvant treatment (22.2 vs. 14.1 months, p = 0.18). Additionally, univariate analysis found that tumor size large than 10 cm, and a mitotic rate >10/10hpf were independent prognostic factors for worse DFS. CONCLUSIONS Though DFS was more favorable among those who received adjuvant therapy, it was not statistically significant, and thus based on this data adjuvant therapy for resected uLMS is still in question.
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Affiliation(s)
- Jomjit Chantharasamee
- Division of Hematology-Oncology, Department of Medicine, University of California, Los Angeles, California, USA.,Division of Medical Oncology, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Karlton Wong
- Division of Hematology-Oncology, Department of Medicine, University of California, Los Angeles, California, USA
| | | | - Amir Qorbani
- Department of Pathology, University of California, Los Angeles, California, USA
| | - Neda Motamed
- Department of Pathology, University of California, Los Angeles, California, USA
| | - Sandra Brackert
- Division of Hematology-Oncology, Department of Medicine, University of California, Los Angeles, California, USA
| | - Joshua Cohen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Los Angeles, California, USA
| | - Bartosz Chmielowski
- Division of Hematology-Oncology, Department of Medicine, University of California, Los Angeles, California, USA
| | - Anusha Kalbasi
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Jianyu Rao
- Department of Pathology, University of California, Los Angeles, California, USA
| | - Scott Nelson
- Department of Pathology, University of California, Los Angeles, California, USA
| | - Arun Singh
- Division of Hematology-Oncology, Department of Medicine, University of California, Los Angeles, California, USA
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Su MH, Wu HH, Huang HY, Lee NR, Chang WH, Lin SC, Chen YJ, Wang PH. Comparing paclitaxel-platinum with ifosfamide-platinum as the front-line chemotherapy for patients with advanced-stage uterine carcinosarcoma. J Chin Med Assoc 2022; 85:204-211. [PMID: 34698689 DOI: 10.1097/jcma.0000000000000643] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Uterine carcinosarcoma (UCS) is a rare but highly lethal disease. Adjuvant chemotherapy is highly recommended for advanced UCS. To date, the standard chemotherapy regimen is still uncertain, although two regimens as paclitaxel-platinum (PP) and ifosfamide-platinum (IP) regimens are most commonly used. The aims of the current study attempt to compare both regimens in the management of advanced UCS patients. METHODS We evaluated advanced UCS patients who were treated either with PP or with IP after primary cytoreductive surgery in single institute retrospectively. The clinical-pathological parameters, recurrence, and survival were recorded. RESULTS A total of 16 patients were analyzed. Twelve patients received adjuvant PP therapy, and the remaining four patients received IP therapy. The median follow-up time was 28 months, ranging from 3.8 months to 121 months. Disease-related death occurred in 10 patients (62.5%). The median progression-free survival was 4.9 months, ranging from 3.8 months to 36.5 months in IP, and 23.1 months, ranging from 9.3 months to 121 months in PP, with statistically significant difference (p = 0.04). The median overall survival was 9.5 months (ranging from 3.8 months to 36.5 months) and 28.7 months (ranging from 10.3 months to 121 months) in IP and PP, respectively, without statistically significant difference (p = 0.06). Presence of pelvic and para-aortic lymphadenopathy and deep myometrial invasion (>1/2) were associated with worse prognosis by univariate analysis. No prognostic factor could be identified using multivariate analysis model. CONCLUSION In the current study, due to extremely little number of subjects enrolled, the advantage of using paclitaxel-platinum regimen in the management of advanced UCS was still unclear, although a certain trend of favoring was supposed. We are looking forward to seeing more studies to identify the approximate regimen in the management of this highly lethal disease.
