Gynecological sarcomas, surgical management: primary, metastatic, and recurrent disease

Adult-type gynecological soft tissue and visceral sarcomas are rare tumors, with an estimated incidence of 13% of all sarcomas and 4% of all gynecological malignancies. They most often develop in the uterus (83%), followed by the ovaries (8%), vulva and vagina (5%), and other gynecological organs (2%). The objective of this review is to provide an overview of the current management of gynecological sarcomas, according to international guidelines. The management of gynecological sarcomas should follow the recommendations for the management of soft tissue and visceral sarcomas. Centralizing cases in expert centers improves patient survival, both for the diagnostic phase and for multidisciplinary therapeutic management. In the case of pelvic soft tissue sarcomas, a radiological biopsy is essential before any surgical decision is taken. In the case of a myometrial tumour which may correspond to a sarcoma, if conservative surgery such as myomectomy or morcellation is planned, an ultrasound-guided biopsy with pathological analysis including comparative genomic hybridization analysis must be carried out. In all cases, en bloc surgery, without rupture, is mandatory. Many rare histological subtypes require specific surgical management.

Frontiers of Ovarian Carcinosarcoma

OPINION STATEMENT

Ovarian carcinosarcoma (OCS), also known as a malignant mixed Müllerian tumour (MMMT), is a rare and aggressive form of cancer that accounts for less than 5% of ovarian cancers. It is characterized by high morbidity and mortality rates, with a median overall survival (OS) of less than 2 years. Several factors, including advancing age, nulliparity, reduced lactation rates, decreased use of oral contraceptive pills, genetic mutations in BRCA (breast cancer) genes, and the use of assisted reproductive technology, may increase the risk of OCS. Poor prognostic factors include an advanced stage at diagnosis, older age, lymph node metastasis, suboptimal surgical cytoreduction, the presence of heterologous features on histopathology, and increased expression of vascular endothelial growth factor (VEGF), tumour protein p53, and p53 alongside Wilms tumour 1 (WT1). The main treatment approach for OCS is cytoreductive surgery followed by platinum-based chemotherapy, although immunotherapy is showing promise. Homologous recombination deficiency (HRD) testing may enhance outcomes by enabling personalized immunotherapy and targeted therapies for specific patient groups, thereby reducing unnecessary side effects and healthcare costs. However, there is currently a lack of standardised treatment regimens for OCS patients, with most studies consisting of case reports and a shortage of suitable comparator groups. This article aims to provide clinicians with information on the epidemiology, risk factors, prognostic factors, and latest therapeutic advancements in OCS.

Molecular characteristics and clinical behaviour of epithelial ovarian cancers

Ovarian carcinoma (OC) is an umbrella term for multiple distinct diseases (histotypes), each with their own developmental origins, clinical behaviour and molecular profile. Accordingly, OC management is progressing away from a one-size-fits all approach, toward more molecularly-driven, histotype-specific management strategies. Our knowledge of driver events in high grade serous OC, the most common histotype, has led to major advances in treatments, including PARP inhibitor use. However, these agents are not suitable for all patients, most notably for many of those with rare OC histotypes. Identification of additional targeted therapeutic strategies will require a detailed understanding of the molecular landscape in each OC histotype. Until recently, tumour profiling studies in rare histotypes were sparse; however, significant advances have been made over the last decade. In particular, reports of genomic characterisation in endometrioid, clear cell, mucinous and low grade serous OC have significantly expanded our understanding of mutational events in these tumour types. Nonetheless, substantial knowledge gaps remain. This review summarises our current understanding of each histotype, highlighting recent advances in these unique diseases and outlining immediate research priorities for accelerating progress toward improving patient outcomes.

The clinical characteristics and treatment of ovarian malignant mesoderm mixed tumor: a systematic review

Background

Ovarian malignant mesoderm mixed tumor (OMMMT) is a rare clinical entity. To provide reference for the treatment and prognosis of OMMMT, we analyzed the clinical features, pathology and molecular biology characteristic of published cases.

Methods

The English and Chinese reported cases of OMMMT were selected from PubMed, Clinical Trials.gov and CNKI database from 2000 to December 15th, 2021 following the PRISMA guidelines.

Results

A total of 63 literatures including 199 OMMMT cases were included. The average age of patients at diagnosis was 56.46 years, the highest incidence age was 60-65 years, and 82% of them were menopausal women. Most patients were diagnosed in FIGO III stage (59.64%). The most common symptom of OMMMT was abdominal pain (60.5%). 61.6% of patients were accompanied by ascites, while ascites was not associated with metastatic tumor and local recurrence. The CA125 of 88.68% patients increased. The most common reported carcinomatous component and sarcomatous component were serous adenocarcinoma (44.96%) and chondrosarcoma (24.81%), respectively. Initial treatment included surgery (94.97%) and taxanes-based (55.10%) or platinum-based (85.71%) chemotherapy regimens. The median survival time of patients was 20 months. Heterologous sarcoma component did not shorten life expectancy. The optimal ovarian tumor cell debulking surgery (OOTCDS), radiotherapy and chemotherapy could significantly prolong the median survival time of patients. Furthermore, platinum drugs could significantly prolong the survival time after comparing various chemotherapy schemes. Besides, the combination of platinum and taxanes was therapeutically superior to the combination of platinum and biological alkylating agents.

Conclusion

The OOTCDS and platinum-based chemotherapy regimen can improve the prognosis of OMMMT. Targeted therapy might become a new research direction in the future. Since the elderly patients are the majority, the toxicity of new drugs on the elderly patients is more noteworthy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13048-022-01037-6.

Management of a rare ovarian carcinosarcoma: A case report and literature review

Ovarian carcinosarcoma (OCS) is a rare and lethal gynecological cancer. The present study reports on the case of a 61-year-old post-menopausal female with abdominal distension who was detected to have a large OCS. The patient underwent cytoreductive surgery, including sub-extensive hysterectomy, bilateral adnexectomy, sigmoid colon and partial rectal resection, and lymph node dissection. Postoperative pathology of the bilateral adnexal masses revealed carcinosarcoma. The main components of the carcinoma included serous carcinoma and a small amount of squamous cell carcinoma. The sarcoma components mainly contained fibrosarcoma, as well as a small amount of chondrosarcoma and rhabdomyosarcoma. Infiltrating cells in cancer tissues or metastasis were observed in the serosal surface, muscular and subserosal layers of the uterus, as well as the sigmoid colon and part of the rectum. The patient was diagnosed postoperatively with International Federation of Gynecology and Obstetrics stage IIIC ovarian carcinosarcoma and T3cN1M0 based on the TNM system. The patient then received six cycles of combination chemotherapy using carboplatin, paclitaxel plus bevacizumab. As severe myelosuppression occurred during and after chemotherapy, and bevacizumab was expensive, bevacizumab therapy was not maintained after chemotherapy. However, following chemotherapy, the patient received niraparib oral maintenance therapy. At 6 months after the sixth chemotherapy, cancer antigen 125 levels dropped to 4.55 U/ml (within normal range). Short-term follow-up of 6 months after the end of chemotherapy indicated that the patient had a remission prognosis based on the ultrasonography, computed tomography, magnetic resonance imaging examinations and serum tumor marker levels. The present study indicated that combined chemotherapy and targeted therapy after cytoreductive surgery may be a promising way for the treatment of OCS.

