Exogenous sex hormone use, correlates of endogenous hormone levels, and the incidence of histologic types of sarcoma of the uterus

Uterine carcinosarcoma: A 10-year single institution experience

Objective

This study aimed to determine 5-year progression-free and overall survival in patients with uterine carcinosarcoma, to determine clinical and surgical-pathologic features, to recognize patterns of recurrence and to identify prognostic factors influencing progression-free survival (PFS) and overall survival (OS).

Design

This was a single institution, retrospective 10-year review of patients treated at Tygerberg Hospital in South Africa with pathologically confirmed uterine carcinosarcoma.

Methods

A total of 61 patients were studied. Demographic, clinicopathological, treatment and outcome information were obtained. Kaplan-Meier survival analysis and Cox proportional hazards models were used to determine the effects of variables on PFS and OS.

Results

Eighteen patients (29%) presented as FIGO stage I disease, 5 patients (8%) as stage II, 16 patients (26%) as stage III and 22 patients (36%) as stage IV disease. Fifty of the 61 patients (82%) had surgery. Five-year PFS and 5-year OS were 17.3% (CI 8.9%-27.9%) and 19.7% (CI 10.6%-30.8%), respectively. Seventeen patients presented with recurrence of which 5 (29.4%) were local and 12 (70.6%) were outside the pelvis.

In the univariate analysis, tumour diameter ≥ 100mm (HR 4.57; 95% CI 1.59–13.19; p-value 0.005) was associated with 5-year PFS and in univariate analysis of OS, a positive family history (HR 0.42; 95% CI 0.18–0.99; p-value 0.047), receiving a full staging operation (HR 0.37; 95% CI 0.18–0.78; p-value 0.008) and receiving any other modality of treatment, with or without surgery, (HR 0.48; 95% CI 0.27–0.85; p-value 0.012) were associated with better survival. An abnormal cervical smear (HR 2.4; 95% CI 1.03–5.6; p-value 0.041), late-stage disease (HR 3.48; 95% CI 1.79–6.77; p-value < 0.001), presence of residual tumour (HR 3.66; 95% CI 1.90–7.02; p-value < 0.001), myometrial invasion more than 50% (HR 2.29; 95% CI 1.15–4.57; p-value 0.019), cervical involvement (HR 3.38; 95% CI 1.64–6.97; p-value 0.001) and adnexal involvement (HR 3.21; 95% CI 1.56–6.63; p-value 0.002) were associated with a higher risk of death.

In the multivariate analysis, full staging operation was associated with a risk of progression of disease (HR 3.49; 95% CI 1.17–10.41; p-value 0.025). Advanced stage (HR 4.2; 95% CI 2.09–8.44; p-value < 0.001) was associated with a higher risk of death. Any other modality of treatment (HR 0.28; 95% CI 0.15–0.53; p-value < 0.001) and full staging laparotomy (HR 0.27; 95% CI 0.12–0.59; p-value 0.001) was a protective factor for death.

Conclusions

Carcinosarcoma is an aggressive cancer with poorer survival in this specific cohort than has been described in other contemporary cohorts. Biological or genetic factors are a possible explanation for lower overall survival in this population. Although it is also possible that later diagnosis and poor access to health care contribute to poorer survival. Most recurrences occur outside of the pelvis. Full staging surgery (including pelvic lymphadenectomy) and additional use of other modalities (either for radical or palliative intent) improve survival.

MR Imaging of uterine sarcomas: a comprehensive review with radiologic-pathologic correlation

The aim of this article is to summarize the MRI features of each sarcoma subtype and to correlate them with its pathological findings. Literature review through PubMed/Medline database to identify relevant articles on uterine sarcomas, with a special emphasis on their MRI findings and pathological features. While several, more generalistic, MRI findings of a uterine tumour should raise suspicion for malignancy (including irregular contour, intra-tumoral necrosis/hemorrhage and low ADC values), some particular features may suggest their specific histological subtype such as the gross lymphovascular invasion associated with endometrial stromal sarcomas, the "bag of worms" appearance of the low-grade endometrial stromal sarcoma and the "lattice-like" aspect of adenosarcomas which results from the mixed composition of solid and multiseptated cystic components. Knowledge of the different histological uterine sarcoma subtypes, their specific MRI features and comprehension of their pathological background allows for a more confident diagnosis and may indicate the correct histological subtype.

Autophagy inhibitor potentiates the antitumor efficacy of apatinib in uterine sarcoma by stimulating PI3K/Akt/mTOR pathway

AIM

The present study aims to examine the effects of apatinib combined with autophagy inhibitor 3-Methyladenine (3-MA) on the proliferation and apoptosis of human uterine sarcoma in FU-MMT-1 and MES-SA cells and its tumor inhibition effect in xenograft model of uterine sarcoma.

METHODS

Different concentrations of 3-MA and apatinib were used to treat the uterine sarcoma cell lines (MES-SA and FU-MMT-1 cells). The cell viability was detected by CCK8 method. Flow cytometry was used to detect the apoptosis and cell cycle. Wound closure assay and Transwell assay were performed to measure the migration ability of cells. Western blot was used to determine the apoptosis proteins and autophagy proteins. A nude mice sarcoma xenograft model was established and treated with apatinib alone, 3-MA alone, or combined incubation of them. Tumor size of xenograft and the mice survival rate were measured.

RESULTS

Combination of 3-MA and apatinib significantly inhibited the proliferation and migration ability, but increased the apoptosis rate of uterine sarcoma cells compared to apatinib. The combination of 3-MA and apatinib significantly limited the tumor size of xenograft and increased the survival rate of mice compared to apatinib alone. Apatinib inhibited the PI3K/Akt/mTOR pathway, while 3-MA and the combination of 3-MA and apatinib significantly activated the PI3K/Akt/mTOR pathway and inhibited autophagy. Combination of 3-MA and apatinib increased apoptosis compared to apatinib alone. The expression of VEGFR-2 was not impacted by 3-MA.

CONCLUSION

Combination of apatinib and autophagy inhibitor 3-MA significantly inhibited the growth and migration of uterine sarcoma cells and xenograft. Autophagy inhibition may increase the antitumor effect of apatinib via the PI3K/Akt/mTOR pathway.

Predictive Histologic Factors in Carcinosarcomas of the Uterus: A Multi-institutional Study

Uterine carcinosarcomas are rare aggressive biphasic neoplasms. Because of its rarity, limited data are available on potential prognostic parameters. While several studies support that carcinomatous components predict outcomes, others do not. In this study, we evaluated the clinical and histopathologic features of 196 uterine carcinosarcomas to identify potential prognostic factors. Patients' ages ranged from 34 to 95 yr (median, 68 yr). Seventy-three (38%) patients experienced tumor recurrence during follow-up. Tumors ≥5 cm, outer half myometrial invasion, lymphovascular invasion, lymph node metastasis, advanced stage (International Federation of Gynecology and Obstetrics stages III-IV), sarcomatous component on recurrence, sarcoma dominance, and positive cytology were significantly associated with shorter disease-free interval (P<0.05). In addition, serous histology and rhabdomyoblastic differentiation was significantly associated with worse 3-yr overall survival. Our data supports that both carcinomatous and sarcomatous components play a role in tumor progression and survival of uterine carcinosarcoma patients, suggesting their equal importance in guiding management decisions.

