Uterine Flashcards
Uterine LMS and Endometrial Stromal Sarcoma Staging
What is the most important personal prognostic factor in endometrial cancer?
Race
What type of uterine sarcoma is most associated with prior RT?
Carcinosarcoma formerly known as Malignant mixed mullerian tumors (MMMT)
What chemo is least active in MMMT (carcinosarcoma)?
a) Carbo/taxol
b) Cis/Ifos
c) Ifos/Taxol
d) gemcitabine/docetaxel
d) Gemzar/taxotere
—> this is uterine sarcoma treatment! Not MMMT
What is the most commonly sporadically altered tumor-suppressor gene in type 2 endometrial CA?
p53
What is the most common sporadic oncogene amplified in type 2 endometrial CA?
HER2/neu
Which sporadic oncogenes are most commonly altered in type 1 endometrial cancer?
B-catenin, PIK3CA, KRAS (also FGFR2)
Which sporadic tumor suppressor gene is most commonly altered in type I endometrial cancer?
PTEN, followed by MLH1
Which hereditary tumor suppressor genes are most commonly altered in endometrial ca?
MLH1, MSH2, MSH6, PMS2
(All Lynch Syndrome genes here but EPCAM)
Describe the histology of endometrioid uterine carcinoma
Key feature is confluent or back to back glands lacking intervening stroma
Cribriform or microacinar configurations
Complex papillary, micropapillary or villoglandular structures
Resembles proliferative type endometrium with varying features / degrees of atypia but cytology must differ from that of surrounding nonneoplastic glands
Treatment for solitary endometrial stromal sarcoma (ESS) lung nodule?
A) surgery
B) letrozole
C) RT
D) chemo
surgery
Most likely to be assocaited with lymphatic spread?
A) Adenosarcoma
B) Carcinosarcoma (MMMT)
C) Leiomyosarcoma
D) Undifferentiated sarcoma
B) Carcinosarcoma (MMMT)
*pure sarcomas commonly metastasize hematogeneously
Chemotherapy for LMS
gemcitabine/docetaxel OR doxorubicin
doxorubicin/trabectedin
Chemotherapy for carcinosarcoma
carbo/taxol
OR
tax/ifos or cis/ifos
*carbo/taxol/dorstalimab (Stage III-IV tumors)
*carbo/taxol/trastuzamab (Stage III-IV her 2 positive carcinosarcoma)
(old Justin’s question noted that carbo/tax was not listed as an option)
GOG 108 - Ifos vs. Ifos/cisplatin shows no difference with more toxic regimen including cis
Best imaging to evaluate for myometrial invasion of uterine cancer
MRI
What is best adjuvant treatment for woman referred to you s/p TAH/BSO with diagnosis of leiomyosarcoma ?
A) Whole pelvic radiation
B) gem/taxotere
C) brachy
D) staging procedure
B) gem/taxotere
*Others:
doxorubicin
doxorubicin/trabectedin
doxorubicin/ifos
doxorubicin/dacarbazine
Endometrial stromal nodule vs
Low grade Endometrial stromal sarcoma vs
high grade Endometrial stromal sarcoma vs
undifferentiated uterine sarcoma
Histological findings differentiating these
ESN -circumscribed, noninfiltrating border without invasion. 2/3s found as isolated lesions in myometrium with no connection to endometrium. May be confused grossly and histologically with leiomyoma
LG-ESS - have myometrial and/or vascular invasion, distinctive finger-like projections that invade the myometrium, veins, and lymphatics; minimal cellular pleomorphism, mild nuclear atypia, and variable mitotic figures
HG-ESS - exhibit high-grade nuclear atypia; infiltrative pattern similar to LG-ESS, more destructive growth pattern with extensive myometrial invasion, necrosis, and LVSI. Mitotic activity >10 / 10hpf
USS - marked cytologic atypia, nuclear pleomorphism, high mitotic activity, and extensive invasion. Lack any features of normal endometrial stromal differentiation, exhibit hemorrhage and necrosis. Do not have the finger-like projections characteristic of LG-ESS, but show destructive myometrial invasion.
What is the Stanford criteria for diagnosing histologic diagnosis of LMS?
at least two of the following criteria:
- diffuse moderate-to-severe atypia
- abundant mitoses (≥10/10hpf)
- areas of coagulative necrosis
Best tx s/p surgery for Stage 1 ESS
A) Observe
B) Hormonal tx
C) Chemo
D) Radiation
A) Observe (regardless of grade)
- consider BSO if premenopausal for grade 1
Worst prognosic factor for endometrial cancer
A) LUS involvement
B) LVSI
C) Tumor size
LVSI
How does sarcomatous overgrowth affect prognosis in adenosarcoma?
Worse prognosis - uterine adenosarcoma is considered less aggressive than its high-grade counterpart, carcinosarcoma, and hysterectomy alone is often curative. Uterine adenosarcoma with sarcomatous overgrowth, however, has a malignant potential more akin to that of high-grade sarcoma.
Best treatment for recurrent LG or HG endometrial stromal sarcoma?
- Oligometastatic
- Widely metastatic
Surgical resection is a reasonable option for women with recurrent LG-ESS, particularly for select women with solitary metastases
Endocrine therapy is the primary treatment for recurrent and metastatic LG-ESS (aromatase inhibitors for ER/PR positive uterine sarcomas), fulvestrant, megestror or medroxyporgesterone, GnRH analogs
Chemotherapy is the treatment of choice for patients with recurrent or metastatic HG-ESS and UUS. As with patients with metastatic LG-ESS, selected patients who present with a solitary metastasis should be considered for metastasectomy.
Best image for early stage endometrial, desires fertility
MRI to look for myometrial invasion
A patient with stage IA Grade 1 endometrioid endometrial adenocarcinoma recurs 4 years after initial therapy with TAH/BSO with an isolated 7 cm pulmonary metastasis. What is best initial therapy?
A) megace
B) thoracotomy
C) multiagent chemotherapy
D) single chemotherapy with cisplatin
E) radiation
B) thoracotomy
*Resection of oligometastatic disease
A patient is diagnosed with stage I leiomyosarcoma with > 30 mitoses/10 HPF and lymphvascular space invasion. What is the most appropriate next step?
Observation
Observe all stage 1 LMS, ESS, UUS, PEComa, Adenosarcoma
- LG ESS & AS - add BSO if premenopausal
Staging for endometrial cancer - glandular cervical involvment, cytology, 40% myometrial invasion
IA
What disease process is this?
Endometrioid Endometrial Cancer
Key feature is confluent or back to back glands lacking intervening stroma
Cribriform or microacinar configurations
Complex papillary, micropapillary or villoglandular structures
Resembles proliferative type endometrium with varying features / degrees of atypia but cytology must differ from that of surrounding nonneoplastic glands
