Uterine papillary serous carcinoma: study of 19 cases

Analysis of clinical and pathological characteristics, treatment methods, survival, and prognosis of uterine papillary serous carcinoma

PURPOSE

Uterine papillary serous carcinoma (UPSC) is an atypical variant of endometrial carcinoma with a poor prognosis. It is commonly associated with an increased risk of extrauterine disease. The aim of this study was to investigate clinical and pathological characteristics, therapeutic methods, and prognostic factors in women with UPSC.

METHODS

All patients who underwent surgery for UPSC at a single high-volume cancer center between January 1995 and December 2010 were retrospectively reviewed. Patients who did not undergo surgical staging and those with mixed tumor histology were excluded. Univariate and multivariate regression models were used to identify the risk factors for overall survival (OS) and progression-free survival (PFS).

RESULTS

A total of 46 patients were included, the majority of whom having stage I disease (IA, 13 [28.2%] and IB, 12 [26.7%]). Stages II, III, and IV were identified in 5 (10.9%), 8 (17.4%), and 8 (17.4%) women, respectively. Optimal cytoreduction was obtained in 67.3% of patients. Recurrences developed in 8 (17.4%) patients. Multivariate analysis confirmed that lymphovascular space invasion (LVSI) (odds ratio [OR] 26.83, p = 0.003) was the only independent prognostic factor for OS, whereas LVSI and optimal cytoreduction were found to be independent prognostic factors for PFS (OR 6.91, p = 0.013 and OR 2.69, p = 0.037, respectively). The 5-year overall survival rate was 63%.

CONCLUSIONS

Our study demonstrated that LVSI is the only independent prognostic factor for OS, whereas LVSI and optimal cytoreduction are independent prognostic factors for PFS in patients with UPSC.

Optimal cytoreduction, depth of myometrial invasion, and age are independent prognostic factors for survival in women with uterine papillary serous and clear cell carcinomas

OBJECTIVE

The purpose of this study was to investigate the clinicopathological characteristics, treatment methods, and prognostic factors in women with uterine papillary serous carcinoma (UPSC) and uterine clear-cell carcinoma (UCCC).

STUDY DESIGN

All patients who had undergone surgery for UPCS and UCCC between January 1995 and December 2012 were retrospectively reviewed. Patients with missing data, who did not undergo surgical staging and patients with mixed tumor histology were excluded. Multivariate regression models were used to identify the risk factors for overall survival (OS) and progression-free survival (PFS).

RESULTS

A total of 49 UPSC and 22 UCCC women were included. The majority of the patients were at stage I [IA, 22 (31%) and IB, 18 (25.4%)]. Stages II, III, and IV were identified in 9 (12.7%), 13 (18.3%), and 9 (12.7%) of cases, respectively. Optimal cytoreduction was achieved in 71.8% of cases. Recurrences occurred in 16 patients (22.5%). The 5-year OS rates were 67% for UPSC; 76% for UCCC; 68% for both histology, respectively. Multivariate analysis pointed out that age>67 years (odds ratio (OR): 3.85, p = 0.009 and OR: 3.35, p = 0.014), >50% myometrial invasion (MI) (OR: 2.87, p = 0.037 and OR: 2.46, p = 0.046) and optimal cytoreduction (OR: 3.26, p = 0.006 and OR: 2.77, p = 0.015) were the independent prognostic factors for both PFS and OS.

CONCLUSIONS

Our study demonstrated that optimal cytoreduction, >50% MI, and age >67 years are the most significant factors affecting survival in women with UPSC and UCCC.

Management of women with surgically staged 1 uterine papillary serous cancer

Objective. To review the management and outcomes of women with surgically staged 1 UPSC. Methods. We report on a case series from 2008-2010 from Hamilton Canada. We summarize the data from a literature search on surgically staged 1 UPSC. Results. There is a group women with Stage 1A UPSC with no residual disease at time of surgery who do not require adjuvant therapy. Vault recurrences appear to be lower in women who received adjuvant vault radiation. Chemotherapy appears to confer longer survival for those women with Stage 1B or 1C disease compared of those observed or who had radiation alone. Conclusion. Adjuvant therapy appears to confer benefit in certain groups of women with stage 1 UPSC. A randomized controlled study would clarify the degree of benefit.

Optimal surgical debulking in uterine papillary serous carcinoma affects survival

OBJECTIVE

UPSC is similar to papillary serous ovarian carcinoma in its histology and pattern of spread. The survival advantage with optimal debulking for ovarian cancer has been demonstrated. We examined our experience with UPSC.