Prognostic factors, survival outcomes, and surgical practices when dealing with uterine sarcomas: 8 years’ clinical experience

Objective

To determine the clinical and pathologic characteristics, prognostic factors, surgical practice, adjuvant therapies, and survival outcomes of patients with uterine sarcoma diagnosed and treated in our institution.

Material and Methods

Patients diagnosed and treated for uterine sarcomas at our institution from 2009 to 2017 were retrospectively evaluated. All histologic slides from the specimens underwent a thorough pathologic review by a gynecologic pathologist. The following variables were assessed: age, family history of cancer, smoking status, age of menarche, parity, age at first delivery, related symptoms, clinical staging, histologic type, treatment received, disease-free period, and the time and site of recurrence, as well as treatment of the latter and overall survival.

Results

Ten patients were diagnosed as having leiomyosarcoma, a further 10 patients had malignant mixed mullerian tumors, and five had endometrial stromal sarcoma; the remaining nine patients had other tumors. At the end of our study, 12 (35.3%) patients were alive and in remission, four (11.8%) were alive with disease, 10 (29.4%) were lost to follow-up, and eight (23.5%) had died. The mean survival time was 80.92 months, and the 2-year survival rate was 75.6%. We found that survival was significantly shorter in the presence of lymph node involvement, residual tumor, and recurrence.

Conclusion

This study serves to inform physicians about the outcome of various uterine sarcomas that were diagnosed and managed at our center. We found that 35.3% of our patients were alive and in remission, 11.8% were alive with disease, 29.4% were lost to follow-up, and 23.5% of patients died.

Uterine Carcinosarcomas

Uterine carcinosarcoma (UCS) is a rare and aggressive variant of endometrial cancer, distinguished by its containment of both epithelial and sarcomatous elements. This article reviews the epidemiology, pathologic classification and staging of UCS, along with the typical findings seen on different imaging modalities. Prognosis and therapies will also be discussed.

Primary low-grade endometrial stromal sarcoma arising in the vagina: report of an unusual case and literature review

Endometrial stromal sarcoma rarely occurs as an extrauterine neoplasm and it is even more unlikely to be found in the vagina. To the best of our knowledge, only six cases of primary vaginal endometrial stromal sarcoma without association with endometriosis have been published to this day. We describe a case of a 58-year-old female with a history of vaginal heaviness caused by a mass lesion. After a biopsy was taken, the histopathological findings and immunohistochemical stains were consistent with low-grade endometrial stromal sarcoma. The patient underwent total hysterectomy and bilateral salpingo-oophorectomy with lymph node dissection followed by hormonal therapy. This line of management was heavily based on the treatment guidelines for endometrial stromal sarcoma.

Uterine Sarcoma: Analysis of 13,089 Cases Based on Surveillance, Epidemiology, and End Results Database

OBJECTIVE

The aim was to study the incidence and survival of patients with uterine sarcoma diagnosed in the period from 2000 to 2012 based on Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

All 18 registries of the SEER database were used to select cases. We included women aged 30 years or older diagnosed with uterine sarcoma. Histological subtypes were defined as leiomyosarcoma, carcinosarcoma, stromal sarcoma, adenosarcoma, and sarcoma not otherwise specified according to the 2003 World Health Organization classification. Using SEER*Stat software version 8.1.2. We calculated the age-adjusted incidence rates, extent of disease at time of diagnosis, and survival rates with different treatment modalities for white, black, and other races. Univariate and multivariate Cox proportional hazards analysis were done to examine factors affecting survival.

RESULTS

We identified 13,089 patients diagnosed with uterine sarcoma in the period from 2000 to 2012. The age-adjusted incidence rate for patients aged 50 years or older was more than that of younger patients (6.4/10 vs 1.5/10, P < 0.0001). Also, the age-adjusted incidence rate for black women was twice that of white women (7.3/10 vs 3.5/10, P < 0.0001). Carcinosarcoma was the most commonly diagnosed subtype followed by leiomyosarcoma. Women aged 50 years or older had worse survival than those younger than 50 years (hazard ratio, 1.78; 95% confidence interval, 1.64-1.92; P < 0.001). The overall survival of patients who had surgery with radiation was better than those who had surgery alone (hazard ratio, 0.89; 95% confidence interval, 0.83-0.95; P < 0.001). In women with localized disease, surgery was associated with better survival than surgery with radiation (66.4% vs 74.4%, P < 0.00001).

CONCLUSIONS

Uterine sarcoma is an aggressive tumor that occurs more in old age and among women of black race. Poor survival was associated with old age, black race, and advanced disease stage. Radiotherapy in patients with localized stage does not improve the survival.

Uterine sarcoma - current perspectives

Uterine sarcomas comprise a group of rare tumors with differing tumor biology, natural history and response to treatment. Diagnosis is often made following surgery for presumed benign disease. Currently, preoperative imaging does not reliably distinguish between benign leiomyomas and other malignant pathology. Uterine leiomyosarcoma is the most common sarcoma, but other subtypes include endometrial stromal sarcoma (low grade and high grade), undifferentiated uterine sarcoma and adenosarcoma. Clinical trials have shown no definite survival benefit of adjuvant radiotherapy or chemotherapy and have been hampered by the rarity and heterogeneity of these disease types. There is a role of adjuvant treatment in carefully selected cases following multidisciplinary discussion at sarcoma reference centers. In patients with metastatic disease, systemic chemotherapy can then be considered. There is activity of a number of agents, including doxorubicin, trabectedin, gemcitabine-based chemotherapy, eribulin and pazopanib. Patients should be considered for clinical trial entry where possible. Close international collaboration is important to allow progress in this group of diseases.

Potential Therapeutic Targets in Uterine Sarcomas

Uterine sarcomas are rare tumors accounting for 3,4% of all uterine cancers. Even after radical hysterectomy, most patients relapse or present with distant metastases. The very limited clinical benefit of adjuvant cytotoxic treatments is reflected by high mortality rates, emphasizing the need for new treatment strategies. This review summarizes rising potential targets in four distinct subtypes of uterine sarcomas: leiomyosarcoma, low-grade and high-grade endometrial stromal sarcoma, and undifferentiated uterine sarcoma. Based on clinical reports, promising approaches for uterine leiomyosarcoma patients include inhibition of VEGF and mTOR signaling, preferably in combination with other targeted or cytotoxic compounds. Currently, the only targeted therapy approved in leiomyosarcoma patients is pazopanib, a multitargeted inhibitor blocking VEGFR, PDGFR, FGFR, and c-KIT. Additionally, preclinical evidence suggests effect of the inhibition of histone deacetylases, tyrosine kinase receptors, and the mitotic checkpoint protein aurora kinase A. In low-grade endometrial stromal sarcomas, antihormonal therapies including aromatase inhibitors and progestins have proven activity. Other potential targets are PDGFR, VEGFR, and histone deacetylases. In high-grade ESS that carry the YWHAE/FAM22A/B fusion gene, the generated 14-3-3 oncoprotein is a putative target, next to c-KIT and the Wnt pathway. The observation of heterogeneity within uterine sarcoma subtypes warrants a personalized treatment approach.