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Affiliation(s)
- Ming-Hsuan Su
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Hua-Hsi Wu
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Hsin-Yi Huang
- Biostatics Task Force, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Na-Rong Lee
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Nursing, Taipei Veterans General Hospital, Taiwan, ROC
| | - Wen-Hsun Chang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Nursing, Taipei Veterans General Hospital, Taiwan, ROC
| | - Shih-Chieh Lin
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Nursing, Taipei Veterans General Hospital, Taiwan, ROC
| | - Yi-Jen Chen
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Pathology and Laboratory Medicine, Taipei, Taiwan, ROC
- Female Cancer Foundation, Taipei, Taiwan, ROC
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11
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Romeo C, Le Saux O, Jacobs M, Joly F, Ferron G, Favier L, Fumet JD, Isambert N, Colombo PE, Sabatier R, Bastide L, Charreton A, Devouassoux-Shisheboran M, Gertych W, Dubot C, Bello Roufai D, Bataillon G, Berton D, Kalbacher E, Pautier P, Pomel C, Cornou C, Treilleux I, Lardy-Cleaud A, Ray-Coquard I. Therapeutic Challenges in Patients with Gynecologic Carcinosarcomas: Analysis of a Multicenter National Cohort Study from the French Prospective TMRG Network. Cancers (Basel) 2022; 14:354. [PMID: 35053517 PMCID: PMC8773830 DOI: 10.3390/cancers14020354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/28/2021] [Accepted: 01/06/2022] [Indexed: 01/27/2023] Open
Abstract
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.
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Affiliation(s)
- Clémence Romeo
- Medical Oncology Department, Centre Léon Bérard, 69008 Lyon, France; (A.C.); (I.R.-C.)
| | - Olivia Le Saux
- Cancer Research Center of Lyon CRCL, UMR Inserm 1052, CNRS 5286, Centre Léon Bérard, 69008 Lyon, France;
| | - Margaux Jacobs
- Medical Oncology Department, Centre François Baclesse, 14000 Caen, France; (M.J.); (F.J.)
| | - Florence Joly
- Medical Oncology Department, Centre François Baclesse, 14000 Caen, France; (M.J.); (F.J.)
- GINECO Group, 75008 Paris, France; (G.F.); (L.F.); (N.I.); (P.-E.C.); (R.S.); (M.D.-S.); (C.D.); (G.B.); (D.B.); (E.K.); (P.P.); (C.P.); (I.T.)
| | - Gwenael Ferron
- GINECO Group, 75008 Paris, France; (G.F.); (L.F.); (N.I.); (P.-E.C.); (R.S.); (M.D.-S.); (C.D.); (G.B.); (D.B.); (E.K.); (P.P.); (C.P.); (I.T.)
- Department of Surgical Oncology, Institut Claudius Regaud-IUCT, 31100 Toulouse, France
| | - Laure Favier
- GINECO Group, 75008 Paris, France; (G.F.); (L.F.); (N.I.); (P.-E.C.); (R.S.); (M.D.-S.); (C.D.); (G.B.); (D.B.); (E.K.); (P.P.); (C.P.); (I.T.)
- Medical Oncology Department, Centre Georges François Leclerc, 21000 Dijon, France;
| | - Jean-David Fumet
- Medical Oncology Department, Centre Georges François Leclerc, 21000 Dijon, France;
| | - Nicolas Isambert
- GINECO Group, 75008 Paris, France; (G.F.); (L.F.); (N.I.); (P.-E.C.); (R.S.); (M.D.-S.); (C.D.); (G.B.); (D.B.); (E.K.); (P.P.); (C.P.); (I.T.)
- Medical Oncology Department, Centre Georges François Leclerc, 21000 Dijon, France;
| | - Pierre-Emmanuel Colombo
- GINECO Group, 75008 Paris, France; (G.F.); (L.F.); (N.I.); (P.-E.C.); (R.S.); (M.D.-S.); (C.D.); (G.B.); (D.B.); (E.K.); (P.P.); (C.P.); (I.T.)
- Surgical Oncology Department, Institut du Cancer de Montpellier, 34090 Montpellier, France
| | - Renaud Sabatier
- GINECO Group, 75008 Paris, France; (G.F.); (L.F.); (N.I.); (P.-E.C.); (R.S.); (M.D.-S.); (C.D.); (G.B.); (D.B.); (E.K.); (P.P.); (C.P.); (I.T.)
- Medical Oncology Department, Institut Paoli Calmettes, 13009 Marseille, France;
| | - Ludovic Bastide
- Medical Oncology Department, Institut Paoli Calmettes, 13009 Marseille, France;
| | - Amandine Charreton
- Medical Oncology Department, Centre Léon Bérard, 69008 Lyon, France; (A.C.); (I.R.-C.)
| | - Mojgan Devouassoux-Shisheboran
- GINECO Group, 75008 Paris, France; (G.F.); (L.F.); (N.I.); (P.-E.C.); (R.S.); (M.D.-S.); (C.D.); (G.B.); (D.B.); (E.K.); (P.P.); (C.P.); (I.T.)