Ovarian carcinosarcoma is a distinct form of ovarian cancer with poorer survival compared to tubo-ovarian high-grade serous carcinoma

Background

Ovarian carcinosarcoma (OCS) is an uncommon, biphasic and highly aggressive ovarian cancer type, which has received relatively little research attention.

Methods

We curated the largest pathologically confirmed OCS cohort to date, performing detailed histopathological characterisation, analysis of features associated with survival and comparison against high-grade serous ovarian carcinoma (HGSOC).

Results

Eighty-two OCS patients were identified; overall survival was poor (median 12.7 months). In all, 79% demonstrated epithelial components of high-grade serous (HGS) type, while 21% were endometrioid. Heterologous elements were common (chondrosarcoma in 32%, rhabdomyosarcoma in 21%, liposarcoma in 2%); chondrosarcoma was more frequent in OCS with endometrioid carcinomatous components. Earlier stage, complete resection and platinum-containing adjuvant chemotherapy were associated with prolonged survival; however, risk of relapse and mortality was high across all patient groups. Histological subclassification did not identify subgroups with distinct survival. Compared to HGSOC, OCS patients were older (P < 0.0001), more likely to be FIGO stage I (P = 0.025), demonstrated lower chemotherapy response rate (P = 0.001) and had significantly poorer survival (P < 0.0001).

Conclusion

OCS represents a distinct, highly lethal form of ovarian cancer for which new treatment strategies are urgently needed. Histological subclassification does not identify patient subgroups with distinct survival. Aggressive adjuvant chemotherapy should be considered for all cases, including those with early-stage disease.

Incidence and treatment outcomes of ovarian sarcoma compared to epithelial ovarian cancer from the national cancer registry

PURPOSE

To investigate the incidence and survival outcomes of primary ovarian sarcoma compared to those of epithelial ovarian cancer.

METHODS

Data on primary ovarian sarcoma patients (n = 1361) and epithelial ovarian cancer patients (n = 30,366) between 1999 and 2017 were obtained from the Korea Central Cancer Registry, and their respective age-standardized incidence rate (ASR) and relative survival rate were calculated and compared.

RESULTS

Based on the ASR, the incidence of epithelial ovarian cancer was 4.75 per 100,000 women, while that of primary ovarian sarcoma was 0.22 per 100,000 women. The ASR ratio was 21.94 without significant change of ASR during the study period. Primary ovarian sarcoma had a better survival curve compared with epithelial ovarian cancer, though the difference was not statistically significant (5 yr overall survival 64.0% vs. 61.5%; p = 0.6030). In addition, among the pure sarcomas, the fibrosarcoma histologic subtype showed the best overall survival, and that of liposarcomas and stromal cell sarcoma were behind that (5 yr overall survival 85.0%, 76.7%, and 72.7%; p < 0.0001).

CONCLUSIONS

The incidence of primary ovarian sarcoma is quite low, with an ASR of 0.22/100,000 during the last 20 years. There were no significant differences between survival rates of primary ovarian sarcoma and epithelial ovarian cancer.

Cancer of the ovary, fallopian tube, and peritoneum: 2021 update

In 2014, FIGO's Committee for Gynecologic Oncology revised the staging of ovarian cancer, incorporating ovarian, fallopian tube, and peritoneal cancer into the same system. Most of these malignancies are high-grade serous carcinomas (HGSC). Stage IC is now divided into three categories: IC1 (surgical spill); IC2 (capsule ruptured before surgery or tumor on ovarian or fallopian tube surface); and IC3 (malignant cells in the ascites or peritoneal washings). The updated staging includes a revision of Stage IIIC based on spread to the retroperitoneal lymph nodes alone without intraperitoneal dissemination. This category is now subdivided into IIIA1(i) (metastasis ≤10 mm in greatest dimension), and IIIA1(ii) (metastasis >10 mm in greatest dimension). Stage IIIA2 is now "microscopic extrapelvic peritoneal involvement with or without positive retroperitoneal lymph node" metastasis. This review summarizes the genetics, surgical management, chemotherapy, and targeted therapies for epithelial cancers, and the treatment of ovarian germ cell and stromal malignancies.

Ovarian Carcinosarcoma with Retroperitoneal Para-Aortic Lymph Node Dissemination Followed by an Unusual Postoperative Complication: A Case Report with a Brief Literature Review

Introduction. Ovarian carcinosarcoma (OCS), also known as malignant mixed Müllerian tumour (MMMT), is one of the rarest histological subtypes of ovarian cancer. It is an aggressive tumour with a dismal prognosis-the median survival of patients is less than two years. The rarity of the disease generates many controversies about histogenesis, prognostic factors and treatment of OCS. Histologically, OCS is composed of an epithelial and sarcomatous component. Case report. In the present case, a patient with bilateral ovarian cysts and bulky paraaortic lymph nodes is reported. Retroperitoneal paraaortic lymph node metastases were the only extrapelvic dissemination of OCS. The patient underwent comprehensive surgical staging procedures, including total abdominal hysterectomy and bilateral salpingo-oophorectomy, supracolic omentectomy and selective para-aortic lymphadenectomy. Histologically the ovarian carcinosarcoma was composed of an epithelial component (high-grade serous adenocarcinoma) and three sarcomatous components (homologous-endometrial stromal cell sarcoma, and heterologous-chondrosarcoma, rhabdomyosarcoma). Immunohistochemistry staining was performed. A postoperative complication (adhesion between the abdominal aorta and terminal ileum causing obstructive ileus) that has never been reported in the medical literature occurred. Conclusion. Carcinosarcomas are carcinomas with epithelial-mesenchymal transition and heterologous differentiation. Retroperitoneal pelvic and paraaortic lymph nodes should be carefully inspected in patients with ovarian tumours. Adhesions between the small bowels and abdominal aorta are possible complications after lymph node dissection in the paraaortic region.

Ovarian fibrosarcoma: A single-institution experience and a review of the literature

Ovarian fibrosarcoma is an extremely rare and malignant sex cord-stromal tumor. Due to its low incidence and poor prognosis, until now, very few cases have been reported, and most of the reported cases have been sporadic. Therefore, the treatments and prognostic factors of ovarian fibrosarcoma are still debatable. Here, we report 5 cases of ovarian fibrosarcoma that presented at Peking Union Medical College Hospital over the past 20 years. The 5 patients were 41, 51, 54, 76, and 76 years of age when initial symptoms of pelvic mass or pain appeared. On ultrasound, this disease usually manifests as unilateral pelvic masses, within which uneven echo enhancement and some blood flow signals are observed. No significant increase was observed in the levels of preoperative tumor markers, such as serum CA125 and sex hormones. The final diagnosis depends on postoperative histopathological results since these tumors are easily misdiagnosed when intraoperative frozen sections are used for examination. Pathologic examinations showed that the tumor cells were spindle-shaped with moderate to severe atypia and high mitotic counts. The immunohistochemistry profile is not specific, but the positive rate of Ki-67 was consistent with the degree of malignancy and the prognosis of patients with this tumor. In addition, the tumor may also be positive for Vimentin, α-inhibin, SMA, estrogen receptor and progesterone receptor. Significant differences were observed in the surgical methods used, and no unified chemotherapy regimen has been established. The overall survival was > 15, >7, > 6, <1, and < 1 year for each patient. After reviewing the literature, evidence-based large-scale case studies were lacking. For treatments, complete cytoreductive surgery plus regimens typically used against malignant sex cord-stromal tumors, as described in the NCCN guidelines, are recommended. Due to its low incidence, both multicenter clinical studies and molecular studies are required to provide gynecologists with a better understanding and guidance for future management of patients with ovarian fibrosarcoma.