Surgical Methods for the Treatment of Uterine Fibroids - Risk of Uterine Sarcoma and Problems of Morcellation: Position Paper of the DGGG

The appropriate surgical technique to treat patients with uterine fibroids is still a matter of debate as is the potential risk of incorrect treatment if histological examination detects a uterine sarcoma instead of uterine fibroids. The published epidemiology for uterine sarcoma is set against the incidence of accidental findings during surgery for uterine fibroids. International comments on this topic are discussed and are incorporated into the assessment by the German Society for Gynecology and Obstetrics (DGGG). The ICD-O-3 version of 2003 was used for the anatomical and topographical coding of uterine sarcomas, and the "Operations- und Prozedurenschlüssel" (OPS) 2014, the German standard for process codes and interventions, was used to determine surgical extirpation methods. Categorical qualifiers were defined to analyze the data provided by the Robert Koch Institute (RKI), the German Federal Bureau of Statistics (DESTATIS; Hospital and Causes of Death Statistics), the population-based Cancer Register of Bavaria. A systematic search was done of the MEDLINE database and the Cochrane collaboration, covering the period from 1966 until November 2014. The incidence of uterine sarcoma and uterine fibroids in uterine surgery was compared to the literature and with the different registries. The incidence of uterine sarcoma in 2010, standardized for age, was 1.53 for Bavaria, or 1.30 for every 100 000 women, respectively, averaged for the years 2002-2011, and 1.30 for every 100 000 women in Germany. The mean incidence collated from various surveys was 2.02 for every 100 000 women (0.35-7.02; standard deviation 2.01). The numbers of inpatient surgical procedures such as myoma enucleation, morcellation, hysterectomy or cervical stump removal to treat the indication "uterine myoma" have steadily declined in Germany across all age groups (an absolute decrease of 17 % in 2012 compared to 2007). There has been a shift in the preferred method of surgical access from an abdominal/vaginal approach to endoscopic or endoscopically assisted procedures to treat uterine fibroids, with the use of morcellation increasing by almost 11 000 coded procedures in 2012. Based on international statements (AAGL, ACOG, ESGE, FDA, SGO) on the risk of uterine sarcoma as an coincidental finding during uterine fibroid surgery and the associated risk of a deterioration of prognosis (in the case of morcellation procedures), this overview presents the opinion of the DGGG in the form of four Statements, five Recommendation and four Demands.

Microarray analysis on gene regulation by estrogen, progesterone and tamoxifen in human endometrial stromal cells

Epithelial stromal cells represent a major cellular component of human uterine endometrium that is subject to tight hormonal regulation. Through cell-cell contacts and/or paracrine mechanisms, stromal cells play a significant role in the malignant transformation of epithelial cells. We isolated stromal cells from normal human endometrium and investigated the morphological and transcriptional changes induced by estrogen, progesterone and tamoxifen. We demonstrated that stromal cells express appreciable levels of estrogen and progesterone receptors and undergo different morphological changes upon hormonal stimulation. Microarray analysis indicated that both estrogen and progesterone induced dramatic alterations in a variety of genes associated with cell structure, transcription, cell cycle, and signaling. However, divergent patterns of changes, and in some genes opposite effects, were observed for the two hormones. A large number of genes are identified as novel targets for hormonal regulation. These hormone-responsive genes may be involved in normal uterine function and the development of endometrial malignancies.

Effects of menopausal hormone therapy on uterine myoma in menopausal women

Objectives

The aim of the present study is to evaluate the long term effects of estrogen-progestogen therapy (EPT) on uterine myomas volume in postmenopausal women.

Methods

We performed a retrospective analysis on postmenopausal women with asymptomatic uterine myoma during the period between April, 2008 and September, 2012. Postmenopause was defined as amenorrhea for longer than a year or serum follicle stimulating hormone levels higher than 40 IU/L. The volume of the myoma was assessed by transvaginal ultrasonography for every 6 months after administration of EPT.

Results

Thirty-eight women were included in the study, with 32 in the EPT group and 6 in the control group. Overall, uterine myoma volume (mean ± standard deviation, cm³) in the EPT group was 19.5 ± 24.6 at baseline, and those at 6 and 12 months were 24.7 ± 35.1 and 28.5 ± 56.4, respectively. Myoma volume did not change significantly with EPT, and these changes were not significantly different from the control group. Myoma volume changes were not significantly different in the subgroups according to the route of estrogen administrations and the method of progestogen administrations. Clinically significant volume increases during one year of EPT was noted in 28.1% (9/32), however, only one showed transient increases.

Conclusion

Our results suggest that treating postmenopausal woman with EPT on a long-term basis does not increase the volume of uterine myomas.

[Uterine leiomyosarcoma: epidemiology, pathology, biology, diagnosis, prognosis and treatment]

Uterine leiomyosarcoma is a rare disease with a poor prognosis. The rarity of this tumor needs a specialized management in tertiary reference centers in order to provide patients with optimal diagnostic, prognostic and therapeutic care. The pathological diagnosis relies on the presence of three characteristics in proliferating smooth muscle cells: necrosis, cytologic atypia and mitosis. Despite progress in the knowledge of the biology of these tumors, no oncogenic driver has been found. Prognosis depends mainly on the age of the patient, race, FIGO stage, mitotic index and hormonal receptor expression in the tumor. Surgery is one of the cornerstones of management and cytotoxic chemotherapy is the mainstay of treatment in metastatic disease with a potential role in the adjuvant setting. In locally advanced or metastatic disease, prognosis is poor with a median overall survival of about 12 to 14 months despite a 30% response rate to polychemotherapy regimens. Anti-angiogenics and hormonal therapy have a role to play in the setting of metastatic disease. It is mandatory to include such patients in clinical trials aiming to improve the therapeutic management of these patients. Multimodal therapy can improve the prognosis of selected patients too.

The etiology of uterine sarcomas: a pooled analysis of the epidemiology of endometrial cancer consortium

BACKGROUND

Uterine sarcomas are characterised by early age at diagnosis, poor prognosis, and higher incidence among Black compared with White women, but their aetiology is poorly understood. Therefore, we performed a pooled analysis of data collected in the Epidemiology of Endometrial Cancer Consortium. We also examined risk factor associations for malignant mixed mullerian tumours (MMMTs) and endometrioid endometrial carcinomas (EECs) for comparison purposes.

METHODS

We pooled data on 229 uterine sarcomas, 244 MMMTs, 7623 EEC cases, and 28,829 controls. Odds ratios (ORs) and 95% confidence intervals (CIs) for risk factors associated with uterine sarcoma, MMMT, and EEC were estimated with polytomous logistic regression. We also examined associations between epidemiological factors and histological subtypes of uterine sarcoma.