- Tumor Biology Department, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, 69495 Lyon, France
| | - Witold Gertych
- Gynaecologic Surgery Department, Hôpital Lyon Sud, Hospices Civils de Lyon, 69495 Lyon, France;
| | - Coraline Dubot
- GINECO Group, 75008 Paris, France; (G.F.); (L.F.); (N.I.); (P.-E.C.); (R.S.); (M.D.-S.); (C.D.); (G.B.); (D.B.); (E.K.); (P.P.); (C.P.); (I.T.)
- Medical Oncology Department, Institut Curie, Saint-Cloud, 92210 Paris, France;
| | - Diana Bello Roufai
- Medical Oncology Department, Institut Curie, Saint-Cloud, 92210 Paris, France;
| | - Guillaume Bataillon
- GINECO Group, 75008 Paris, France; (G.F.); (L.F.); (N.I.); (P.-E.C.); (R.S.); (M.D.-S.); (C.D.); (G.B.); (D.B.); (E.K.); (P.P.); (C.P.); (I.T.)
- Tumor Biology Department, Institut Curie, 75005 Paris, France
| | - Dominique Berton
- GINECO Group, 75008 Paris, France; (G.F.); (L.F.); (N.I.); (P.-E.C.); (R.S.); (M.D.-S.); (C.D.); (G.B.); (D.B.); (E.K.); (P.P.); (C.P.); (I.T.)
- Medical Oncology Department, Institut de Cancérologie de l’Ouest, 44800 Saint Herblain, France
| | - Elsa Kalbacher
- GINECO Group, 75008 Paris, France; (G.F.); (L.F.); (N.I.); (P.-E.C.); (R.S.); (M.D.-S.); (C.D.); (G.B.); (D.B.); (E.K.); (P.P.); (C.P.); (I.T.)
- Medical Oncology Department, CHRU de Besançon, 25000 Besançon, France
| | - Patricia Pautier
- GINECO Group, 75008 Paris, France; (G.F.); (L.F.); (N.I.); (P.-E.C.); (R.S.); (M.D.-S.); (C.D.); (G.B.); (D.B.); (E.K.); (P.P.); (C.P.); (I.T.)
- Medical Oncology Department, Gustave Roussy, 94805 Villejuif, France
| | - Christophe Pomel
- GINECO Group, 75008 Paris, France; (G.F.); (L.F.); (N.I.); (P.-E.C.); (R.S.); (M.D.-S.); (C.D.); (G.B.); (D.B.); (E.K.); (P.P.); (C.P.); (I.T.)
- Surgical Oncology Department, Centre Jean Perrin, 63011 Clermont-Ferrand, France;
| | - Caroline Cornou
- Surgical Oncology Department, Centre Jean Perrin, 63011 Clermont-Ferrand, France;
| | - Isabelle Treilleux
- GINECO Group, 75008 Paris, France; (G.F.); (L.F.); (N.I.); (P.-E.C.); (R.S.); (M.D.-S.); (C.D.); (G.B.); (D.B.); (E.K.); (P.P.); (C.P.); (I.T.)
- Tumor Biology Department, Centre Léon Bérard, 69008 Lyon, France
| | | | - Isabelle Ray-Coquard
- Medical Oncology Department, Centre Léon Bérard, 69008 Lyon, France; (A.C.); (I.R.-C.)
- GINECO Group, 75008 Paris, France; (G.F.); (L.F.); (N.I.); (P.-E.C.); (R.S.); (M.D.-S.); (C.D.); (G.B.); (D.B.); (E.K.); (P.P.); (C.P.); (I.T.)
- University Claude Bernard Lyon 1, 69100 Villeurbanne, France
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12
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Squires BS, Quinn TJ, Nandalur SR, Jawad MS. Adjuvant radiotherapy improves overall survival when added to surgery and chemotherapy for uterine carcinosarcoma: a surveillance, epidemiology, and end results analysis. Int J Clin Oncol 2021; 26:2282-2294. [PMID: 34427803 DOI: 10.1007/s10147-021-02007-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 08/02/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Bryan S Squires
- Department of Radiation Oncology, Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI, 48073, USA.
| | - Thomas J Quinn
- Department of Radiation Oncology, Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI, 48073, USA
| | - Sirisha R Nandalur
- Department of Radiation Oncology, Beaumont Hospital, 44344 Dequindre Rd, Sterling Heights, MI, 48314, USA
| | - M Saada Jawad
- Department of Radiation Oncology, Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI, 48073, USA
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13
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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: 1] [Impact Index Per Article: 0.3] [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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14
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Uterine carcinosarcoma: An overview. Crit Rev Oncol Hematol 2021; 163:103369. [PMID: 34051304 DOI: 10.1016/j.critrevonc.2021.103369] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/11/2021] [Accepted: 05/14/2021] [Indexed: 12/28/2022] Open
Abstract
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.
