uterine sarcoma prof greta dreyer university of pretoria
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Uterine SarcomaProf Greta DreyerUniversity of Pretoria
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Challenging Rare → Limited data
Rapidly growing (doubling time is 4 weeks)
Incidence appears to be increasing
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Epidemiology Rare 2% to 5% of all uterine malignancies
17 per million women annually [Platz, & Benda, 1995]
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Risk Factors prior pelvic radiation (10%-25% of
cases) 3X increase in risk among black
women (Brooks et al, April, 2004)
Data regarding parity and time of menarche and menopause as risk factors are inconclusive (Sherman & Devesa ,2003)
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Long-term adjuvant tamoxifen An increase in the risk of uterine
sarcomas appears to accompany the use of long-term adjuvant tamoxifen in women with breast cancer
[Wickerham et al, 2002, Wysowski et al, 2002].
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Histologic Classification
Type Homologous Heterologous
Pure Leimyosarcoma Rhabdomyosarcoma
Stromal sarcoma Chondrosarcoma
(i) endolymphatic stromal sarcoma
Osteosarcoma
(ii) Endometrial stromal sarcoma
Liposarcoma
Mixed Carcinosarcoma Mixed mesodermal sarcoma
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GOG , 1993 Mixed mullerian sarcomas - 50% Leiomyosarcoma (30%). Endometrial stromal sarcoma (15%) Adenosarcoma (5%)
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Leiomyosarcoma (30%)
Arise from smooth muscles of the uterus usually de novo
Appear grossly as a large (>10 cm) yellow or tan solitary mass with soft, fleshy cut surfaces exhibiting hemorrhage and necrosis [Viereck et
al, 2002].
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Leiomyosarcoma
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Leiomyosarcoma: Low or high grade Frequent mitotic figures significant nuclear atypia, presence of coagulative necrosis of
tumor cells. [Bell et al, 1994 ]
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Zaloudek & Norris classification
Diagnosis
Mitosis/10 HPF Cytological atypia
Leiomyoma
< 5 ---------
Atypical (cellular)
< 5 present
Uncertain malignant potential
5-9 absent
Liemyosarcoma (low risk)
5-9 present
Leimyosarcoma (high risk)
> 10 Absent or present
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Endometrial stromal tumors : A pure homologous neoplasm Subtypes: low and high grade Low grade : slow growing tumors with
infrequent metastasis or recurrence after therapy. [Oliva, et al, 2000].
high grade : enlarge and metastasize quickly and are often fatal.
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Mixed malignant mullerian sarcomas Both carcinomatous and
sarcomatous elements must be present in this type of sarcoma.
metastasize early in the course of the disease via hematogenous and lymphatic pathways
grows as a polypoidal mass with a broad base
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Mixed malignant mullerian sarcomas Mixed müllerian homologous sarcomas
(carcinosarcoma) contain only tissue elements that are endogenous to the uterus.
In contrast, if exogenous tissue is present (eg, bone, cartilage, fat), the tumor should be classified as a mixed heterologous müllerian sarcoma (mixed mesodermal sarcoma).
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Carcinosarcoma or MMMT
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Adenosarcoma both malignant stromal and benign
epithelial components a significantly increased occurrence
of this tumor (Seidman et al, 1999)
present as polypoid masses
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Clinical Diagnosis Vaginal bleeding is the most
common presenting symptom of a uterine sarcoma.
On pelvic examination, the uterus is enlarged and, in some patients, part of the tumor may protrude from the uterine cavity through the cervical os.
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Rapidly growing Among 341 women with a rapidly
growing uterus by clinical or ultrasound examination, only one (0.27 percent) had a uterine sarcoma. [Parker et al, 1994].
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Should be considered in postmenopausal women with a
pelvic mass, abnormal bleeding, and pelvic pain, where the incidence of sarcoma is 1 to 2 percent [Leibsohn et al, 1990]
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Evaluation Ultrasound examination, MRI, or CT
scan cannot reliably distinguish between a sarcoma, leiomyoma or endometrial cancer [Rha et al, 2003].