RESULTS

Significant risk factors for uterine sarcoma included obesity (body mass index (BMI)≥30 vs BMI<25 kg m(-2) (OR: 1.73, 95% CI: 1.22-2.46), P-trend=0.008) and history of diabetes (OR: 2.33, 95% CI: 1.41-3.83). Older age at menarche was inversely associated with uterine sarcoma risk (≥15 years vs <11 years (OR: 0.70, 95% CI: 0.34-1.44), P-trend: 0.04). BMI was significantly, but less strongly related to uterine sarcomas compared with EECs (OR: 3.03, 95% CI: 2.82-3.26) or MMMTs (OR: 2.25, 95% CI: 1.60-3.15, P-heterogeneity=0.01).

CONCLUSION

In the largest aetiological study of uterine sarcomas, associations between menstrual, hormonal, and anthropometric risk factors and uterine sarcoma were similar to those identified for EEC. Further exploration of factors that might explain patterns of age- and race-specific incidence rates for uterine sarcoma are needed.

Incidence of uterine leiomyosarcoma and endometrial stromal sarcoma in Nordic countries: results from NORDCAN and NOCCA databases

OBJECTIVES AND STUDY DESIGN

Uterine sarcomas are an uncommon and heterogeneous group of malignancies. Their etiology is mainly unknown. Here, we analyzed trends in incidence and occupational variation in risk of uterine leiomyosarcomas (LMS) and endometrial stromal sarcomas (ESS) in the Nordic countries aided by NORDCAN and NOCCA (Nordic Occupational Cancer) databases.

MAIN OUTCOME MEASURES

Incidence rates per 100,000 and Standardized incidences rates (SIR) obtained from NORDCAN and NOCCA databases.

RESULTS

The incidence rates were about 0.3 per 100,000 for ESS and about 0.4 per 100,000 for LMS in Denmark, Finland, Iceland, and Norway. During the study-period (1978-2007), the incidence rates in each country were quite similar and constant. The age-specific incidence of LMS showed a peak around menopause. Significantly increased risk for LMS occurred in shoe and leather workers, farmers and teachers, whereas significantly low risk was detected with packers in the NOCCA data from Finland, Norway, and Sweden. For ESS no occupations showed either increased or decreased incidences.

CONCLUSIONS

The incidence trends of LMS and ESS in our study were constant in four Nordic countries over time. The elevated risk for LMS with women exposed to leather work and animal dust indicates further exploration.

Increased risk of secondary uterine leiomyosarcoma in hereditary retinoblastoma

OBJECTIVE

In the US, second non-ocular malignancies are the primary cause of death in retinoblastoma survivors with the germline RB1 mutation. Soft tissue sarcomas are one of the most likely malignancies to pose a risk to these patients, with leiomyosarcoma (LMS) being the most common subtype. As our cohort is followed for a longer period, we discover new second malignancy risks for these patients.

METHODS

We estimated the risk for uterine leiomyosarcoma (ULMS) in a cohort of 1854 patients with retinoblastoma who were diagnosed at two US institutions from 1914 through 1996. The standardized incidence ratio and excess absolute risk were calculated by comparison with population data from the Connecticut Tumor Registry or from National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database. The cumulative risk at 50 years of age was also calculated.

RESULTS

Seven of 525 female hereditary retinoblastoma patients developed ULMS. Five of these patients were used in the risk analysis, resulting in an excess risk of 3.87 per 10,000 women. Among hereditary patients who developed ULMS the excess risk increases dramatically with age: to 20/10,000 for female hereditary retinoblastoma patients aged between 30 and 39 years, and to 27/10,000 for patients aged 40+ years.

CONCLUSION

There is a substantial excess risk of ULMS in female hereditary retinoblastoma patients. As more patients survive into their thirties, this number is likely to increase. These findings raise the question of early childbearing, screening and prophylactic measures in hereditary retinoblastoma patients: all issues that would benefit from confirmation from other retinoblastoma cohorts, to allow for better guided counsel of these patients.

[Twenty-two cases of uterine carcinosarcomas]

OBJECTIVES

Twenty-two uterine carcinosarcomas were treated and followed in two centers over 10 years. We wanted to describe them and review the literature on the subject.

PATIENTS AND METHODS

We describe all uterine carcinosarcomas treated in Lille, over 10 years, both in department of gynecology, Hospital Jeanne-de-Flandre (11 patients), and in department of gynecologic oncology of Centre Oscar-Lambret (11 patients).

RESULTS

For the 22 patients included, we give age at time of diagnosis, body mass index, pre and post surgical histology, details of surgical treatment, adjuvant treatment and evolution of the pathology. Mean age at time of diagnosis was 69.6. Sixty-eight percent of patients had overweight or obesity. Revealing symptoms were in 91% of cases post-menopausal meno- or metrorrhagias. Preoperatively, histology had an important number of false negative and, 57% of diagnoses were ignored in our study. All patients had first intention surgery, only 54% were yet at an early stage. Sixteen had association radiotherapy, eight of chemotherapy, two declined any adjuvant treatment. Ten patients died with a mean survival of 12.9 months, eight had a good evolution still at 35 months, two had recent pelvic relapse, two were lost to follow-up.

CONCLUSION

Uterine carcinosarcomas are rare, aggressive, yet not very well known tumors. First line treatment will be surgery with peritoneal cytology, hysterectomy, bilateral adnexectomy, pelvic and sometimes lumbo-aortic lymphadenectomy, omentectomy, peritoneal biopsies. Adjuvant chemotherapy has shown its interest in this type of tumor. Radiotherapy is still debated.

Carcinosarcoma of the uterus in a woman with Down syndrome

There are only a few reports of uterine cancers in women with Down syndrome, whose tumor profile is marked by a reduced risk for solid neoplasms. There are no reports of a uterine carcinosarcoma arising in a woman with Down syndrome. in our case, a delayed diagnosis of uterine carcinosarcoma was confirmed in a 38-year-old, nulliparous, single, obese woman with Down syndrome, who presented with irregular vaginal bleeding. Although uterine cancers are underrepresented in women with Down syndrome, uterine malignancy should be considered in the differential diagnosis of abnormal vaginal bleeding. A timely and complete gynecological examination will preclude a delay in diagnosis.

Molecular Genetics of Mesenchymal Tumors of the Female Genital Tract

Mesenchymal tumors of the female genital tract are a heterogeneous group of neoplasms that can be classified based on cellular differentiation into 3 main groups: smooth muscle tumors, endometrial stromal tumors, and other differentiated and undifferentiated tumors. Genomic analysis techniques have revealed important genetic aberrations such as the t(7;17) translocation, resulting in JAZF1-JJAZ1 gene fusion, characteristic of endometrial stromal tumors. These analyses have demonstrated genetic complexity and heterogeneity in many mesenchymal tumor types. This article focuses on current understanding of the molecular genetics of mesenchymal tumors of the female genital tract, with emphasis on diagnostic and prognostic molecular features.

Uterine smooth muscle tumor of uncertain malignant potential: a retrospective analysis

OBJECTIVE

This retrospective study was designed to evaluate the clinicopathologic features and outcomes of a cohort of patients diagnosed with uterine smooth muscle tumor of uncertain malignant potential (STUMP) seen at a single institution.