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15
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The Effect of Adjuvant Pelvic Radiotherapy on Distant Metastasis for Uterine Carcinosarcoma. Am J Clin Oncol 2021; 44:169-173. [PMID: 33481373 DOI: 10.1097/coc.0000000000000795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Kyriazoglou A, Liontos M, Ntanasis-Stathopoulos I, Gavriatopoulou M. The systemic treatment of uterine leiomyosarcomas: A systematic review. No news is good news? Medicine (Baltimore) 2021; 100:e25309. [PMID: 33787622 PMCID: PMC8021365 DOI: 10.1097/md.0000000000025309] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 03/05/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Uterine leiomyosarcomas are rare malignant mesenchymal tumors. The systemic treatment of these tumors includes chemotherapy and radiotherapy. However, there are still a lot of unanswered questions regarding the ideal therapeutic approach. METHODS We have conducted a systematic review of the treatment strategies of uterine leiomyosarcomas for the last ten years. RESULTS Adjuvant chemotherapy is still a matter of dilemma. Doxorubicin based chemotherapy or the combination of Gemcitabine-Docetaxel are the regimens of choice for the first line setting. Beyond the first line, there are several options;, including chemotherapy, targeted therapy, and recently efforts of introducing immunotherapy to the therapeutic armamentarium of clinicians treating uterine leiomyosarcomas. CONCLUSIONS Despite the efforts of the clinicians dealing with uterine leiomyosarcomas, the optimal therapeutic algorithm is yet to be described.
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17
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The Role of Postoperative Radiotherapy for Carcinosarcoma of the Uterus. Cancers (Basel) 2020; 12:cancers12123573. [PMID: 33265910 PMCID: PMC7760981 DOI: 10.3390/cancers12123573] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 11/23/2020] [Accepted: 11/27/2020] [Indexed: 11/16/2022] Open
Abstract
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.
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18
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Ferrandina G, Aristei C, Biondetti PR, Cananzi FCM, Casali P, Ciccarone F, Colombo N, Comandone A, Corvo' R, De Iaco P, Dei Tos AP, Donato V, Fiore M, Franchi, Gadducci A, Gronchi A, Guerriero S, Infante A, Odicino F, Pirronti T, Quagliuolo V, Sanfilippo R, Testa AC, Zannoni GF, Scambia G, Lorusso D. Italian consensus conference on management of uterine sarcomas on behalf of S.I.G.O. (Societa' italiana di Ginecologia E Ostetricia). Eur J Cancer 2020; 139:149-168. [PMID: 32992154 DOI: 10.1016/j.ejca.2020.08.016] [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: 06/01/2020] [Revised: 08/10/2020] [Accepted: 08/22/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Uterine sarcomas are very rare tumours with different histotypes, molecular features and clinical outcomes; therefore, it is difficult to carry out prospective clinical trials, and this often results in heterogeneous management of patients in the clinical practice. AIM We planned to set up an Italian consensus conference on these diseases in order to provide recommendations on treatments and quality of care in our country. RESULTS Early-stage uterine sarcomas are managed by hysterectomy + bilateral salpingo-oophorectomy according to menopausal status and histology; lymphadenectomy is not indicated in patients without bulky nodes, and morcellation must be avoided. The postoperative management is represented by observation, even though chemotherapy can be considered in some high-risk patients. In early-stage low-grade endometrial stromal sarcoma and adenosarcomas without sarcomatous overgrowth, hormonal adjuvant treatment can be offered based on hormone receptor expression. In selected cases, external beam radiotherapy ± brachytherapy can be considered to increase local control only. Patients with advanced disease involving the abdomen can be offered primary chemotherapy (or hormonal therapy in the case of low-grade endometrial stromal sarcoma and adenosarcoma without sarcomatous overgrowth), even if potentially resectable in the absence of residual disease in order to test the chemosensitivity (or hormonosensitivity); debulking surgery can be considered in patients with clinical and radiological response. Chemotherapy is based on anthracyclines ± ifosfamide or dacarbazine. Palliative radiotherapy can be offered for symptom control, and stereotactic radiotherapy can be used for up to five isolated metastatic lesions. CONCLUSIONS Treatment of uterine sarcoma should be centralised at referral centres and managed in a multidisciplinary setting.