METHODS

Seventy-eight UPSC patients were seen between 1995 and 2008 at Rush University Medical Center for surgery and/or adjuvant treatment. Information was obtained retrospectively from the Rush computer system, National Death Registry, and charts from chemotherapy, radiation, and gynecologic oncology.

RESULTS

Mean survival was 67.1 months for all stages (95% CI 52.8-81.2), 47.6 months for stage III (95% CI 26.7-68.3), and 21.7 months for stage IV (95% CI 14.5-29.1). No deaths occurred in stages I and II. No significant survival difference was found between African-Americans and Whites (log-rank test, p=0.62), nor between full serous and mixed pathology (log-rank test, p=0.52). Optimally debulked stage IV patients had a mean survival of 30.9 months, compared to 10.3 months in suboptimally debulked patients (p<0.001). Optimal debulking had no significant effect on stage III survival (p=0.47). Although weight was not statistically significant (p=0.059), there was a trend associated with suboptimal debulking. The mean time to recurrence for stage I was 79.9 months (95% CI 12.8-54.9), stage III was 27.4 months (95% CI 7.8-47.1), and stage IV was 20.2 months (95% CI 11.1-29.4) (p<0.001). There were no recurrences in stage II.

CONCLUSION

Our results suggest that UPSC should be optimally debulked. Weight is a risk factor for suboptimal debulking, which decreases mean survival and time to recurrence.

High incidence of BRCA1–2 germline mutations, previous breast cancer and familial cancer history in Jewish patients with uterine serous papillary carcinoma

OBJECTIVE

To test the carrier status of the three germline founder mutations in Jewish patients with uterine serous papillary carcinoma (USPC) and to evaluate its association to their personal and familial cancer records.

METHODS

Retrospective analysis of histologically confirmed USPC Jewish patients diagnosed between April 1, 1997 and December 31, 2003. All cases were genetically tested for the three BRCA1-2 founder germline mutations (185delAG and 5382insC in BRCA1 and 6174delT in BRCA2). The analysis was performed on genomic DNA extracted from whole blood or paraffin embedded normal tissue of these patients, employing PCR amplification of target sequences and differential digestion with restriction enzymes. The carrier frequency was compared to the known population frequency of these mutations.

RESULTS

The study group comprised 22 Jewish patients with USPC diagnosed within this timeframe. The mean age was 71.8 years (range 56-79). FIGO surgical stage distribution revealed 59% at stages III-IV. Seven USPC patients (32%) with a previous diagnosis of breast cancer were identified. Familial cancer history was recorded in 23% of the patients (four with breast cancer and one with ovarian cancer). DNA analysis revealed six BRCA1-2 germline mutation carriers (27%) as follows: three with BRCA2-6174delT, two with BRCA1-185delAG, and one with BRCA1-5382insC mutation. Three of the carriers had a previous diagnosis of breast cancer. Four carriers had familial cancer history in first-degree relative (three with breast cancer and one with ovarian cancer).

CONCLUSIONS

The high rate of BRCA germline mutations in USPC patients observed in the present study, coupled with the strong personal and familial cancer history as well as the histological and clinical resemblance to the ovarian cancer, may indicate that USPC is a part or an expression of the hereditary breast-ovarian cancer syndrome. This option may have implications in our clinical recommendations for non-affected BRCA1-2 carriers.

Improved survival in surgical stage I patients with uterine papillary serous carcinoma (UPSC) treated with adjuvant platinum-based chemotherapy

OBJECTIVE

Uterine papillary serous carcinoma (UPSC) is an aggressive form of endometrial cancer characterized by a high recurrence rate and a poor prognosis. Prior studies evaluating treatment of UPSC have been limited by small numbers of patients and inclusion of partially staged patients. The purpose of this study was to evaluate the efficacy of adjuvant platinum-based chemotherapy and vaginal cuff radiation in a large cohort of surgical stage I UPSC patients.

METHODS

We retrospectively reviewed 74 stage I patients with UPSC who underwent complete surgical staging at our institution between 1987 and 2004.