Carcinosarcoma of the ovary: MR and clinical findings compared with high-grade serous carcinoma

PURPOSE

To clarify imaging and clinical characteristics of ovarian carcinosarcoma (CS) compared with high-grade serous carcinoma (HGSC).

METHODS

We retrospectively reviewed MR imagings of 12 patients with CS and 30 patients with HGSC and evaluated tumor size, shape, appearance, nature of cystic and solid components, hemorrhage, and necrosis. Age, premenopausal or postmenopausal, histologic subtype, presence of endometriosis, tumor markers, and stage were also evaluated. These parameters were compared using the Mann-Whitney U test and the chi-square test/Fisher's exact test.

RESULTS

The mean size of CSs was 13.6 cm, and significantly larger than that of HGSCs (mean 9.0 cm, p = 0.022). The stained-glass appearance (67% vs. 23%, p = 0.013), hemorrhage (100% vs. 50%, p = 0.003), necrosis (75.0% vs. 13%, p = 0.000), and endometriosis (33% vs. 7%, p = 0.012) were significantly more common in CSs. The postmenopausal ratio of CSs was 100% and significantly higher than that of HGSCs (70.0%, p = 0.041). Among the tumor makers, only CA-125 was significantly lower in CSs than in HGSCs (mean 715.1 U/ml vs. 1677.1 U/ml, p = 0.009). The stage distribution was similar and was not significantly different.

CONCLUSION

CSs formed larger masses, and the stained-glass appearance, hemorrhage, and necrosis were more frequently observed in CSs.

Primitive ovarian carcinosarcoma: a clinical and radiological analysis of five cases

BACKGROUND

Ovarian carcinosarcomas (OCS) are very rare tumors composed of a mixture of carcinomatous and sarcomatous elements. There have been only scattered case studies that have described the imaging findings. In order to improve the awareness of this rare tumor, this study aimed to analyze the clinical and imaging features of five cases of OCS confirmed by surgical pathologic evaluation.

METHODS

This retrospective study includes five OCS patients diagnosed and treated at our institute. The clinical course and imaging findings of all patients were retrospectively analyzed. The patients were 31 to 59 years of age. All five patients underwent CT scans, two underwent MRI scans.

RESULTS

The five patients have no specific symptoms. Four patients had elevated CA 125 levels and three patients had elevated CA 153 levels. All patients had unilateral tumors, four in the left ovary, one in the right ovary. The largest transverse diameter of the tumors ranged from 11 cm to 14 cm. Two tumors showed solid masses with unequally sized cystic areas or necrosis, one showed a multilocular cystic mass with a large solid protrusion, two tumors showed a larger cystic mass with multiple mural nodules. The solid components of the tumors demonstrated restricted diffusion (the average ADC value being 998 mm²/s and 1102 mm²/s, respectively), and showed moderate or obvious enhancement. All five patients were treated by surgical resection and adjuvant chemotherapy. One patient is currently undergoing post-operative chemotherapy 1 month after operation and clinical stable. Three patients survived and showed no obvious recurrence and / or metastasis in follow-up from 9 to 59 months. One patient died from recurrence and metastasis.

CONCLUSIONS

OCS are rare and demonstrate variable CT and MRI morphological appearances. Due to the heterogeneous nature and very low morbidity of OCS, combination of careful analysis of imaging findings and clinical features might be useful for a more accurate diagnosis of OCS.

Treatment of Rare Epithelial Ovarian Tumors

Traditionally, the management of epithelial ovarian cancer has been approached using a one-size-fits-all mentality. This strategy does not acknowledge the differences in epidemiology and clinical behavior of many of the histologic and molecular subgroups of ovarian cancer, specifically the rare histologies. While cytoreductive surgery followed by adjuvant platinum and taxane-based chemotherapy is the mainstay of primary treatment of epithelial ovarian cancer as a group, further investigation of novel therapeutics is critical for improving outcomes of these rare histologies. This article focuses on the management of non-high grade serous histologies of ovarian cancer.

Ovarian carcinosarcoma: Current developments and future perspectives

Ovarian carcinosarcoma (OCS) constitute uncommon malignancies accounting for only 1-4% of ovarian cancers. Patients more often present with advanced stage disease and symptoms similar to those of epithelial ovarian cancers (EOC). Optimal tumor cytoreduction appears to be an important determinant of survival. Platinum-based chemotherapy remains the most commonly employed adjuvant treatment. The uncertain origin and poor prognosis of OCS motivate determination of the molecular basis of carcinosarcomas aggressive behavior in the hope of developing novel and effective treatment modalities. The present review summarizes the current knowledge on the epidemiology, pathology, prognostic factors, clinical presentation, and therapeutic interventions including future potential therapeutic targets.

Cancer of the ovary, fallopian tube, and peritoneum

The Gynecologic Oncology Committee of FIGO in 2014 revised the staging of ovarian cancer, incorporating ovarian, fallopian tube, and peritoneal cancer into the same system. Most of these malignancies are high-grade serous carcinomas (HGSC). Stage IC is now divided into three categories: IC1 (surgical spill); IC2 (capsule ruptured before surgery or tumor on ovarian or fallopian tube surface); and IC3 (malignant cells in the ascites or peritoneal washings). The updated staging includes a revision of Stage IIIC based on spread to the retroperitoneal lymph nodes alone without intraperitoneal dissemination. This category is now subdivided into IIIA1(i) (metastasis ≤10 mm in greatest dimension), and IIIA1(ii) (metastasis >10 mm in greatest dimension). Stage IIIA2 is now "microscopic extrapelvic peritoneal involvement with or without positive retroperitoneal lymph node" metastasis. This review summarizes the genetics, surgical management, chemotherapy, and targeted therapies for epithelial cancers, and the treatment of ovarian germ cell and stromal malignancies.

Primary Ovarian Fibrosarcoma-An Unusual Tumor in an Adolescent: Case Report and Review of the Pediatric Literature

BACKGROUND

Primary ovarian fibrosarcomas are rare and usually observed in perimenopausal and postmenopausal women. To our knowledge, to date, there are only 3 reports of ovarian fibrosarcoma in childhood and adolescence in the English-language literature. In this report, we aimed to present to our knowledge, the first pediatric case with advanced stage primary ovarian fibrosarcoma and to compare with previous cases.

CASE

A 14-year-old teenage girl was admitted because of a giant abdominal mass. Imaging techniques revealed a giant heterogeneous and vascular ovarian mass. Salpingo-oophorectomy along with staging procedures were performed. Pathologic examination confirmed grade III ovarian fibrosarcoma with severe nuclear atypia and high mitotic count. Because of pulmonary metastasis, she received 4 courses of adjuvant combination chemotherapy (Ewing protocol). The patient withstood the treatment well and is disease-free at 2 years of follow-up.