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Affiliation(s)
- Gabriella Ferrandina
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Gynecologic Oncology Unit, Roma, Italy; Universita' Cattolica Del Sacro Cuore, Roma, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, Perugia General Hospital, Perugia, Italy
| | - Pietro Raimondo Biondetti
- Department of Radiology, Ca' Granda IRCSS Maggiore Policlinico Hospital Foundation Trust, Milan, Italy
| | | | - Paolo Casali
- Department of Cancer Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Francesca Ciccarone
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Gynecologic Oncology Unit, Roma, Italy
| | - Nicoletta Colombo
- Gynecologic Cancer Program, University of Milan-Bicocca and European Institute of Oncology, IRCCS, Milan, Italy
| | - Alessandro Comandone
- Division of Medical Oncology, Humanitas Gradenigo Hospital, Turin, Italy; ASL Città di Torino, Turin, Italy
| | - Renzo Corvo'
- Radiation Oncology Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Health Science Department (DISSAL), University of Genoa, Genoa, Italy
| | - Pierandrea De Iaco
- Unit of Oncologic Gynecology, Department of Obstetrics and Gynecology, University of Bologna, Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Angelo Paolo Dei Tos
- Department of Pathology, Treviso General Hospital Treviso, Padova, Italy; University of Padua, Padova, Italy
| | - Vittorio Donato
- Radiation Oncology Division, Oncology and Specialty Medicine Department, San Camillo-Forlanini Hospital, Roma, Italy
| | - Marco Fiore
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Franchi
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Angiolo Gadducci
- Department of Clinical and Experimental Medicine, Division of Gynecology and Obstetrics, University of Pisa, Pisa, Italy
| | - Alessandro Gronchi
- Chair Sarcoma Service, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Stefano Guerriero
- Department of Obstetrics and Gynecology, University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato, Cagliari, Italy
| | - Amato Infante
- UOC COVID-2, Department of Bioimaging and Radiological Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Italy
| | - Franco Odicino
- Division of Obstetrics and Gynecology, ASST Spedali Civili di Brescia, Università degli Studi di Brescia, Italy
| | - Tommaso Pirronti
- UOC COVID-2, Department of Bioimaging and Radiological Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Italy; Catholic University of Sacred Hearth, Department of Radiology, Rome, Italy
| | - Vittorio Quagliuolo
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Roberta Sanfilippo
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Antonia Carla Testa
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Gynecologic Oncology Unit, Roma, Italy; Universita' Cattolica Del Sacro Cuore, Roma, Italy
| | - Gian Franco Zannoni
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Department of Woman, Child and Public Health Sciences, Gynecopathology and Breast Pathology Unit, Rome, Italy; Pathological Anatomy Institute, Catholic University of Sacred Hearth, Rome, Italy
| | - Giovanni Scambia
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Gynecologic Oncology Unit, Roma, Italy; Universita' Cattolica Del Sacro Cuore, Roma, Italy.