RESULTS

Stage IA patients were divided into two groups: patients with no cancer in the hysterectomy specimen (defined as no residual uterine disease) and patients with cancer in the hysterectomy specimen (defined as residual uterine disease). Stage IA patients with no residual uterine disease had no recurrences, regardless of adjuvant therapy (n = 12). Stage IA patients with residual uterine disease who were treated with platinum-based chemotherapy had no recurrences (n = 7). However, 6 of 14 (43%) stage IA patients with residual uterine disease who did not receive chemotherapy recurred. The 15 patients with stage IB UPSC who received platinum-based chemotherapy had no recurrences but 10 of the 13 (77%) stage IB patients who did not receive chemotherapy recurred. One of the 7 patients with stage IC UPSC who received platinum-based chemotherapy recurred and 4 of the 5 (80%) stage IC patients who did not receive chemotherapy recurred. Overall platinum-based chemotherapy was associated with improved disease-free survival (P < 0.01) and improved overall survival (P < 0.05) in patients with stage I UPSC. None of the 43 patients who received radiation to the vaginal cuff recurred locally, but 6 of the 31 (19%) patients who were not treated with vaginal radiation recurred at the cuff.

CONCLUSIONS

Platinum-based chemotherapy improves the disease-free and overall survival of patients with stage I UPSC and vaginal cuff radiation provides local control. Stage IA UPSC patients with no residual uterine disease can be observed but concomitant platinum-based chemotherapy and vaginal cuff radiation (referred to as chemoradiation) should be offered to all other stage I UPSC patients.

Uterine papillary serous carcinoma (UPSC): a single institution review of 129 cases

OBJECTIVE

The aim of this study was to identify clinical and pathologic characteristics of patients with uterine papillary serous carcinoma (UPSC) who were all surgically managed at a single institution. The identified characteristics were then correlated with overall survival (OS).

METHODS

One hundred twenty-nine patients with FIGO stage I-IV UPSC who were surgically staged at the University of Texas M. D. Anderson Cancer Center between 1989 and 2002 were identified. For each patient, medical records and pathology reports were reviewed. The Kaplan-Meier method was used to generate OS data. Factors predictive of outcome were compared using the log-rank test and Cox regression analysis.

RESULTS

There were 52 patients with stage I disease, 5 with stage II, 41 with stage III, and 31 with stage IV. The median age at the time of diagnosis was 68 years (range, 44-93 years). A personal history of breast cancer was reported by 12.4% of the patients, and a family history of breast cancer was reported by 16%. The 5-year OS among all patients was 45.9%. Among the stage I patients (IA, n = 19; IB, n = 26; and IC, n = 7), the 5-year OS was 62.9% (IA, 81.5%; IB, 58.6%; and IC, 34.3%). The 5-year OS for patients with stage III and IV disease was 37.3 and 19.9%, respectively. Pathologic features predictive of OS included lymph node status (P </= 0.01), lymph vascular invasion (P </= 0.05), and depth of uterine invasion (P </= 0.05). Among patients with no uterine invasion (n = 32), surgical staging revealed that 37% had stage III or IV disease. Among stage III patients, those who received chemotherapy had a longer OS than those who did not receive chemotherapy (P = 0.03).

CONCLUSION

In this population of nonselected patients with UPSC, approximately 20% had a personal or family history of breast cancer. Stage, lymph node status, lymph vascular invasion, and depth of myometrial invasion were all risk factors for a worse prognosis. Traditional risk factors, however, did not predict the presence or the absence of metastasis. Among patients with noninvasive uterine disease, there was a high proportion with abdominal metastasis. Therefore, complete surgical staging of these patients is vital in determining their prognosis.

Outcome and pattern of failure in pathologic stage I–II papillary serous carcinoma of the endometrium: Implications for adjuvant radiation therapy

PURPOSE

To evaluate the outcome and patterns of failure in women with pathologic Stage I-II papillary serous carcinoma of the uterus and to discuss the implications for adjuvant radiation therapy (RT).

METHODS

Twenty-three pathologic Stage I-II uterine papillary serous carcinoma patients were treated at our institution between 1980 and 2001. All underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy and assessment of peritoneal cytology. Pelvic and para-aortic lymph node sampling was performed in 12 and 8 patients, respectively. FIGO stages were as follows: IA = 3, IB = 8, IC = 6, IIA = 5, and IIB = 1. Adjuvant therapies included the following: 9 none, 10 RT (6 pelvic, 1 vaginal brachytherapy, 3 both), 4 chemotherapy, and 1 hormonal therapy. No patient received whole abdominal radiation therapy or para-aortic RT. Disease-free survival, pelvic recurrence-free survival, and cause-specific survival were estimated using the method of Kaplan-Meier, and prognostic factors were analyzed by the log-rank test. Median follow-up was 38.7 months (range: 3-109 months).