CONCLUSION

Fibrosarcoma of the ovary is an uncommon neoplasm with poor prognosis. To our knowledge, the presented patient is the first pediatric case with advanced staged primary ovarian fibrosarcoma to be treated with surgery and adjuvant chemotherapy.

Prognostic assessment of sarcomatous histologic subtypes of ovarian carcinosarcoma

Objective

Ovarian carcinosarcoma is a rare subtype of this disease that has not been thoroughly investigated. The aim of this study was to evaluate the prognostic factors and out comes in patients with ovarian carcinosarcoma.

Methods

All patients with histologically confirmed ovarian carcinosarcoma who were treated at Cheil General Hospital and Women's Healthcare Center between January 2000 and December 2015 were identified and analyzed. Data were extracted from medical records, and statistical analyses were performed to determine correlations between clinicopathological parameters and survival outcomes.

Results

Of the 822 patients diagnosed with ovarian cancer over 16 years, 11 (1.3%) had ovarian carcinosarcoma histology. Every patient underwent surgery as the initial treatment followed by intravenous adjuvant chemotherapy. Only 18.1% of cases were early stage (I or II) while 81.8% were advanced stage (III or IV) according to the FIGO (International Federation of Gynecology and Obstetrics) classification. Six cases were of the homologous subtype (54.5%) and five were of the heterologous subtype (45.5%). There was no significant difference in survival according to stage (P=0.24). The heterologous subtype and residual disease were associated with poor disease-free survival (P=0.02 and P=0.04) and overall survival (P=0.02 and P=0.04), On multivariate analysis, the histological subtype was an independent prognostic factor (P=0.02).

Conclusion

Optimal cytoreduction without gross residual disease and a homologous subtype are favorable prognostic factors in terms of disease relapse and survival.

"Carcinosarcoma of the ovary, fallopian tube, and peritoneum: Prognostic factors and treatment modalities"

OBJECTIVE

Ovarian carcinosarcoma (OCS) is a rare malignancy accounting for only 1-4% of all ovarian cancers. The treatment of OCS is largely based on data from small case series and management of other histologic subtypes of epithelial ovarian cancer. We reviewed the literature pertinent to the pathology, pathogenesis, diagnosis, and management of women with OCS.

METHODS

MEDLINE was searched in English for literature on OCS, focusing on the past 30years. Given the rarity of this tumor, studies were not limited by design or number of reported patients.

RESULTS

Molecular, epidemiologic, genetic, and histologic data indicate that most OCS are monoclonal. Patients with OCS generally present with advanced stage disease. Most of the available retrospective studies support the role of cytoreductive surgery in the management of OCS, with optimal debulking associated with improved survival. Platinum-based chemotherapy is the current accepted adjuvant treatment. Given the limited data regarding the management of recurrent OCS, patients are usually treated similarly to women diagnosed with other subtypes of epithelial ovarian cancer.

CONCLUSION

OCS represent a rare and aggressive histologic subtype of epithelial ovarian cancer. The goal of surgery is comprehensive staging in patients with early-stage disease and optimal cytoreduction patients with advanced-stage tumors. Platinum-based chemotherapy is the mainstay of adjuvant systemic treatment. Future studies are needed in order to elucidate the molecular basis for OCS and to evaluate the role of targeted therapy in its management.

Clinicopathologic characteristics and survival for adult renal sarcoma: A population-based study

INTRODUCTION

To analyze the association of clinicopathologic characteristics and treatment modality with survival among adult patients with renal sarcoma.

METHODS

We identified 489 adults diagnosed with renal sarcoma from the Surveillance, Epidemiology and End Results registry between 1973 and 2011. Cancer-specific survival was estimated using the Kaplan-Meier method and was compared between groups with log rank and Cox models.

RESULTS

Median age at diagnosis was 61 years, while median tumor size was 11 cm. Tumor histology was leiomyosarcoma in 175, liposarcoma in 100, other subtypes in 129, and unknown in 85 cases. Tumor stage at diagnosis was nonmetastatic in 322 (67%) and metastatic in 167 (33%) cases. Treatment of nonmetastatic disease was surgical resection in 171 patients, radiation in 24, both in 35, neither in 18, and unknown in 74 cases. Treatment of metastatic disease was surgery in 39 patients, radiation in 27, both in 11, neither in 42, and unknown in 48. For nonmetastatic and metastatic disease, 5-year cancer-specific survival rates were 58% and 16%, respectively. On multivariable analysis, surgery was associated with decreased cancer-specific mortality among both patients with nonmetastatic disease (hazard ratio = 0.34; 95% CI: 0.14-0.85) and those with metastatic disease (hazard ratio = 0.38; 95% CI: 0.18-0.77). Age, race, tumor size, and tumor grade were independently associated with cancer death in nonmetastatic disease, whereas race and tumor histology remained associated with mortality in metastatic disease (all P < 0.05).

CONCLUSION

Although metastatic renal sarcoma has an ominous prognosis, durable survival may be achieved for localized tumors. Although we recognize the potential for selection bias, our results suggest an association between surgical resection and decreased mortality for both nonmetastatic and metastatic renal sarcoma.

Prolonged survival of a patient with pelvic recurrence of ovarian malignant mixed mullerian tumor after chemoradiotherapy

Introduction:

Malignant Mixed Mullerian Tumor (MMMT) is a very rare tumor, accounting for less than 1% of all ovarian cancers.

Case Presentation:

We present a 64-year-old woman with stage III MMMT of ovary that was treated with platinum-based chemotherapy after optimal cytoreductive surgery. After 25 months of being disease free, she had a pelvic recurrence and a good response to chemoradiotherapy.

Conclusions:

Optimal cytoreductive surgery and chemotherapy may be the best treatment in MMMT but more discussion and experiences are needed regarding the effectiveness of radiotherapy.

Radical surgical cytoreduction in the treatment of ovarian carcinosarcoma

OBJECTIVE

Carcinosarcomas are rare and aggressive ovarian malignancies. Treatment recommendations, which include surgical cytoreduction followed by platinum based chemotherapy, have been based on small amounts of retrospective data or extrapolated from experience with high-grade epithelial ovarian adenocarcinoma. Our objective was to determine the effects of radical primary cytoreduction on progression-free survival (PFS) and overall survival (OS).

METHODS

Following IRB approval, records of women with ovarian carcinosarcomas diagnosed between 2000 and 2012 at our institution were reviewed. Demographics, tumor characteristics, treatments, PFS, and OS were collected. Patients were divided into three groups based on the amount of residual disease: >1cm of disease, ≤ 1 cm of disease, or no visible disease. Chi-square and student's t-test were used to compare variables among groups. Kaplan-Meier survival curves were generated and compared with the log-rank test.

RESULTS

51 patients with ovarian carcinosarcoma were identified and all underwent primary cytoreductive surgery. Following surgical cytoreduction, 18 patients (35%) had no visible disease, 20 (39%) had ≤ 1 cm of disease, and 13 (25%) had >1cm of residual disease. Median PFS varied significantly among groups: 29 vs. 21 vs. 2 months (p=0.036) as did median OS: 57 vs. 32 vs. 11 months (p=0.015). When patients with stage 3 disease were analyzed separately, median OS still varied significantly among groups: 57 versus 31 versus 3 months (p=0.009).