METHODS

All patients diagnosed with uterine STUMP and seen between 1990 and 2005 at The University of Texas M. D. Anderson Cancer Center were identified using the institution's databases. Variables of interest included age at diagnosis, recurrence rate, and disease-free and overall survival.

RESULTS

Forty-one patients with uterine STUMP were identified and included in the study. The mean age at diagnosis was 43 years (range 25-75 years). The mean follow-up time was 45 months (range 1-171 months). Three patients (7.3%) had a recurrence during the follow-up period. One of the three patients who had recurrent disease was found to have a leiomyosarcoma at the time of recurrence. Recurrence rates were similar for women who underwent myomectomy and those who underwent hysterectomy. All three patients with recurrence were alive and disease-free at a mean follow-up time of 121 months.

CONCLUSION

Our results suggest that in this cohort of patients with uterine STUMP the recurrence rate was 7%. Recurrences can be in the form of STUMP or leiomyosarcoma.

Relationships of uterine and ovarian tumors to pre-existing chronic conditions

OBJECTIVE

Several chronic diseases have been hypothesized to affect the risk of subsequent gynecologic malignancies, possibly through shared hormonal mechanisms.

METHODS

Using record linkage techniques, we assessed the relationships between hospital and outpatient admissions for gallbladder disease, diabetes, hypertension, thyroid diseases and obesity and the subsequent development of uterine and ovarian cancers in Denmark between 1978 and 1998. Based on a subsample of more than 99,000 women, including 1398 uterine and 2491 ovarian cancers, we derived relative risks (RRs) and 95% confidence intervals (CIs) associated with overall and histology-specific cancer risks after adjustment for age, calendar time and reproductive characteristics.

RESULTS

Uterine cancers were related to previous diagnoses of thyroid diseases (RR=1.52, 95% CI 1.17-1.98) and obesity (2.05, 1.40-3.00). Associations with diabetes were confounded by obesity, but there were some elevations in risk for subjects diagnosed with obesity prior to age 45 (RRs 1.66-1.79). Although the "usual types" of endometrial cancer largely accounted for the observed associations, there was some evidence that uterine sarcomas (n=137) were related to prior diagnoses of thyroid diseases (2.78, 1.41-5.50). In contrast, ovarian cancers were not strongly related to most documented chronic diseases. Serous carcinomas were associated with gallbladder diseases of short durations, but detection bias or misdiagnosis probably accounts for this association. An association of obesity and endometrioid ovarian cancer was not identified.

CONCLUSIONS

Uterine cancers, including sarcomas, appear to be influenced by selected chronic diseases. Further attention should focus on possible biologic mechanisms underlying observed associations with thyroid diseases and obesity.

Prognoses and Prognostic Factors of Carcinosarcoma, Endometrial Stromal Sarcoma and Uterine Leiomyosarcoma: A Comparison with Uterine Endometrial Adenocarcinoma

AIMS

The aims of this study were to evaluate the factors affecting prognosis in patients with uterine sarcomas and to demonstrate that carcinosarcoma bears a similarity to high-grade endometrial carcinoma in terms of its prognosis and clinicopathological parameters.

METHODS

In June 2004, 17 Japanese institutions received questionnaires regarding uterine sarcomas. Study patients had uterine sarcomas initially treated at each institution between January 1990 and May 2004. Survival analyses and comparisons were performed by univariate methods. Patient data of 921 cases of endometrial adenocarcinoma were also analyzed and compared to the data with the uterine sarcomas.

RESULTS

One hundred twenty-one patients with uterine sarcomas were identified who met study eligibility criteria. In uterine sarcomas, carcinosarcoma had a worse prognosis than other sarcomas, but the difference was not significant (p = 0.302). In carcinosarcoma, significant differences were observed with age (p = 0.0388), stage (p < 0.01) and surgical procedure (with or without pelvic lymphadenectomy, p = 0.0316). In carcinosarcoma and G3 adenocarcinoma, no significant difference was identified with regard to overall survival in univariate (p = 0.191) and multivariate (p = 0.168) analyses.

CONCLUSION

Our results demonstrate that the clinical behavior of carcinosarcoma strongly resembles that of G3 endometrial adenocarcinoma, setting it apart from other 'pure' uterine sarcomas.

Incidence patterns of soft tissue sarcomas, regardless of primary site, in the surveillance, epidemiology and end results program, 1978-2001: An analysis of 26,758 cases

Soft tissue sarcomas (STS) are a heterogeneous group of uncommon tumors that show a broad range of differentiation that may reflect etiologic distinction. Routine tabulations of STS are not morphology-specific. Further, the lack of inclusion of sarcomas arising in all organs in most standard evaluations underestimates the true rates. We analyzed the 1978-2001 Surveillance, Epidemiology and End Results program incidence rates of STS regardless of primary site, except bones and joints, using the 2002 criteria of the WHO classification. There were 26,758 cases available for analysis. Leiomyosarcomas accounted for 23.9%, malignant fibrous histiocytomas 17.1%, liposarcomas 11.5%, dermatofibrosarcomas 10.5%, rhabdomyosarcomas 4.6% and angiosarcomas 4.1%. Almost half (47.9%) of the sarcomas arose in the soft tissues, 14.0% in the skin and 7.0% in the uterus. Overall, incidence rates were highest among black women (6.26/100,000 woman-years) and the lowest among white women (4.60/100,000). Age-adjusted rates increased at 1.2% and 0.8% per year among white males and females, respectively, both trends statistically significant, while rates among blacks declined slightly. About 40% of leiomyosarcomas among women were uterine in origin, with a black/white rate ratio of 1.7. This rate ratio increased to 2.0 when we accounted for the lower prevalence of intact uteri among black compared to white women. Total STS rates rose exponentially with age. Rates for both uterine leiomyosarcoma and dermatofibrosarcoma increased rapidly during the childbearing years, peaking at about age 40 and 50, respectively. Incidence patterns of STS varied markedly by histologic type, supporting the notion that these tumors may be etiologically distinct.

Use of X-chromosome inactivation pattern to determine the clonal origins of uterine leiomyoma and leiomyosarcoma

Uterine leiomyomas (LMs) and leiomyosarcomas (LMSs), both of smooth muscle origin, sometimes coexist in the same uterus. Little genetic evidence exists concerning the developmental relationship between LM and LMS. Using the X-chromosome inactivation pattern of the human androgen receptor gene, we examined the clonality of LM and LMS. Of the 24 patients with LM, 21 had multiple neoplasms; all were clonal and individual LMs derived from separate clones. Of the 20 patients with LMS, 6 exhibited multiple tumors in the uterus, and 4 of these individuals also harbored coexisting uterine LMs. We found all LMSs to be clonal. Separate tumors showed identical pattern of X inactivation in 4 patients, and in 2 other individuals, multiple LMSs developed from independent clones. Among the 4 patients with LMS and coexisting LM, 3 showed the same pattern of X inactivation in LMS and the adjacent LM. In 2 of the 3 patients, the tumor also exhibited a morphological transition between benign cells in LM and malignant cells in LMS, supporting the possibility of transformation from LM to LMS. One patient displayed different clones in LMS and the coexisting LM, indicating their independent origins. We conclude that (i) both LM and LMS are clonal; (ii) different nodules in multiple LM are of independent origins; (iii) multiple lesions of LMS may be either monoclonal or multiclonal; (iv) most LMSs are solitary lesions and are most likely de novo, but an individual LM may undergo "malignant transformation" to a LMS; and (v) some LMSs and coexisting LMs are of independent origins.

