A retrospective assessment of outcomes of chemotherapy-based versus radiation-only adjuvant treatment for completely resected stage I-IV uterine carcinosarcoma

PurposeTo determine the progression-free survival (PFS) and overall survival (OS) in a cohort of patients who received either platinum-based chemotherapy with or without radiation therapy (pelvic or WAI), or RT alone.MethodsMemorial Sloan-Kettering Cancer Center (MSKCC) electronic medical records from 8/1/1995 to 10/3/2007 were reviewed for patient age, diagnosis date, type of primary surgery, residual disease at the completion of primary surgery, FIGO stage, treatment details, dates of progression and death, and site(s) of first recurrence. PFS and OS by stage (I/II v III/IV) and by treatment type (chemotherapy with or without RT v RT alone) were determined using landmark analyses 8 weeks after surgery. Patients who received chemotherapy with or without RT (pelvic or abdominal) or RT alone (pelvic or abdominal) were included in the analysis. Both groups were allowed to have received intravaginal radiation therapy (IVRT).ResultsForty-nine patients met study criteria. Thirty-eight/49 patients received chemotherapy: 23/38 (60.5%) received paclitaxel-carboplatin; 7/38 (18.4%) received ifosfamide-platinum; 8/38 (21.0%) received other chemotherapy. FIGO stage was: I = 15 (31%); II = 5 (10%); III = 21 (43%); IV = 8 (16%). Three-year PFS for the entire cohort was 24%. Three-year OS for the entire cohort was 60%. Three-year median PFS time for the entire cohort was 15 months (95% CI: 11–25 months). Three-year median OS time for the entire cohort was 67 months (95% CI: 23–89 months). Three-year PFS for stages I–II was 43% v 14% for stages III–IV (HR = 1.98 [0.9–4.33]); P = 0.082. Three-year OS for stages I–II was 68% v 55% for stages III–IV (HR = 1.26 [0.47–3.41]); P = 0.648. Three-year PFS for chemotherapy with or without RT was 35% v 9% for RT alone (HR = 1.74 [0.79–3.85]); P = 0.164. Three-year OS for chemotherapy with or without RT was 66% v 34% for RT alone (HR = 2.02 [0.77–5.33]); P = 0.146.ConclusionsOur study corroborates GOG 150 results, and shows that paclitaxel-carboplatin appears to be an efficacious adjuvant chemotherapy regimen for completely resected uterine carcinosarcoma. The role of adjuvant RT in addition to chemotherapy warrants further investigation.     

Comparison of outcomes in early stage uterine carcinosarcoma and uterine serous carcinoma

Objective

To assess whether contemporary adjuvant management of early stage uterine carcinosarcoma (CS) produces equal outcomes as in uterine serous carcinoma (USC).

Methods

We reviewed 172 women treated from 2000 to 2011 for stage I–II USC (n = 112, 65%) or CS (n = 60, 35%). Adjuvant therapy was initiated in 154 (90%) patients, with 111 patients receiving intravaginal radiotherapy (IVRT)/chemotherapy. Median follow up was 4.6 years for surviving patients.

Results

Characteristics for USC vs. CS did not differ significantly by age ≥ 60, pelvic or para-aortic node sampling, stage, lymphovascular invasion, chemotherapy use, RT use or omission of adjuvant therapy. Outcomes were better for USC vs. CS in 5-year actuarial rates of recurrence [17% (C.I. 10–25%) vs. 45% (C.I. 31–59%), p < 0.001],disease-related mortality (DRM) [11% (5–17%) vs. 30% (16–44%), p = 0.016], and all-cause mortality [12% (C.I. 6–18%) vs. 34% (C.I. 20–48%), p = 0.007]. In multivariable analysis, CS histology remained a significant predictor of risk for recurrence [HR 3.1 (C.I. 1.7–5.7), p < 0.001], DRM [HR 2.4 (C.I. 1.1–5.1), p = 0.024], and all-cause mortality [HR 2.4 (C.I. 1.2–4.8), p = 0.012]. On sub-group analysis of 111 patients (77 USC, 34 CS) able to receive IVRT/chemotherapy, CS no longer was associated significantly with increased recurrence (29% vs. 15%, p = 0.18), DRM (22% vs. 10%, p = 0.39), or all-cause mortality (22% vs. 10%, p = 0.45).

Conclusions

CS was associated with worse outcomes than USC. However, that difference was not maintained in patients able to receive IVRT and chemotherapy. While intriguing, this result may be due in part to selection against rapid early relapsing CS patients in this group.     