CONCLUSION

Degree of surgical cytoreduction appears to correlate with PFS and OS. Radical surgery resulting in no visible disease is recommended for the upfront surgical treatment of ovarian carcinosarcoma.

Primary Treatment and Prognostic Factors of Carcinosarcoma of the Ovary, Fallopian Tube, and Peritoneum: A Taiwanese Gynecologic Oncology Group Study

Objective

This study aimed to determine the clinical prognostic factors involved in carcinosarcoma of the ovary, fallopian tube, and peritoneum.

Materials and Methods

This retrospective study was undertaken by the Taiwanese Gynecologic Oncology Group. The retrieved clinical data included demographic characteristics, medical disease, tumor status, extent of surgery, and adjuvant chemotherapy.

Results

In total, 63 patients with carcinosarcoma of the ovary, fallopian tube, and peritoneum were identified. Sixty-one patients with complete data were enrolled for further data analysis. The mean follow-up period was 1.0 year, and the mean overall survival was 15.4 months. By log-rank tests, age, menopausal status, parity, hypertension, diabetes, primary tumor size, para-aortic lymph node metastasis, pretreatment CA-125, preceding diagnostic surgery, hysterectomy, lymphadenectomy, other surgeries, and paclitaxel use were not predictive of overall survival.

Omentectomy, no gross residual implants after surgery, platinum treatment, and no pelvic lymph node metastasis had a trend toward better survival. Early diagnosis at stage I and cisplatin/ifosfamide regimen were significant associated with a better overall survival in log-rank and simple Cox regression tests. Bilateral ovarian tumors and metastatic tumors larger than 2 cm were significantly associated with a poorer overall survival.

Conclusions

Early diagnosis at stage I, unilateral ovarian tumor, metastatic tumors less than 2 cm, and cisplatin/ifosfamide regimen were predictive of a better survival.

Omentectomy and complete debulking surgery also showed a trend toward better survival. Thus, these treatment strategies should be applied in patients with carcinosarcoma of the ovary, fallopian tube, and peritoneum.

Carcinosarcoma of the ovary: natural history, patterns of treatment, and outcome

OBJECTIVE

Ovarian carcinosarcomas (OCS) are rare tumors composed of both malignant epithelial and mesenchymal elements. We compared the natural history and outcomes of OCS to serous carcinoma of the ovary.

METHODS

Patients with OCS and serous carcinomas registered in the Surveillance, Epidemiology, and End Results (SEER) database between 1988 and 2007 were analyzed. Demographic and clinical characteristics were compared using chi square tests while survival was analyzed using Cox proportional hazards models and the Kaplan-Meier method.

RESULTS

A total of 27,737 women, including 1763 (6.4%) with OCS and 25,974 (93.6%) with serous carcinomas, were identified. Patients with carcinosarcomas tended to be older and have unstaged tumors (P<0.0001). After adjusting for other prognostic factors, women with carcinosarcomas were 72% more likely to die from their tumors (HR=1.72; 95% CI, 1.52-1.96). Five-year survival for stage I carcinosarcomas was 65.2% (95% CI, 58.0-71.4%) vs. 80.6% (95% CI, 78.9-82.2%) for serous tumors. Similarly, five-year survival for stage IIIC patients was 18.2% (95% CI, 14.5-22.4%) for carcinosarcomas compared to 33.3% (95% 32.1-34.5%) for serous carcinomas.

CONCLUSIONS

Ovarian carcinosarcomas are aggressive tumors with a natural history that is distinct from serous cancers. The survival for both early and late stage carcinosarcoma is inferior to serous tumors.

Carcinosarcoma of the ovary compared to papillary serous ovarian carcinoma: a SEER analysis

OBJECTIVE

The aims of this study are to determine if outcomes of patients with ovarian carcinosarcoma (OCS) differ from women with high grade papillary serous ovarian carcinoma when compared by stage as well as to identify any associated clinico-pathologic factors.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) Program data for all 18 registries from 1998 to 2009 was reviewed to identify women with OCS and high grade papillary serous carcinoma of the ovary. Demographic and clinical data were compared, and the impact of tumor histology on survival was analyzed using the Kaplan-Meier method. Factors predictive of outcome were compared using the Cox proportional hazard model.

RESULTS

The final study group consisted of 14,753 women. 1334 (9.04%) had OCS and 13,419 (90.96%) had high grade papillary serous carcinoma of the ovary. Overall, women with OCS had a worse five-year, disease specific survival rate, 28.2% vs. 38.4% (P<0.001). This difference persisted for each FIGO disease stages I-IV, with five year survival consistently worse for women with OCS compared with papillary serous carcinoma. Over the entire study period, after adjusting for histology, age, period of diagnosis, SEER registry, marital status, stage, surgery, radiotherapy, lymph node dissection, and history of secondary malignancy after the diagnosis of ovarian cancer, carcinosarcoma histology was associated with decreased cancer-specific survival.

CONCLUSIONS

OCS is associated with a poor prognosis compared to high grade papillary serous carcinoma of the ovary. This difference was noted across all FIGO stages.

Synchronous occurrence of primary malignant mixed müllerian tumor in ovary and uterus

Malignant mixed müllerian tumor (MMMT) arising from female internal genitalia is rare with the uterine corpus being the most prevalently affected site. It is even more rare when it occurs on both uterus and ovary at the same time. We describe a case of synchronized occurrence of MMMT on ovary and uterine adenosarcoma with review of literature.

Presence of a sarcomatous component outside the ovary is an adverse prognostic factor for primary ovarian malignant mixed mesodermal/mullerian tumors: a clinicopathologic study of 47 cases

Primary ovarian malignant mixed mesodermal tumors are uncommon. There exist few data in the literature on the significance of the sarcomatous component (SC) in these tumors. Here we investigated this aspect in 47 such tumors, with particular interest in whether the presence of SC outside the ovary confers a worse prognosis. We correlated various features of the SC (homologous vs. heterologous, type of heterologous SC, extent/percentage, mitotic count, necrosis, whether or not SC is present outside the ovary) with disease-specific survival (DSS) using the Kaplan-Meier method and log-rank test. We also correlated other clinicopathologic parameters with DSS: age, stage, tumor size, tumor laterality, type of the carcinomatous component (CC), lymph node status, vascular invasion, and degree of surgical debulking. The mean age was 69.0 years (range, 43 to 89 y). The tumor was located in the left and right ovary in 18 and 24 patients, respectively (laterality could not be determined in 5 cases). The mean tumor size was 13.6 cm. Surgical debulking was optimal in 28, suboptimal in 6, and unclear in 13 patients. FIGO stage was I in 1 patient, II in 5 patients, III in 40 (IIIA in 1, IIIB in 11, IIIC in 28), and IV in 1 patient. Node metastasis and vascular invasion were noted in 6/17 and 29/47 patients, respectively. The mean percentage of SC was 29% (median 20%; range, 1% to 90%). The SC was heterologous in 34 (72%) and homologous in 13 (28%) patients. The mitotic figures per 10 HPF in SC were 33 (0 to 128). Tumor necrosis was present in 45/47 cases (mean 10%; range, 1% to 40%, only in CC in 14, only in SC in 2, in both SC and CC in 29). The CC was high-grade serous in 27 patients, endometrioid in 2, mixed high-grade serous and endometrioid in 17, and mixed high-grade serous and clear cell carcinoma in 1 patient. The extraovarian tumor contained only CC in 17 cases, only SC in 1 case, and both SC and CC in 28 cases. The median follow-up was 29 months (range, 1 to 183 mo): 6 patients were lost to follow-up, 3 died postoperatively, 29 died from disease, 2 died from other causes, and 7 were still alive (14 to 183 mo). The DSS rate at 1, 2, and 5 years was 75%, 56%, and 21%, respectively. Presence of SC outside the ovary was a significant adverse prognostic factor (P=0.03), whereas other parameters were not. After adjusting for FIGO stage, presence of SC outside the ovary was still a significant adverse prognosticator for stage III patients (P=0.003), whereas others were not. Therefore, our findings showed that presence of SC outside the ovary was a significant adverse prognostic factor. We advocate listing the specific extraovarian tumor component (SC and/or CC) in the pathology report for primary ovarian malignant mixed mesodermal tumors.