Malignant mixed Mullerian tumors

Malignant mixed Mullerian tumours (MMMTs) are rare neoplasms, highly aggressive and with an extremely poor prognosis, usually arising in elderly postmenopausal women and presenting at an advanced stage. MMMTs derive from the mullerian mesodermus that differentiates in epithelial and stromal elements, both malignant elements. The clinic pathological features of 3 uterine MMMTs are reported here. The patients ranged in age from 25 to 69 years. The initial manifestations were mainly bloody discharge, abdominal pain and increase of the volume of the uterus. Treatment in 2 patients was hysterectomy with double ooforectomy, and resection of the pelvic mass was the treatment in the third case. Adjuvant radio chemotherapy was administrated in 2 of the 3 cases. Follow-up revealed recurrent pelvic tumour in 1 patient at 59 months, and breast metastases at 20 months in the second one. Because of the high incidence of recurrence and poor prognosis of these tumours, they should be studied and managed by a multidisciplinary team composed by surgeons, oncologists, radiotherapists and pathologists.

Response of recurrent uterine high-grade malignant mixed müllerian tumor to letrozole

Uterine malignant mixed müllerian tumor (MMMT) is a rare malignancy occurring most often in postmenopausal women. Despite the use of multimodality treatments including surgery, chemotherapy, and radiotherapy, prognosis is still poor in most cases. We report the case of a 69-year-old woman with recurrent metastatic high-grade MMMT that responded to letrozole, an aromatase inhibitor. At the initial diagnosis of high-grade uterine MMMT in February 2001, the patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and postoperative pelvic radiotherapy. Two years later, an asymptomatic retroperitoneal mass was discovered on surveillance abdominal computed tomography scanning. The 3.5- x 3.0-cm mass was considered inoperable owing to its location near the aorta at the level of the renal vessels. The patient declined radiation or chemotherapy. Treatment with letrozole was begun at 2.5 mg daily. Serial computed tomography scans demonstrated marked tumor shrinkage; after 11 months of letrozole therapy, the tumor had shrunk to less than 25% of its original volume. Further study of letrozole for high-grade uterine MMMT is warranted.

Malignant Transformation of Myomas: Myth or Reality?

The possibility that a fibroid may actually be a smooth muscle tumor of uncertain malignant potential or a leiomyosarcoma often dictates the clinical management of rapidly growing fibroids. This article provides a clinicopathologic background regarding uterine leiomyosarcomas and answers common questions that obstetricians and gynecologists have about the management of rapidly growing fibroids and leiomyosarcoma. The clinician must be aware that the infrequent occurrence of uterine leiomyosarcomas makes it difficult to establish absolutely firm recommendations for the diagnosis and management of this disease, particularly with regard to fertility preservation. Nevertheless, this article addresses major issues that a clinician might face in the evaluation of a smooth muscle tumor of the uterus that clinically may be malignant.

Relationship of benign gynecologic diseases to subsequent risk of ovarian and uterine tumors

OBJECTIVE

Although endometriosis and uterine leiomyomas are common conditions, the extent to which either is associated with certain types of malignancies remains uncertain.

METHODS

Using record linkage techniques, we assessed the relationships between hospital and outpatient admissions for endometriosis or leiomyomas and the development of ovarian and uterine cancers in Denmark between 1978 and 1998. Based on a population-based cohort exceeding 99,000 women, including 2,491 ovarian cancers, 860 borderline ovarian tumors, and 1,398 uterine cancers, we derived relative risks (RR) and 95% confidence intervals (95% CI) associated with overall and histology-specific tumor risks after adjustment for calendar time and reproductive characteristics.

RESULTS

Endometriosis seemed to predispose to the development of ovarian cancer, with the association restricted to endometrioid or clear cell malignancies. Five or more years after the diagnosis of endometriosis, the RRs (95% CIs) were 2.53 (1.19-5.38) for endometrioid (7 exposed cases) and 3.37 (1.24-9.14) for clear cell (4 exposed cases) malignancies. Uterine leiomyomas were associated with increases in the risk of uterine malignancies, particularly sarcomas, where the RRs (95% CIs) were 20.80 (11.32-38.22) for women with 1 to 4 years of follow-up (11 exposed cases) and 5.70 (2.27-14.32) for those with more extended follow-up (5 exposed cases).

CONCLUSION

In combination with clinical, pathologic, and molecular data, our results support that some endometriotic lesions may predispose to clear cell and endometrioid ovarian cancers. Uterine leiomyomas also showed a strong connection with subsequent uterine sarcomas, although it was difficult to decipher whether this reflected detection bias, shared risk factors, or an etiologic relationship.

Lack of prepubertal administration of ethinyl estradiol on susceptibility to multiple organ carcinogenesis in rats exposed to 7,12-dimethylbenz[a]anthracene and N-bis(2-hydroxypropyl)nitrosamine during adolescence

Estrogen exposure during the adult period is widely known to promote tumor development in the female genital system, as well as in the mammary gland in experimental animals, but its carcinogenic potential with exposure at the prepubertal stage, for 6 weeks after birth, is not completely understood. In the present study, we therefore evaluated the modifying effects of prepubertal ethinyl estradiol (EE) treatment on susceptibility to multiple organ carcinogenesis with subsequent carcinogen exposure in F344 rats. Dams during the lactation period and their weaned offspring until postnatal-week 6 were fed diet containing 0, 0.2 or 1.0 ppm EE. The offsprings were then administered 7,12-dimethylbenz[a]anthracene (DMBA, 50mg/kg body weight) by gavage for mammary tumor induction in week 7 and given free access to drinking water containing N-bis (2-hydroxypropyl)nitrosamine (DHPN, 0.2%) for wide spectrum tumor induction in organs such as the thyroid, liver, lung and kidney from weeks 6-14. Male and female offspring were euthanized at weeks 27 and 36, respectively, for histopathological examination. While the incidence and multiplicity of mammary tumors showed a tendency for increase in females of the 0.2 and 1.0 ppm EE groups, this was without statistical significance. Furthermore, prepubertal EE exposure did not affect tumor induction in the thyroid, liver, lung, kidney, esophagus, ovary and lymphoid tissue in either sex. The present results thus indicate a lack of influence of estrogen early in life on carcinogenic susceptibility, although the possible impact on mammary carcinogenesis requires further examination.

Molecular genetic characterization of tamoxifen-associated endometrial cancer

OBJECTIVES

The non-steroidal, selective estrogen receptor modulator tamoxifen is currently the most extensively used hormonal agent for the prevention and treatment of estrogen receptor-positive breast cancer. Epidemiologic studies and clinical trials have shown an increased risk of endometrial cancer with tamoxifen exposure; however, few studies have examined these tumors on a molecular level. We sought to elucidate the molecular genetic alterations found in tamoxifen-associated endometrial cancer.