Case of uterine cervical carcinosarcoma

Carcinosarcoma (CS) is a rare neoplasm that is called a mixed epithelial and mesenchymal malignancy. CS of the uterine cervix is much less common than its counterparts in the uterine corpus. A 61-year-old, gravida 2, para 2 woman, who had undergone menopause 16 years prior to the presentation, was diagnosed with CS of the uterine cervix. A semiradical hysterectomy was carried out on the diagnosis of stage Ib1 cervical cancer. The patient underwent whole pelvic 45 Gy radiation as a postoperative additional treatment, but she died from multiple organ failure by metastasis 17 months after the operation. The tumor protruded from the cervix to the vagina and measured 4.5 x 3.0 cm. Histologically, the tumor was characterized as a squamous cell carcinoma and mesenchymal malignancy, represented by osteosarcomatous components. The stroma was largely composed of atypical spindle-shaped cells, which were immunohistochemically demonstrated to be of epithelial origin. Uterine cervical CS is one of the aggressive malignancies, and squamous cell carcinomas are common epithelial counterparts of cervical CS as well as adenocarcinomas.     

Adjuvant therapy for stage I uterine sarcoma

A retrospective evaluation of adjuvant therapy in 64 patients with Stage I sarcoma was undertaken. A combination of operation and adjuvant radiation was compared with operation alone. A decreased recurrence of both pelvic and distant tumor was noted for endometrial sarcoma but not for leiomyosarcoma treated with adjuvant radiation. A Cox regression analysis showed a trend for improved survival, but the results were not statistically significant. Survival after vaginal cuff recurrence and treatment with radiation therapy (two patients) or combined radiation and chemotherapy (one patient) is reported. Seven patients received adjuvant chemotherapy with Adriamycin-based regimens. Chemotherapy alone did not statistically decrease recurrence in this small sample.     

Combined diagnostic imaging of uterine carcinosarcoma: A case report

Abstract. Umesaki N, Tanaka T, Miyama M, Ogita S, Ochi H. Combined diagnostic imaging of uterine carcinosarcoma. A case report.
The diagnostic imaging characteristics of uterine carcinosarcoma have not been established because the tumor is very rare. We studied magnetic resonance (MR) imaging, power Doppler ultrasonography, and positron emission tomography (PET) in one such carcinosarcoma to define its imaging characteristics. On T1-weighted MR images, the tumor mass in the uterus was low-signal intensity and had a slight inhomogeneous appearance. On T2-weighted images, it had a heterogeneous appearance and was of medium- or high-signal intensity; marked flow void was apparent from the myometrium to the tumor mass. The MR flow void was also detected by power Doppler ultrasonography. Increased glucose metabolism was detected on PET images, suggesting a malignant tumor in the endometrial cavity. Combined diagnostic images with MR, power Doppler ultrasonography, and PET is recommended as the diagnostic method for uterine carcinosarcoma.     

A comparison between different postoperative treatment modalities of uterine carcinosarcoma

OBJECTIVE: Uterine carcinosarcomas are highly aggressive neoplasms with no established effective adjuvant therapy. The aim of the present study was to compare between the outcome in three medical institutions in each of which a different postoperative treatment modality was preferred, namely, chemotherapy in one, whole pelvic irradiation (WPI) in another, and sequential treatment (i.e., chemotherapy followed by WPI) in the third. METHODS: The hospital records of all 49 uterine carcinosarcoma patients diagnosed and operated from 1995 to 2003 in the three institutions were reviewed. Non-parametric test was used to compare the median age between the treatment groups. Survival was calculated using the Kaplan-Meier method and compared by the log-rank test. Cox proportional hazard regression model was used to assess the effect of treatment type on survival after adjustment for stage. RESULTS: Only about half of the patients (51%) had stage I at diagnosis and the majority of the patients (83.7%) had postoperative adjuvant treatment. The overall 5-year survival of the 41 patients that had postoperative treatment was 49.6%. The highest median survival and 5-year survival rate was observed in the sequential treatment group. Controlling for stage, this treatment modality was associated with a significant decrease in mortality of about 80% when compared to postoperative chemotherapy alone, and a non-significant decrease in mortality of about 50% when compared to WPI alone (HR = 0.20; 95% CI 0.04-0.99, P = 0.049 and HR = 0.50; 95% CI 0.1-2.32, P = 0.4, respectively). CONCLUSIONS: The improved outcome in patients who received postoperative sequential treatment seems to indicate that further exploration of this treatment modality is justified.     