The diagnosis of uterine sarcomas is made from histologic examination of the entire uterus
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Staging:
based on FIGO staging for endometrial cancer
Stage Description
I Sarcoma is confined to the corpus
II Sarcoma is confined to the corpus and cervix
III Sarcoma has spread outside the uterus but is confined to the true pelvis
IV Sarcoma has spread outside the true pelvis
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Lymph node dissection patients with uterine sarcoma
grossly confined to the uterus/cervix showed lymph node metastases in 5 of 101 patients
should be done in all women who can tolerate the procedure?? / with clinically suspicious nodes?? [Leitao et al, 2003 ]
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Further support In one series of 208 women with
uterine leiomyosarcoma, only four of 36 who underwent lymph node sampling had positive nodes [Giuntoli
et al, 2003].
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Screening
because of their rarity, uterine sarcomas are not suitable for screening. (Levenback, 1996)
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Surgery
is the only curative therapy for uterine sarcomas [Morice et
al, 2003]
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Modalities Surgery (total abdominal
hysterectomy, bilateral salpingo-oophorectomy).
Surgery plus adjuvant chemotherapy.
Surgery plus adjuvant irradiation
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Is it beneficial Interpretation of the possible benefit
of different modalities is hampered by the difficulty in comparing outcomes from series in which patients of varying stages and histologies were reported
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The five year survivals Surgery alone (46 %) Surgery and radiotherapy (62 %) Surgery and chemotherapy (43 %) Radiation alone (8 %)
Weitmann et al, 2001
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The three-year local recurrence rates No adjuvant treatment 62 % Whole pelvis external beam
radiation therapy 31 % Chemotherapy alone 71 percent
[Livi et al, 2003]
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Adjuvant radiation therapy The value of pelvic radiation is not
established Some studies of postoperative radiation
suggest a survival benefit [Moskovic et al, 1993 Knocke et al, 1998, Weitmann et al, 2001].
Other studies showed cure rate was similar for those treated with surgery alone or followed by radiation, regardless of the stage of disease [Giuntoli et al, 2003]
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Complications of Radiation Complications of Radiation Tx:Tx:
Acute: Fever Perforation Diarrhea Bladder spasm
Chronic:
Fistula Enteritis Cystitis (a/w
UTI) Proctitis
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Adjuvant chemotherapy Current studies consist primarily of
Phase II chemotherapy trials for advanced disease
The role of chemotherapy in the treatment of uterine sarcomas has been limited
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Adjuvant therapy Adjuvant chemotherapy following
complete resection (stage I and II) has not been established to be effective in a randomized trial
nonrandomized trials have reported improved survival following adjuvant chemotherapy with or without radiation therapy Piver et al, 1988 ,van Nagell , et al, 1986, Peters et al, 1989
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Leiomyosarcoma doxorubicin is an effective drug for
advanced leiomyosarcoma combinations with doxorubicin
increase the objective response rate but add substantial toxicity
A very recent small trial showed promising results with gemcitabine plus docetaxel [Hensley et al, 2002].
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Carcinosarcoma
Women with carcinosarcoma may benefit from cisplatin-based chemotherapy, particularly combinations of cisplatin with doxorubicin and ifosfamide, or single agent paclitaxel [Gallup et al, 2003 , van Rijswijk et al, 2003, Harris et al, 2003]
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Mixed mesodermal tumors Cisplatin and ifosfamide appear to
have greater activity than does doxorubicin alone [Ramondetta et al,
2003]. In a very small uncontrolled trial :
cisplatin, doxorubicin, and dacarbazine give three year survivals of 51 % [Baker et al, 1991].
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Hormone therapy Estrogen, progesterone, and other
hormone receptors are present in leiomyosarcomas and endometrial stromal sarcomas but do not predict hormone responsiveness.
In fact, only one of 28 patients with residual or recurrent disease following surgery had an objective response to hormone therapy
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Recurrent Disease Most relapses occur in the pelvis,
followed by lung and abdomen currently no standard therapy for
patients with recurrent disease
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In a recent RCT 2000 ifosfamide with or without cisplatin
for recurrent sarcoma demonstrated a higher response
rate on the combination arm However,use of the combination was
not justified because of increased toxic effects [Sutton et al, 2000]
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Prognosis
poor prognosis the 5-year survival : stage I less than
50% remaining stages : 0% to 20%. strongest predictor of survival was
menopausal status at time of diagnosis[Major et al, 1993]
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leiomyosarcoma age over 50 years was a poor
prognostic factor, as was size greater than 5 cm [Giuntoli et al,
2003].
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Conclusion Aggressive surgical cytoreduction at
the time of initial diagnosis offers the best survival
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Thank You