METHODS

Twenty-nine breast cancer patients with a history of tamoxifen use who subsequently developed endometrial cancer were retrospectively identified and matched for endometrial histologic subtype and grade to 29 endometrial cancers from breast cancer patients never exposed to tamoxifen. Endometrial tumor tissue was microdissected and genomic DNA extracted for each case. Direct DNA sequencing of the most commonly mutated genes in sporadic endometrial cancer, PTEN, K-RAS, TP53, and CTNNB1, was performed in addition to microsatellite instability (MI) studies. Fisher's Exact Test was utilized for statistical analyses.

RESULTS

Of 29 tamoxifen-associated cancers, 10 (34.5%) contained PTEN mutations compared to 13 (44.8%) of the non-tamoxifen-associated cancers (P = 0.59). All PTEN mutations were found in tumors with endometrioid histology, reflecting what is seen in sporadic endometrial cancers. Mutations of K-RAS, TP53, and microsatellite instability were present in similar frequencies between the two breast cancer groups, and moreover, these were similar to mutational frequencies found in sporadic endometrial cancer.

CONCLUSION

Tamoxifen and non-tamoxifen-associated endometrial carcinomas arising in women with breast cancer contain similar genetic alterations to those of sporadic endometrial carcinomas.

Biphasic sarcomatoid basal cell carcinoma (carcinosarcoma): four cases with immunohistochemistry and review of the literature

BACKGROUND

Biphasic sarcomatoid carcinoma (BSC), or carcinosarcoma, is an uncommon biphasic neoplasm that has been reported in diverse anatomical sites. The tumor is composed of a malignant epithelial component intimately associated with a malignant mesenchymal component, which may be homologous or heterologous. Twenty-three cases of primary cutaneous BSC have been reported in the English literature. In only eight of these cases was basal cell carcinoma the epithelial component.

METHODS

We report a further four cases of primary cutaneous biphasic basal cell carcinoma, and include the clinical, histological and immunohistochemical features.

RESULTS

The four cases showed basal cell carcinoma associated with a pleomorphic sarcomatous stroma. In addition, myofibroblastic differentiation and foci of osteoid were present in one case, and leiomyosarcomatous areas in another. The epithelial components were positive for several epithelial markers. The mesenchymal components were positive for vimentin and CD99, and negative for epithelial markers. p53 was positive with equal intensity in both epithelial and mesenchymal components. A significantly worse outcome was observed in patients with tumors measuring 40 mm or more at excision.

CONCLUSIONS

The sarcomatous component of the tumor is best regarded as a metaplastic transformation of the carcinomatous component. These tumors are potentially aggressive if incompletely excised, and complete resection is recommended.

Surveillance, epidemiology, and end results analysis of 2677 cases of uterine sarcoma 1989-1999

OBJECTIVES

To determine the association of race with incidence, histology, treatment, and survival in women with uterine sarcoma during the period 1989-1999.

METHODS

Uterine sarcomas were defined as leiomyosarcoma, carcinosarcoma, high-grade endometrial stromal sarcoma (HGESS), adenosarcoma, and sarcoma not otherwise specified (NOS). We used cases from Surveillance, Epidemiology, and End Results (SEER) program to compare uterine sarcoma among women >35 years of age. Using data from 1989 to 1999, we compared race-specific age-adjusted incidences, histological distributions, extent of disease at diagnosis, and race-specific survival.

RESULTS

During the period of 1989-1999, 2677 women were diagnosed with uterine sarcoma, 2098 (78%) of whom were white and 420 (16%) of whom were black, and 159 (6%) of whom were of other races. The overall age-adjusted incidence for blacks was twice that of whites and more than twice that of women of other races (7/10(5) vs. 3.6/10(5) vs. 2.7/10(5), P < 0.0001). Racial differences in the incidence of uterine sarcoma existed for leiomyosarcoma (1.51/10(5) for blacks vs. 0.91/10(5) for whites, and 0.89 for women of other races, P < 0.01) and carcinosarcoma (4.3/10(5) for blacks, vs. 1.7/10(5) for whites, and 0.99 for women of other races, P < 0.001), but not for other histological types. Blacks with stage II disease were less likely to receive radiation in addition to surgery compared to whites (33% vs. 54%, P < 0.05). Five-year relative survival of patients with disease beyond the uterus was significantly longer for those that received radiation and surgery compared to those that received surgery alone. There were no racial differences in survival for women that received similar therapy.

CONCLUSIONS

Adjuvant therapy improved survival for women with stage II-IV disease. Survival of black and white patients who received comparable treatment was similar.

2-methoxyestradiol strongly inhibits human uterine sarcomatous cell growth

OBJECTIVES

The objective was to test the hypothesis that uterine sarcomatous cells are hormone-sensitive. We included 2-methoxyestradiol, an endogenous metabolite of estradiol with antiproliferative properties.

METHODS

Proliferation assays assessed the effects of estradiol, progesterone, tamoxifen, raloxifen, [D-Trp(6)]leuteinizing hormone-releasing hormone (LHRH), ICI 182,780 (faslodex or fulvestrant), and 2-methoxyestradiol on cell growth of a cell line derived from uterine carcinosarcoma, but consisting solely of mesenchymal cells (SK-UT-1). Morphological changes of SK-UT-1 cells after exposure to 2-methoxyestradiol were evaluated and fluorescence immunohistochemistry for tubulin was used to detect changes in the mitotic spindle. Flow cytometry was used to assess the influence of 2-methoxyestradiol on the SK-UT-1 cell cycle as well as the role of p53 in apoptosis.

RESULTS

Cell proliferation analysis revealed that SK-UT-1 cells were stimulated by progesterone, tamoxifen, and [D-Trp(6)]LHRH. Cells were insensitive to estradiol, raloxifen, and ICI 182,780. Inhibition occurred after exposure to 2-methoxyestradiol and was accompanied by a threefold increase in the G2/M population, with a concomitant decrease in the G1 population, as shown by cell cycle analysis. SK-UT-1 cells exposed to 2-methoxyestradiol showed morphological changes indicative of apoptosis. Examination of signaling pathways that mediate 2-methoxyestradiol-induced apoptosis showed p53-independent growth inhibition. The inhibition of SK-UT-1 cell growth by arresting the cells during G2/M progression could be attributed to interference with the microtubule system, as determined by fluorescence immunohistochemistry.

CONCLUSIONS

The stimulatory effect of progesterone, tamoxifen, and [D-Trp(6)]LHRH suggests that uterine sarcomatous cells are hormone-sensitive. Our finding that 2-methoxyestradiol-mediated growth inhibition of uterine sarcomatous cells occurred in a p53-independent manner may have considerable clinical significance. The inadequate armature against uterine sarcomas and the limited toxicity of 2-methoxyestradiol may render these observations especially important.

A phase II trial of cisplatin, ifosfamide, and mesna in patients with advanced or recurrent uterine malignant mixed müllerian tumors with evaluation of potential molecular targets

OBJECTIVE

The aim of this study was to determine the efficacy of cisplatin, ifosfamide, and mesna in uterine malignant mixed müllerian tumor (MMMT) and to evaluate the expression of clinically relevant molecular markers.