Optimal debulking surgery followed by paclitaxel/platinum chemotherapy is very effective in treating ovarian carcinosarcomas: a single center experience

BACKGROUND

There have been only a few reports on the survival and management of patients with ovarian carcinosarcomas. We evaluated the clinical characteristics, outcomes and prognostic factors of ovarian carcinosarcomas.

METHODS

Retrospective analysis of data obtained from medical records of 40 patients treated at the Asan Medical Center, Seoul, Korea, between January 1989 and January 2008.

RESULTS

Median survival was significantly longer in patients <60 years of age than in those ≥60 (p = 0.001), patients with early-stage compared to advanced tumors (p = 0.035), those with optimally debulked tumors compared to suboptimally (p < 0.001) in the advanced stage, and patients treated with paclitaxel/platinum compared to patients treated with other chemotherapies (p < 0.001). The progression-free interval was longer in patients with early-stage (p = 0.003) and optimally debulked tumors (p = 0.001), as well as in those treated with paclitaxel/platinum (p = 0.049). Multivariate analysis showed that advanced-stage, non-optimal debulking and non-paclitaxel/platinum chemotherapy were significant independent predictors of a shorter progression-free interval, and that non-optimal debulking and non-paclitaxel/platinum chemotherapy were significant independent predictors of shorter overall survival.

CONCLUSIONS

Early-stage optimal debulking and adequate chemotherapy can influence time to progression and survival, indicating that the most effective treatment for patients with ovarian carcinosarcomas consists of optimal debulking surgery followed by paclitaxel/platinum chemotherapy.

Carcinosarcoma of the ovary: analysis of 13 cases and review of the literature

OBJECTIVES

The aim of this study was to evaluate our experience with patients affected by ovarian carcinosarcoma.

PATIENTS AND METHODS

During a 16-year period, data on 13 patients with ovarian carcinosarcoma were collected. They were obtained from hospital charts and follow-up visits. Survival curves were estimated by the Kaplan-Meier method and compared using the log-rank test. All tests were two-tailed with p values < 0.05 considered significant.

RESULTS

Our study was conducted on 13 patients with ovarian carcinosarcoma referred to our unit, during an observation time of about 16 years (March 1994 to October 2010). An improved survival was observed in patients treated with optimal cytoreductive surgery with residual tumors <2 cm (30 vs. 5 months; p = 0.042). All patients underwent adjuvant chemotherapy based on the combination of cisplatin, epirubicin and ifosfamide (PEI) and taxol and carboplatin (TAX-CBDCA) regimen. Overall survival of the patient population was 17 months.

CONCLUSIONS

Similarly to data published in the literature, we observed that malignant mixed mullerian ovarian tumors are very aggressive and are usually diagnosed at an advanced age and at an advanced stage of disease. Therefore, due to the rarity of the tumor we would like to add our series to those already published in the literature, although our treatment recommendations are actually based upon retrospective studies with a small patient population.

Carcinosarcoma of the ovary: a case-control study

INTRODUCTION

Carcinosarcoma of the ovary is a rare tumor with a grim prognosis. Chemotherapy for these tumors is chosen according to guidelines established for epithelial ovarian cancer (EOC). The purpose of this study is to compare response to chemotherapy and survival in patients with advanced stage carcinosarcoma of the ovary.

METHODS

We identified women with advanced carcinosarcoma of the ovary who underwent first-line platinum and taxane-based chemotherapy. Each case was matched to two women with serous EOC. Cases and controls were matched by age, stage, and year of diagnosis. The Kaplan-Meier method was used to generate overall survival (OS) data. Factors predictive of outcome were compared using the log-rank test and Cox proportional hazards model.

RESULTS

Fifty women treated with first line platinum and taxane-based chemotherapy had advanced carcinosarcoma of the ovary and were selected as cases. The response rates to chemotherapy for cases and controls were 62% and 83% (P=0.03), respectively. Median progression-free survival was 11 months (95% CI, 8 to 14 months) versus 16 months (95% CI, 12 to 21 months; P=0.02) and median overall survival was 24 months (95% CI, 18 to 29 months) versus 41 months (95% CI, 33 to 49 months; P=0.002) for cases and controls, respectively.

CONCLUSION

Patients with advanced carcinosarcoma of the ovary have a poorer response to platinum and taxane-based first-line chemotherapy and worse survival, compared to patients with serous EOC. Aggressive surgical treatment may play an important role. However, other alternative systemic therapeutic approaches should be sought for patients with carcinosarcoma of the ovary.

Malignant mixed Mullerian tumor of the ovary with two cases and review of the literature

INTRODUCTION

Malignant mixed Müllerian tumor (MMMT) of the ovary is a rare and highly aggressive tumor. It accounts <1% of all ovarian carcinomas. It is characterized by the presence of both carcinomatous and sarcomatous components and tends to occur in low parity postmenopausal woman. These are mixed, mostly monoclonal tumors, and the predominance of the stromal component aggravates the prognosis. The staging system for ovarian and primary peritoneal cancer is also used for MMMT. After complete surgical staging, patient with stage II-IV at the time of surgery should have postoperative chemotherapy. Chemotherapy can be considered for stage I MMMT. Its optimal treatment is debatable. Taxane and platinum combination is standard for the epithelial ovarian carcinoma. There is very limited literature reporting this combination therapy in ovarian MMMTs. CASE 1 AND CASE 2: We presented two cases of stage III primary ovarian MMMT. The patients were treated with the taxane/platin combination, without adverse events following surgery, and remained in clinical remission in Case 1 at follow-up. Case 2 has progressed after first line taxane/platin regimen and treated like epithelial ovarian carcinoma. Case 1 was in complete remission in the follow-up visit 2 years later. Case 2 died 14 months later after the tumor was initially diagnosed.

CONCLUSION

Predominating carcinomatous or sarcomatous component should be taken into consideration in predicting the response and planning the chemotherapy protocol.

