Sarcoma of uterus Flashcards
What % of uterine malignancies are sarcomas?
Sarcomas account for <10% of uterine malignancies.
What are the 3 most common histologic subtypes of uterine sarcoma?
Most common uterine sarcomas (From most common to least common):
- Leiomyosarcoma (LMS)
- Endometrial stromal sarcoma (ESS)
- Adenosarcoma
By strict definition, Carcinosarcoma, aka malignant mixed müllerian tumor (MMMT), is not considered to be a sarcoma, but rather an epithelial malignancy (carcinoma). The epithelial component predicts for lymphatic spread and the sarcomatous component predicts for local spread. (Tropé CG et al., Acta Oncol 2012)
How does a uterine sarcoma typically present?
Typical presentation by histologic subtype:
LMS and ESS: similar Sx and signs as uterine fibroids—fullness, early satiety, etc.
MMMT: vaginal bleeding
What is the incidence of nodal mets?
MMMT: 30% (20%–38%)
LMS: 8% (6.6%–9.1%), usually associated with extrauterine Dz
ESS: traditionally thought to be low. (A recent study of 831 pts with ESS showed a 10% incidence.) (Chan JK et al., Br J Cancer 2008)
How does the risk of DM compare b/t endometrial cancer and uterine sarcoma?
In general, uterine sarcomas have a higher rate of DM than endometrial cancer.
What is the most common site of mets in uterine sarcoma?
In uterine sarcoma, the most common site of mets is the lung.
For which histologic subtype of uterine sarcoma is grade most important
Grade is most important for ESS. Low-grade ESS is a hormone-sensitive low-grade malignancy with an indolent course, whereas high-grade ESS is
characterized by an aggressive clinical course and is now considered a different Dz entity.
What 4 categories comprise ESS?
- Endometrial stromal nodule
- ESS-low grade
- ESS-high grade
- Undifferentiated Uterine Sarcoma
What is the FIGO staging for uterine sarcoma?
MMMT is still staged according to the FIGO system for endometrial adenocarcinoma.
LMS and ESS staging:
FIGO I: limited to uterus
FIGO IA: ≤5 cm
FIGO IB: >5 cm
FIGO II: extends beyond uterus within pelvis
FIGO IIA: adnexal involvement
FIGO IIB: involves other pelvic structures
FIGO III: invades abdominal tissues (not just protruding into abdomen)
FIGO IIIA: 1 abdominal site
FIGO IIIB: >1 abdominal site
FIGO IIIC: mets to pelvic LNs, para-aortic (P-A) LNs, or both
FIGO IVA: invades bladder or rectum
FIGO IVB: DM (excludes abdominal, pelvic, or adnexa tissue)
What is the AJCC 8th edition staging for LMS and EMS?
T1a = FIGO IA T1b = FIGO IB T2a = FIGO IIA T2b = FIGO IIB T3a = FIGO IIIA T3b = FIGO IIIB T4 = FIGO IVA N0(i+) = isolated tumor cells ≤0.2 mm (note, no FIGO staging for N0(i+)) N1 = IIIC M1 = FIGO IVB
What is the FIGO and AJCC 8th edition staging for adenosarcoma?
FIGO I (T1): limited within uterus FIGO IA (T1a): only in endometrium and/or endocervix FIGO IB (T1b): <50% myometrium FIGO IC (T1c): >50% myometrium FIGO II (T2): beyond uterus within pelvis FIGO IIA (T2a): adnexa FIGO IIB (T2b): other pelvic structures FIGO III (T3): invades tissues of abdomen FIGO IIIA (T3a): 1 site FIGO IIIB (T3b): >1 site FIGO IIIC (N1): mets to pelvic LNs, P-A LNs, or both FIGO IVA: invades bladder or rectum FIGO IVB: DMs
How should the initial workup for uterine sarcoma differ from the workup for endometrial cancer?
The initial workup for uterine sarcoma is identical to the workup for endometrial cancer, but it should include a chest CT b/c of the increased risk
of pulmonary mets. Pelvic MRI should also be considered to determine extent of local spread. There is also anecdotal evidence that PET/CT may be
useful.
What is the primary Tx modality for uterine sarcoma?
Uterine sarcoma primary Tx modality: Type I hysterectomy and BSO is the mainstay. Ovarian preservation may be considered in young pts with earlystage LMS and low-grade ESS. The role of RT, chemo, and HRT is still controversial.
What is the role of LND in the Tx of uterine sarcoma?
Pelvic LND, P-A LND, or both for uterine sarcoma is considered controversial. They usually are recommended in MMMT and undifferentiated
sarcoma. They usually are not recommended in LMS and ESS without extrauterine Dz.
Is there a benefit to postop pelvic RT for the management of uterine sarcomas?
The role of adj RT remains controversial. The issue has been addressed in at least 1 randomized trial and multiple retrospective studies. In general, the
data suggest adj RT offers LC benefit with a limited, if any, OS benefit for MMMT. The role of adj RT in LMS, which has a high DM rate, is unclear but likely limited, if any
Princess Margaret reported on 69 pts with primary uterine LMS who rcvd hysterectomy +/– pelvic RT. 7% were low grade and 93% were high grade. Median dose of RT was 45Gy. RT was associated with a decrease in 3-yr LR (39→19%) and increase in OS (35→69%). (Wong P et al., Radiat Oncol 2013)
EORTC 55874 randomized 224 pts with stages I–II high-grade uterine sarcoma (46% LMS, 41% carcinosarcoma, 13% endometrial stromal tumor) s/p TSH/BSO, washings (75%), and optional nodal sampling (25%) to either (1) observation or (2) pelvic RT to 50.4 Gy. The results suggest that pelvic RT improves LC but not OS or PFS for MMMT; however, there is no benefit for LMS. (Reed NS, Eur J Cancer 2008)
A SEER-based study found that adj RT offered survival benefits in pts with early MMMT but not in LMS. (Wright JD et al., Am J Obstet Gynecol 2008)
A Mayo Clinic retrospective study included 208 pts with uterine LMS. Pelvic RT had no impact on DSS (p = 0.06), but it was associated with a significant improvement in LR. (Giuntoli R et al., Gyn Oncol 2003)