METHODS

Women with advanced or recurrent MMMT were treated every 28 days with cisplatin (75 mg/m(2)), ifosfamide (1.2 gm/m(2)), and mesna (240 mg/m(2)). Treatment continued until disease progression or for six courses in the case of nonmeasurable disease. Immunohistochemical analysis for estrogen receptor (ER), progesterone receptor (PR), HER-2/neu, C-kit, Abl, and PDGFR-beta expression were performed.

RESULTS

Sixteen patients received 1-10 cycles; 2 died of disease progression after 1 cycle; 3 stopped after 1 cycle because of toxicity. Of 6 with measurable disease, 2 had a partial response, 1 had stable disease (SD), and 3 had progression (RR 33%). Partial response durations were 6 and 9 months; SD duration was 6 months. Of 5 patients without measurable disease, 4 received 6 cycles; 1 received 4 cycles. Four died of recurrent disease and 1 was without disease 6.5 years after treatment. Thirty-six percent experienced at least one neutropenic G3 or G4 event. All experienced G1 gastrointestinal toxicity. Four required dose reductions. At 7.5 months, only 1 with measurable disease was still living. Immunohistochemical analyses revealed that 24% expressed ER or PR, 19% expressed HER-2/neu, and none expressed C-kit. However, 45% expressed Abl and 100% expressed PDGFR-beta.

CONCLUSION

Although the combination of cisplatin, ifosfamide, and mesna in patients with MMMT had moderate activity, the high toxicity and short response duration in this uncommon, aggressive malignancy suggest that this regiment continues to be a disappointing treatment choice for uterine MMMT. HER-2/Neu, Abl, or PDGFR-beta expression may be of value in order to investigate novel multimodality treatment strategies.

Uterine carcinosarcomas (malignant mixed Mullerian tumors) are metaplastic carcinomas

Uterine carcinosarcomas (malignant mixed mullerian tumors) are metaplastic carcinomas. Uterine carcinosarcomas (malignant mixed Mullerian tumors) have been traditionally regarded as a subtype of uterine sarcoma. Adjuvant oncological treatments have often been similar to those directed against high-grade uterine sarcomas such as leiomyosarcoma and undifferentiated uterine sarcoma. However, there is now convincing evidence that most uterine carcinosarcomas are monoclonal neoplasms and are in reality metaplastic carcinomas. Although aggressive, the behavior of uterine carcinosarcoma is more akin to that of high-grade endometrioid type endometrial adenocarcinoma and aggressive morphological subtypes of uterine carcinoma. The sarcomatous component is derived from the carcinomatous element which is the driving force. Although the designation carcinosarcoma is likely to remain, adjuvant treatments should probably be similar to those directed against aggressive high grade endometrial carcinomas. Prospective studies should be performed to ascertain whether such adjuvant therapies are more effective than traditional sarcoma based therapies in the treatment of these aggressive neoplasms.

Malignant mixed mesodermal tumours: biology and clinical aspects

Mixed mesodermal tumours (MMTs) are relatively rare gynaecological tumours that have been poorly studied in clinical and molecular terms. They are chemosensitive (at least initially), although ultimately they have a poor prognosis. The biology of the tumour is fascinating in view of its composition of both epithelial and mesenchymal entities. We review herein the literature on the clinical and biological aspects of this malignancy.

Malignant biphasic uterine tumours: carcinosarcomas or metaplastic carcinomas?

Uterine carcinosarcomas (malignant mixed Mullerian tumours) are highly aggressive and have traditionally been regarded as a subtype of uterine sarcoma. However, in recent years convincing evidence has suggested that most, but not all, are monoclonal in origin rather than true collision tumours. Data confirm that the carcinomatous element is the "driving force" and that the sarcomatous component is derived from the carcinoma or from a stem cell that undergoes divergent differentiation. Thus, uterine carcinosarcomas are best regarded as metaplastic carcinomas, although the designation carcinosarcoma is likely to remain. Adjuvant treatment for uterine carcinosarcoma should probably be similar to that directed against aggressive high grade endometrial carcinomas rather than being sarcoma based. Importantly, a small proportion of uterine carcinosarcomas are true collision tumours and should be recognised as such because, in some instances, the prognosis may be better than for a similar stage carcinosarcoma.

Roles of androgens in the development, growth, and carcinogenesis of the mammary gland

Androgens influence the development and growth of the mammary gland in women. Treatment of animals and cultured cells with androgens has either inhibitory or stimulatory effects on the proliferation of mammary epithelia and cancer cells; the mechanisms for these dual functions are still not very clear and are discussed in this review. Epidemiological data suggest that, similar to increased estrogens, elevated androgens in serum may be associated with the development of breast cancer. Experiments in rodents have also shown that simultaneous treatment of androgen and estrogen synergizes for mammary gland carcinogenesis. Similar synergistic effects of both hormones have been observed for carcinogenesis of the uterine myometrium of female animals and for carcinogenesis of the prostate and deferens of males. There are also clinical and experimental indications for a possible association of elevated levels of both androgens and estrogens with the development of ovarian and endometrial cancers. A hypothesis is thus proposed that concomitant elevation in both androgens and estrogens may confer a greater risk for tumorigenesis of the mammary gland, and probably other female reproductive tissues than an elevation of each hormone alone.

Characteristics of ovarian and uterine cancers in a cohort of in vitro fertilization patients

OBJECTIVE

The aim of this study was to describe the features of cancers of the uterus, ovary, and other uterine adnexae in a large cohort of in vitro fertilization (IVF) patients and to thereby assist gynecologic oncologists in counseling patients with a history of infertility.

METHODS

Record-linkage to population-based cancer registries was used to determine the incidence of invasive cancer in a cohort of 29,700 IVF patients. Pathology reports were made available by the cancer registries and reviewed blind to IVF treatment status. Patient information was abstracted from IVF clinic records.

RESULTS

Twelve cancers of the uterus and 13 cancers of the ovary and other uterine adnexae were identified and pathology reports were reviewed for all but 1. Patients ranged in age at diagnosis from 28 to 48 years. Five cancers were diagnosed within 8 months of referral for IVF or IVF treatment; the others were diagnosed between 1 and 12 years later. The ovarian cancers were of the following histologic types: serous (4), mucinous (1), seromucinous (1), endometrioid (3), clear cell (2), and unknown type (1). A choriocarcinoma of the fallopian tube was diagnosed in a woman with a history of tubal infertility. Cancers of the uterus included endometrial adenocarcinomas (8), stromal sarcomas (2), and leiomyosarcomas (2). Ovarian cancer was diagnosed in a woman with Bloom's syndrome, a rare autosomal recessive disorder associated with increased cancer risk.

CONCLUSION

Cancer cases in this large, well-defined cohort of IVF patients show a broad range of patient and tumor characteristics. We found an increased incidence of uterine sarcoma in women with a history of infertility. Increased ascertainment of preexisting cancers in the course of infertility investigations and management is to be expected.