Conditional inactivation of Brca1, p53 and Rb in mouse ovaries results in the development of leiomyosarcomas

Epithelial ovarian cancer (EOC) is thought to arise in part from the ovarian surface epithelium (OSE); however, the molecular events underlying this transformation are poorly understood. Germline mutations in the BRCA1 tumor suppressor gene result in a significantly increased risk of developing EOC and a large proportion of sporadic EOCs display some sort of BRCA1 dysfunction. To generate a model in which Brca1-mediated transformation can be studied, we previously inactivated Brca1 alone in murine OSE, which resulted in an increased accumulation of premalignant changes, but no tumor formation. In this study, we examined tumor formation in mice with conditionally expressed alleles of Brca1, p53 and Rb, alone or in combination. Intrabursal injection of adenovirus expressing Cre recombinase to inactivate p53 resulted in tumors in 100% of mice. Tumor progression was accelerated in mice with concomitant inactivation of Brca1 and p53, but not Rb and p53. Immunohistologic analyses classified the tumors as leiomyosarcomas that may be arising from the ovarian bursa. Brca1 inactivation in primary cultures of murine OSE cells led to a suppression of proliferation that could be rescued by concomitant inactivation of p53 and/or Rb. Brca1-deficient OSE cells displayed an increased sensitivity to the DNA damaging agent cisplatin, and this effect could be modulated by inactivation of p53 and/or Rb. These results indicate that Brca1 deficiency can accelerate tumor development and alter the sensitivity of OSE cells to chemotherapeutic agents. Intrabursal delivery of adenovirus intended to alter gene expression in the ovarian surface epithelium may, in some strains of mice, result in more rapid transformation of adjacent cells, resulting in leiomyosarcomas.

Platinum, anthracycline, and alkylating agent-based chemotherapy for ovarian carcinosarcoma

BACKGROUND

Ovarian carcinosarcoma (OCS) is a rare malignancy associated with a poor prognosis. Platinum, anthracyclines, and alkylating agents are the most effective antiblastic drugs for treatment of gynecologic epithelial and stromal tumors. The aim of this study was to determine response rate and overall survival (OS) of patients with OCS who were treated with a combination of these 3 drugs.

METHODS

Forty-one women with OCS who were referred to the Department of Gynecologic Oncology of San Gerardo Hospital in Monza and European Institute of Oncology in Milan, between January 1995, and December 2006, and treated with a combination regimen of cisplatin, adriamycin, and cyclophosphamide or a combination regimen containing of cisplatin, epirubicin, and ifosfamide plus granulocyte colony-stimulating factor were considered for this study.

RESULTS

Four women had OCS stage I; 7, stage II; 23, stage III; and 7, stage IV. Heterologous, homologous, and mixed stromal components were described in 17, 14, and 10 patients, respectively. Thirteen women were treated with a combination of cisplatin, adriamycin, and cyclophosphamide and 28 with a combination of cisplatin, epirubicin, and ifosfamide plus granulocyte colony-stimulating factor. Two women did not complete their treatment because of the rapid progression of their disease and severe toxicity. Among 22 women considered evaluable for response, 10 (46%) achieved a complete response and 3 (13%) achieved a partial response (global response rate, 59%). Overall progression-free survival was 11.8 months (range, 0.9-96 months) and 13.8 and 10.1 months in stage I-II and III-IV, respectively (P = 0.13). Median OS was 20 months (range, 1-123 months), not reached in stage I-II, and 19.7 months in stage III-IV (P = 0.07). No significant difference between homologous and heterologous sarcomatous components was observed (P = 0.95), whereas no significant trend of improved OS was noticed for stage IIIC-IV with optimal debulking surgery (n = 9), compared with suboptimal cytoreduction (n = 19; 32.6 vs 14.5 months, P = 0.14).

CONCLUSION

The combination of anthracycline, alkylating agent, and cisplatin showed a good response rate but also a high toxicity. The prognosis of OCS remains poor. Optimal cytoreduction may improve survival, but new anticancer drugs or more effective regimens are awaited.

Carcinosarcoma of the ovary a review

Carcinosarcoma of the ovary, also referred to as mixed mullerian tumor of the ovary, is a rare and aggressive tumor. This tumor type is unique in that it contains malignant epithelial and stromal elements. The average survival for a woman diagnosed with carcinosarcoma of the ovary is less than 2 years. Due to the rarity of this tumor, the optimal treatment for carcinosarcoma of the ovary has not been determined. We review the pathology, risk factors, and current treatment recommendations for carcinosarcoma of the ovary.

Carcinosarcoma of the ovary

The objective of this study was to evaluate the treatment and outcome in patients with ovarian carcinosarcoma. The Tumor Board Registry was reviewed for patients with ovarian carcinosarcoma treated at our institution from June 1993 to December 2004. The medical records were retrospectively analyzed with emphasis on cytoreduction, cytotoxic regimens, progression-free interval, and survival. Twenty-two patients were identified. All but two presented with advanced stage disease. The median survival for the entire cohort was 38 months. Median survival was 46 months for 18 optimally debulked (<1 cm) patients and 27 months for four suboptimally debulked (>1 cm) patients. Six patients were treated with optimal cytoreduction and adjuvant cisplatin (40 mg/m(2)x 1 day) and ifosfamide (1200 mg/m(2)/day x 4 days) every 28 days. Median progression-free interval in the cisplatin and ifosfamide group was 13 months, and median survival was 51 months. The combination of carboplatin (AUC 5) and taxol (175 mg/m(2)) every 21 days was administered to four patients as first-line chemotherapy following optimal cytoreduction. In the carboplatin and taxol group, median progression-free interval was 6 months and median survival was 38 months. The difference in survival between the cisplatin and ifosfamide group and the carboplatin and taxol group was not statistically significant (P= 0.48). In conclusion, patients with ovarian carcinosarcoma usually present with advanced stage disease. Treatment consists of optimal cytoreduction and chemotherapy. The most effective cytotoxic regimen remains to be determined. First-line cisplatin and ifosfamide or carboplatin and taxol can achieve survival rates observed in epithelial ovarian cancer.

Ovarian carcinosarcomas: clinicopathological prognostic factors and evaluation of chemotherapy regimens containing platinum

OBJECTIVE

To evaluate the clinicopathological prognostic factors and outcome of chemotherapy in ovarian carcinosarcomas.

METHODS

We reviewed the records of 26 patients treated from 1990 to 2006 at the Oncology Institute of Istanbul University. Clinical data including demographics, stage, surgery, chemotherapy, and survival were collected from patients' charts.

RESULTS

All patients underwent initial debulking surgery. Optimal debulking was achieved in 21 (81%) patients. The most striking clinicopathological finding was the high incidence of hemorrhagic ascites (n: 6) which was observed in 60% of the patients with ascites (n: 10). The overall median survival of the patients was 26 months. Residual disease was associated with a decreased overall survival, P=0.04. Median survival (50 months vs 9.7 months, P=0.042) of the patients with early stage disease were longer than the patients with advanced stage. Twenty-two patients received platinum-based combination chemotherapy. There was a trend for increased median survival in the patients who were treated with carboplatin/paclitaxel combination (P=0.066). Although the numbers were insufficient for statistical evaluation, the patients treated with ifosfamide combinations had improved survival (36 months vs 26 months). However, when the patients treated with ifosfamide and carboplatin/paclitaxel combinations were combined, survival was statistically improved compared to the other regimens (36 months vs 9.7 months, P=0.04). Chemotherapy regimens containing doxorubicin or cyclophosphamide were not encouraging. Stage (P=0.02) and adjuvant platinum-based chemotherapy containing either paclitaxel or ifosfamide (P=0.024) remained predictive of outcome in the multivariate analysis.