Correlation of tumor size with other prognostic factors in uterine serous carcinoma: A large multi-institutional study

ObjectiveUterine serous carcinoma (USC) constitutes 10% of uterine cancers but ~ 40% of deaths. Tumor size is a known prognostic factor in other solid tumors. In endometriod cancers it is one element used to identify the need for complete staging, while its significance in USC is debated. Therefore tumor size was examined as an independent prognostic factor.MethodsClinical and pathologic variables were recorded for 236 institutional patients, and those patients in the SEER database with USC. Chi-square and Fisher exact t-tests were utilized and survival data generated via Kaplan–Meier method; multivariate analysis was performed via cox-regression.ResultsThe patients' mean age was 67.2 years (range 40–91). Survival ranged from 0 to 184 months (mean 42.8). We used a tumor size cut-off of 1 cm and noted significant associations with myometrial invasion (p < 0.0001), angiolymphatic invasion (p < 0.0001), peritoneal washings (p = 0.03), stage (p = 0.015) and positive lymph nodes (p = 0.05). Furthermore, recurrence was associated with larger tumors (p = 0.03). In multivariate analysis, extra-uterine disease was the only factor associated with both recurrence and survival. Review of the SEER database noted association of larger tumors with lymph node involvement and a significant survival advantage with tumors < 1 cm in both univariate and multivariate analysis.ConclusionsTreatment options for USC are often predicated on the surgical stage and therefore components of the staging are vitally important. The 1 cm tumor-size cut-off should be studied prospectively as a prognostic indicator of survival and recurrence in USC and considered for inclusion in USC staging.     

A patient-preference cohort study of office versus inpatient uterine polyp treatment for abnormal uterine bleeding

Uterine polyps can cause abnormal bleeding in women. Conventional practise is to remove them under general anaesthesia but advances in technology have made it possible to perform polypectomy in the office setting. We conducted a patient-preference study to explore women’s preferences for treatment setting and to evaluate the effectiveness and treatment experience of women undergoing uterine polypectomy. Three hundred ninety-nine women with abnormal uterine bleeding who were found to have uterine polyps at diagnostic hysteroscopy were recruited. Office polypectomies were performed in office hysteroscopy clinics, and inpatient procedures were undertaken in operating theatres. Three hundred twenty-four of 399 (81 %) expressed a preference for office treatment. There was no difference found between office treatment and inpatient treatment in terms of alleviating abnormal uterine bleeding as assessed by patients and in improving disease-specific quality of life. Acceptability was lower and patient pain scores were significantly higher in the office group. When offered a choice of treatment setting for uterine polypectomy, patients have a preference for office over inpatient treatment. Ambulatory gynaecology services should be available within healthcare systems to meet patient demand.     

Significance of venous thromboembolism in women with uterine carcinosarcoma

Objective

To identify risk factors for venous thromboembolism (VTE) and to examine the association of VTE and survival in women with uterine carcinosarcoma.

Five-year outcomes of adjuvant carboplatin/paclitaxel chemotherapy and intravaginal radiation for stage I-II papillary serous endometrial cancer

Objective

The purpose of this study is to report our single-institution experience with concurrent adjuvant intravaginal radiation (IVRT) and carboplatin/paclitaxel chemotherapy for early stage uterine papillary serous carcinoma (UPSC).

Methods

From 10/2000 to 12/2009, 41 women with stage I-II UPSC underwent surgery followed by IVRT (median dose of 21 Gy in 3 fractions) and concurrent carboplatin (AUC = 5-6) and paclitaxel (175 mg/m²) for six planned cycles. IVRT was administered on non-chemotherapy weeks. The Kaplan-Meier method was used to estimate survival, and the log-rank test was used for comparisons.

Results

Median patient age was 67 years (51-80 years). Surgery included hysterectomy, bilateral salpingo-oophorectomy, peritoneal washings, omental biopsy, and pelvic and paraaortic lymph node sampling. FIGO 2009 stage was IA in 73%, IB in 10%, and II in 17%. Histology was pure serous in 71% of cases. Thirty-five patients (85%) completed all planned treatment. With a median follow-up time of 58 months, the 5-year disease-free (DFS) and overall survival (OS) rates were 85% (95%CI, 73-96%) and 90% (95%CI, 80-100%). The 5-year pelvic, para-aortic, and distant recurrence rates were 9%, 5%, and 10%, respectively. There were no vaginal recurrences. Of the 4 pelvic recurrences, 2 were isolated and were successfully salvaged. Patients with stage II disease had lower DFS (71% vs. 88%; p = 0.017) and OS (71% vs. 93%; p = 0.001) than patients with stage I disease.

Conclusions

Concurrent adjuvant carboplatin/paclitaxel chemotherapy and IVRT provide excellent outcomes for early stage UPSC. Whether this regimen is superior to pelvic radiation will require confirmation from the ongoing randomized trial.