| | - Domenica Lorusso
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Gynecologic Oncology Unit, Roma, Italy; Universita' Cattolica Del Sacro Cuore, Roma, Italy
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Setia A, Kumar D, Bains L, Sharma P, Tempe A, Mallya V. Renal Hemangioblastoma with Mixed Mullerian tumour of endometrium: A tale of two rare primary tumours. World J Surg Oncol 2020; 18:154. [PMID: 32631354 PMCID: PMC7339407 DOI: 10.1186/s12957-020-01929-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 06/22/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Renal hemangioblastoma (RH) is a very rare benign tumour. Hemangioblastoma most commonly occurs in the central nervous system (CNS), and only few cases of RH have been reported as they occur most commonly as asymptomatic masses found incidentally. Mixed Mullerian tumour (MMT) of the uterus is a rarer and aggressive form of uterine malignancy. The detection of two primary rare tumours incidentally is a rare entity. CASE PRESENTATION A 50-year-old female presented with abnormal uterine bleeding which on endometrial sampling was diagnosed as a rare variety of endometrial cancer, i.e. MMT or uterine carcinosarcoma. On preoperative imaging, a renal mass was also detected which was highly vascular and was mimicking renal cell carcinoma (RCC). Fine needle aspiration cytology (FNAC) was done from the renal mass to differentiate between RCC and metastasis, but it showed only blood cells. Patient underwent staging laparotomy for endometrial cancer and frozen section examination of the renal mass which was inconclusive with few atypical cells, and thus, patient underwent radical nephrectomy too. Histopathological examination revealed it to be a RH which is a very rare benign tumour. DISCUSSION RH is a rare benign tumour which does not require any treatment in majority of the patients. Only 26 cases of RH outside the CNS have been reported till date. MMT is a rare aggressive uterine tumour with an incidence of 1-2 % of all uterine neoplasms, which metastasizes early, and thus, early identification and treatment is the key. RH needs to be differentiated from RCC to avoid over treatment. Morphological findings are similar in RCC and RH; preoperative FNAC, PET scan, and intraoperative frozen section can be utilized to differentiate the two, in well-circumcised tumours and high index of suspicion. Occurrence of renal mass as an incidental finding in the preoperative work up of uterine malignancy directed us to the differentials of metastasis or another histologically distinct primary tumour. The presence of two rare primary tumours, i.e. RH and MMT in the same patient which are unrelated, is a rare entity.
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Affiliation(s)
- Aparna Setia
- Department of Obstetrics and Gynaecology, Maulana Azad Medical College, New Delhi, India
| | - Devender Kumar
- Department of Obstetrics and Gynaecology, Maulana Azad Medical College, New Delhi, India
| | - Lovenish Bains
- Department of Surgery, Maulana Azad Medical College, New Delhi, India.
| | - Pallavi Sharma
- Department of Obstetrics and Gynaecology, Maulana Azad Medical College, New Delhi, India
| | - Anjali Tempe
- Department of Obstetrics and Gynaecology, Maulana Azad Medical College, New Delhi, India
| | - Varuna Mallya
- Department of Pathology, Maulana Azad Medical College, New Delhi, India
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Meng Y, Yang Y, Zhang Y, Li X. Construction and Validation of Nomograms for Predicting the Prognosis of Uterine Leiomyosarcoma: A Population-Based Study. Med Sci Monit 2020; 26:e922739. [PMID: 32270788 PMCID: PMC7170014 DOI: 10.12659/msm.922739] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Uterine leiomyosarcoma (uLMS) is a rare female malignancy with poor survival rates. The objective of this study was to construct prognostic nomograms for predicting the prognosis of women with uLMS. MATERIAL AND METHODS Patients with uLMS diagnosed between 2004 and 2015 were identified in the Surveillance, Epidemiology, and End Results (SEER) database. The essential clinical predictors were identified via univariate and multivariate Cox analysis models. Nomograms were constructed to predict the 3- and 5-year cancer-specific survival (CSS) and overall survival (OS) rates. Concordance index (C-index) and calibration plots were constructed to validate the predictive performance of nomograms. RESULTS We enrolled 1448 patients with uLMS from the SEER database, with 1016 categorized into a training set and 432 categorized into a validation set. In multivariate analysis of the training set, predictors including age, disease stage, histological grade, tumor size, and surgery type were found to be associated with OS and CSS. Race and chemotherapy were only associated with OS. Construction of nomograms based on these predictors was performed to evaluate the prognosis of uLMS patients. The C-index and calibration curves also showed the satisfactory performance of these nomograms for prediction of prognosis. CONCLUSIONS The developed nomograms are useful tools for precisely analyzing the prognosis of uLMS patients, which could help clinicians in making personalized survival predictions and assessing individualized clinical options.