CONCLUSIONS

Hemorrhagic ascites can be used in the initial differential diagnosis of ovarian carcinosarcomas. Stage, optimal debulking and type of adjuvant therapy were statistically significant prognostic predictors of ovarian carcinosarcomas. We advise that patients with ovarian carcinosarcomas should be treated by optimal cytoreduction followed by adjuvant platinum/taxan or platinum/ifosfamide combinations.

Carcinosarcoma of the ovary treated with platinum and taxane: The memorial Sloan-Kettering Cancer Center experience

INTRODUCTION

Due to the rarity of ovarian carcinosarcomas, the optimal chemotherapeutic regimen to treat this aggressive disease is yet to be determined. The purpose of this study was to determine the response rate, recurrence-free survival, and overall survival of patients with ovarian carcinosarcoma who were treated with the combination of platinum and a taxane as first-line chemotherapy.

METHODS

We identified all patients with ovarian carcinosarcoma who received a combination of platinum and taxane either after initial tumor resection or as neoadjuvant therapy. Data extracted from the medical records included residual tumor after surgery, number, type and dose of chemotherapy cycles, tumor response, and survival outcome.

RESULTS

Between 1991 and 2005, 30 patients were identified for analysis. Twenty-four patients had stage III disease, 5 had stage IV disease, and 1 had stage II disease. All patients underwent surgical resection and 17 (57%) were cytoreduced to less than 1 cm. Twenty-eight patients received chemotherapy after surgery, and 2 patients received chemotherapy before surgery. Twenty-four patients (80%) received carboplatin and paclitaxel, 3 (10%) received carboplatin and docetaxel, and 3 (10%) received cisplatin and paclitaxel. Twelve (40%) had a complete response, 7 (23%) a partial response, 2 (7%) stable disease, and 9 (30%) progression of disease. The median time to progression for responders was 12 months. With a median follow-up of 23 months, the median overall survival was 43 months for survivors. The 3- and 5-year survival rates were 53% and 30%, respectively.

CONCLUSION

The combination of platinum and a taxane is a viable first-line treatment option for patients with ovarian carcinosarcoma.

A pilot study of cisplatin, ifosfamide and mesna in the treatment of malignant mixed mesodermal tumors of the ovary

PURPOSE

To evaluate the efficacy and toxicity of cisplatin and ifosfamide in the treatment of patients with malignant mixed mesodermal tumor (MMMT) of the ovary.

METHODS

Ten patients with histologically confirmed primary MMMT of the ovary diagnosed between 1993 and 2001 were enrolled in the study. Treatment consisted of cisplatin 75 mg/m2 on day 1, followed by ifosfamide 2.0 g/m2 over 24 h on days 1, 2 and 3. Mesna, 400 mg/m2, was given IV immediately prior to and 4 and 8 h after the start of each ifosfamide infusion. Chemotherapy was repeated on a 28-day cycle if blood counts permitted. Standard response criteria were used. Nine patients were evaluable for response.

RESULTS

Eight of the nine patients responded to therapy, with 7 complete responses (78%) and 1 partial response. Seven of the eight responders (87.5%) eventually recurred. The median progression-free survival was 10 months (range 0-94.4 months). The median overall survival was 17.1 months (range 8-125.5 months). One patient remained free of disease 94.4 months after diagnosis, and one patient remained alive with recurrence 125.5 months following diagnosis. There were 13 grade 3 toxicities and 4 grade 4 toxicities. Four patients had grade 4 and three had grade 3 neutropenia, all of which required dose reductions.

CONCLUSION

The combination of cisplatin and ifosfamide/mesna demonstrated activity against MMMT of the ovary. Response durations were short, however, and the regimen was associated with significant toxicity. Novel agents with activity against MMMT of the ovary and acceptable toxicity are needed.

Carcinosarcoma of the ovary—a case series

OBJECTIVE

To evaluate our experience with ovarian carcinosarcoma and identify prognostic factors.

METHODS

Thirty-one cases of ovarian carcinosarcoma were identified over a 6-year time period through tumor registry and pathology records. Fisher exact test and log rank using Kaplan-Meier method (P < 0.05) were used to compare variables with outcome.

RESULTS

All 31 patients underwent initial surgical treatment with an appropriate staging procedure. Stage distribution: 1 stage I, 6 stage II, 23 stage III, and 1 stage IV. The median follow-up was 28 months. The median survival for the entire group was 21 months. Early vs. advanced stage significantly influenced progression-free interval, P = 0.05. Nineteen patients were found to have stage IIIC disease and required debulking procedures. In patients with stage IIIC disease, presence of residual disease was associated with decreased overall survival, P = 0.03. 29 patients received adjuvant chemotherapy with 11 patients receiving ifosfamide/cisplatin and 16 patients receiving carboplatin/taxol. Progression-free interval was improved with the use of ifosfamide/cisplatin vs. carboplatin/taxol. The median PFI was 12 months in the carbo/taxol group and has not been reached in the ifos/cisplatin group (P = 0.005). The overall survival was also significantly improved with the use of ifosfamide/cisplatin, P = 0.03. In advanced stage patients, overall survival was not significantly influenced by type of adjuvant chemotherapy administered, P = 0.13.

CONCLUSIONS

Ovarian carcinosarcoma has a poor overall prognosis with median survival rates reported in the literature ranging from 7-10 months. Our series, although limited by a small number of patients, exhibits a more encouraging median survival of 21 months for the overall group. Aggressive debulking to eliminate residual disease and the use of ifosfamide/cisplatin chemotherapy seem to be factors in this improved outcome.

Malignant mixed mullerian tumor (MMMT) of the cervix

OBJECTIVES

To characterize the clinical characteristics, therapeutic options, and potential outcomes in patients diagnosed with malignant mixed mullerian tumor (MMMT) of the uterine cervix.

METHODS

Five women ranging in age from 25 to 66 (mean 49.6 years) were diagnosed with MMMT of the cervix and treated at the University of Iowa Hospitals and Clinics between 1986 and 2001. Data were retrospectively analyzed from available charts and pathological reports with particular attention to patient demographics, presenting symptoms, treatment, and follow-up.

RESULTS

Abnormal vaginal bleeding was a common presenting symptom in all but one patient, in whom an abnormal screening Pap smear was the primary reason for referral. FIGO disease staging at initial diagnosis included two patients with stage IB1 (ages 29 and 66 years), two patients with stage IB2 (ages 25 and 64 years), and one patient with stage IVB (age 64 years) MMMT of the cervix. Organ-confined, early stage lesions (stages IB1 and IB2) responded well to regimens of either surgery alone or surgery plus radiation therapy, with no evidence of recurrent disease at last follow-up 28, 35, 42, and 65 months later, respectively. The lone patient with advanced stage IVB disease, however, was unresponsive to both external beam radiation therapy and ifosfamide chemotherapy, and succumbed to disease within 5 months.

CONCLUSIONS

Cervical MMMT is an uncommon disease, but long-term survival is possible in organ-confined early stage disease with primary therapy.