Pathologic Variables and Survival for Patients with Surgically Evaluated Carcinomasarcoma of the Uterus
Pathologic Variables and Survival for Patients with Surgically Evaluated Carcinomasarcoma of the Uterus
abstract & commentary
Synopsis: More than half of patients with carcinosarcoma clinically confined to the uterine corpus harbor occult metastases in a pattern similar to that found with endometrial carcinoma.
Source: Yamada DS, et al. Cancer 2000;88:2782-2786.
Yamada and colleagues identified patients with carcinosarcoma clinically confined to the uterine corpus who underwent primary surgical assessment. The purpose of their study was to determine clinicopathologic variables associated with extrauterine disease, recurrence, and survival. Occult metastases were found in 38 of 62 patients (61%). At last follow-up, 31 (50%) had recurrence, with an extrapelvic component in 43%, and 53% had died. Depth of myometrial invasion and lymph-vascular space invasion (LVSI) were associated with extrauterine disease. Factors associated with recurrence and survival included depth of myometrial invasion, LVSI, adnexal and serosal involvement, positive cytology, and lymph node metastases. Of 24 patients with uterine disease only, 11 received no adjuvant therapy, yet eight (73%) were free of disease at last follow-up. Neither adjuvant radiotherapy nor chemotherapy was identified as an independent prognostic factor for recurrence or survival. Yamada et al concluded that more than half of patients with carcinosarcoma clinically confined to the uterine corpus harbor occult metastases in a pattern similar to that found with endometrial carcinoma. They further stated that, although the benefit of adjuvant therapy cannot be demonstrated by this study, a number of early-stage patients survive without adjuvant therapy. They recommend extending the International Federation of Gynecology and Obstetrics (FIGO) surgical staging system for endometrial carcinoma to include carcinosarcoma, and they also recommend conducting prospective trials to examine the benefits of adjuvant therapy for patients with early stage disease.
Comment by David M. Gershenson, MD
Mixed mullerian tumors of the uterus, or carcinosarcoma, comprise approximately 5% of all uterine cancers. They are the most common of the uterine sarcomas, and they are noted to have an aggressive behavior. As Yamada et al point out, these tumors are excluded from the FIGO staging system. In this study, 61% of patients had occult extrauterine metastases—an incidence higher than in most series. This high incidence is probably related to surgical staging that was more extensive than usual in this study population. The extent of surgical staging was also responsible for the higher than usual five-year survival for patients with disease confined to the uterine corpus—74%. In most studies, the five-year survival for this group is approximately 50%. Such findings argue for comprehensive surgical staging in patients with such tumors. This study highlights the most important issue regarding uterine sarcomas—the efficacy of adjuvant treatment for patients with disease limited to the uterine corpus. Interestingly, eight out of 11 (73%) patients who received no adjuvant therapy were disease-free at the time of follow-up; however, the number of patients in this study is much too small to resolve this dilemma. The dogma states that, for instance, adjuvant radiotherapy may reduce the incidence of local recurrence but does not improve survival. The few randomized trials that have been conducted have shown no benefits of the adjuvant therapy studied. I agree with Yamada et al that there is a need for further prospective randomized trials to identify efficacious adjuvant therapy.
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