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Affiliation(s)
- Yue Meng
- Department of Gynecology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Yuebo Yang
- Department of Gynecology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Yu Zhang
- Department of Gynecology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Xiaomao Li
- Department of Gynecology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
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de Almeida BC, dos Anjos LG, Uno M, da Cunha IW, Soares FA, Baiocchi G, Baracat EC, Carvalho KC. Let-7 miRNA's Expression Profile and Its Potential Prognostic Role in Uterine Leiomyosarcoma. Cells 2019; 8:cells8111452. [PMID: 31744257 PMCID: PMC6912804 DOI: 10.3390/cells8111452] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/06/2019] [Accepted: 11/14/2019] [Indexed: 02/06/2023] Open
Abstract
The lethal-7 (let-7) family is an important microRNA (miRNA) group that usually exerts functions as a tumor suppressor. We aimed to evaluate the expression profile of let-7a, let-7b, let-7c, let-7d, let-7e, let-7f, let-7g, and let-7i and to assess their value as prognostic markers in uterine leiomyosarcoma (LMS) patients. The miRNAs expression profile was assessed in 34 LMS and 13 normal myometrium (MM) paraffin-embedded samples. All let-7 family members showed downregulation in LMS. Our findings showed that patients with let-7e downregulation had worse overall survival (OS) and is an independent prognostic factor (hazard ratio [HR] = 2.24). In addition, almost half the patients had distant metastasis. LMS patients with downregulated let-7b and let-7d had worse disease-free survival (DFS); they are not independent prognostic factors (HR = 2.65). Patients’ ages were associated with let-7d, let-7e and let-7f (p = 0.0160) downregulation. In conclusion, all the let-7 family members were downregulated in LMS patients, and the greater the loss of expression of these molecules, the greater their relationship with worse prognosis of patients. Let-7e expression might influence the OS, while let-7b and le-7d might influence the DFS. The lowest expression levels of let-7d, let-7e, and let-7f were associated with the oldest patients. Our findings indicate strong evidence of let-7’s role as a potential prognostic biomarker in LMS.
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Affiliation(s)
- Bruna Cristine de Almeida
- Laboratório de Ginecologia Estrutural e Molecular (LIM 58), Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, HCFMUSP, SP, BR Av. Dr Arnaldo 455, sala 4121, Cerqueira Cesar, São Paulo 05403-010, Brazil; (B.C.d.A.); (L.G.d.A.); (E.C.B.)
| | - Laura Gonzalez dos Anjos
- Laboratório de Ginecologia Estrutural e Molecular (LIM 58), Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, HCFMUSP, SP, BR Av. Dr Arnaldo 455, sala 4121, Cerqueira Cesar, São Paulo 05403-010, Brazil; (B.C.d.A.); (L.G.d.A.); (E.C.B.)
| | - Miyuki Uno
- Centro de Investigação Translacional em Oncologia (LIM 24), Instituto do Câncer do Estado de São Paulo (CTO/ICESP) Av Dr Arnaldo 251 sala 23 8 andar, São Paulo 01246000, Brazil;
| | - Isabela Werneck da Cunha
- Department of Pathology, Rede D’OR-São Luiz, Rua das Perobas, 344-Jabaquara, São Paulo 04321-120, Brazil; (I.W.d.C.); (F.A.S.)
- Hospital A C Camargo Cancer Center, SP, BR R. Tamandaré, 753 Liberdade, São Paulo 05403-010, Brazil
- National Institute for Science and Technology in Oncogenomics and Therapeutic Innovation, SP, BR R. Tamandaré, 753 Liberdade, São Paulo 05403-010, Brazil
| | - Fernando Augusto Soares
- Department of Pathology, Rede D’OR-São Luiz, Rua das Perobas, 344-Jabaquara, São Paulo 04321-120, Brazil; (I.W.d.C.); (F.A.S.)
- Hospital A C Camargo Cancer Center, SP, BR R. Tamandaré, 753 Liberdade, São Paulo 05403-010, Brazil
- National Institute for Science and Technology in Oncogenomics and Therapeutic Innovation, SP, BR R. Tamandaré, 753 Liberdade, São Paulo 05403-010, Brazil
| | - Glauco Baiocchi
- Department of Gynecology Oncology, A.C.Camargo Cancer Center, Rua Prof Antonio Prudente 211, São Paulo 01509-001, Brazil;
| | - Edmund Chada Baracat
- Laboratório de Ginecologia Estrutural e Molecular (LIM 58), Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, HCFMUSP, SP, BR Av. Dr Arnaldo 455, sala 4121, Cerqueira Cesar, São Paulo 05403-010, Brazil; (B.C.d.A.); (L.G.d.A.); (E.C.B.)
| | - Katia Candido Carvalho
- Laboratório de Ginecologia Estrutural e Molecular (LIM 58), Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, HCFMUSP, SP, BR Av. Dr Arnaldo 455, sala 4121, Cerqueira Cesar, São Paulo 05403-010, Brazil; (B.C.d.A.); (L.G.d.A.); (E.C.B.)
- Correspondence: ; Tel.: +55-011-3061-7486
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