RESULTS

The 5-year actuarial disease-free survival and cause-specific survival for the entire group was 41% and 73.6%, respectively. Nine patients developed recurrent disease. Five failed in the pelvis, of which 4 relapsed in the vagina. No pelvic failures occurred in women treated with adjuvant RT. Patients treated with adjuvant RT had a better 5-year actuarial pelvic recurrence-free survival (100% vs. 57.5%, p = 0.06) than patients treated with surgery alone. Two patients failed in the abdomen. However, neither developed an isolated abdominal recurrence. Six patients failed in distant sites, primarily the lungs and bone.

CONCLUSION

Although patients with pathologic Stage I-II uterine papillary serous carcinomas have organ-confined disease, recurrence is common, particularly in the pelvis and distant sites. Our results suggest that adjuvant RT reduces the risk of pelvic failure. Contrary to traditional assumptions, however, abdominal recurrence was uncommon in our patients, despite the lack of whole abdominal radiation therapy. Our results support the use of pelvic RT in these patients. Future studies should investigate the role of adjuvant chemotherapy.

Patterns of failure after the multimodality treatment of uterine papillary serous carcinoma

PURPOSE

Uterine papillary serous carcinoma (UPSC) is an aggressive variant of endometrial carcinoma. The majority of patients with clinical Stage I UPSC are found to have extrauterine disease at the time of surgery. Most authors report survival rates of 35-50% for Stage I-II and 0-15% for Stage III and IV UPSC. Surgical treatment as the sole therapy for patients with Stage I-IV UPSC is unacceptable because of high recurrence rates. Chemotherapy, radiotherapy, or both have been added after surgery in an attempt to improve survival. However, the survival benefit to patients from such multimodality therapy remains uncertain. This study analyzes the patterns of failure in patients with FIGO Stages I-IV UPSC treated by multimodality therapy.

METHODS AND MATERIALS

Forty-two women with FIGO Stages I-IV UPSC who were treated by multimodality therapy were analyzed retrospectively between 1988 and 1998. Data were obtained from tumor registry, hospital, and radiotherapy chart reviews, operative notes, pathology, and chemotherapy flow sheets. All the patients underwent staging laparotomy, peritoneal cytology, total abdominal hysterectomy and salpingo oophorectomy, pelvic and para-aortic lymph node sampling, omentectomy, and cytoreductive surgery, when indicated followed by radiotherapy and/or chemotherapy. Therapy consisted of external beam radiation therapy in 11 patients (26%), systemic chemotherapy in 20 (48%), and both radiotherapy and chemotherapy in 11 (26%). The treatments were not assigned in a randomized fashion. The dose of external beam radiation therapy ranged from 45-50.40 Gy (median 45). Of the 31 patients (74%) who received chemotherapy, 18 received single-agent (58%), whereas 13 received multiagent chemotherapy (42%).

RESULTS

Median follow-up for all patients was 19 months (range 4-72). Median follow-up for the surviving patients was 36 months (range 21-72). Their median age was 65 years. Six patients (14%) had Stage I, 8 patients (19%) had Stage II, 10 (24%) had Stage III, and 18 (43%) had Stage IV disease. Twenty-nine patients (69%) had suffered recurrence at the time of last follow-up. The actuarial failure rate at 2 and 5 years was 58% and 67%, respectively. The majority of the patients (19/29) recurred in the abdomen, vagina, or pelvis (66%). Metastases outside the abdomen were much less common as the first site of failure (17%). Twenty-five patients (60%) had died at the time of reporting; the observed survival rate at 2 years and 5 years was 52% and 43%, respectively.

CONCLUSIONS

Our data suggest that, after multimodality therapy of FIGO Stage I-IV UPSC, most patients developed abdominopelvic (locoregional) failure, and the great majority of the failures occurred in the abdomen, vagina, and pelvis (66%). Abdominopelvic failure as a component of distant failure occurred in an additional 5 patients (17%). Distant failure alone occurred in 17% of the patients.We propose that future studies should combine whole abdominal radiotherapy (WART) with pelvic and vaginal boosts, in addition to chemotherapy for FIGO Stage I-IV UPSC, especially in patients with minimal residual disease, to attempt to improve the dismal prognosis of patients with UPSC.

Uterine Endometrioid Carcinoma with Small Nonvillous Papillae: An Analysis of 26 Cases of a Favorable-Prognosis Tumor To Be Distinguished from Serous Carcinoma

We have encountered a number of endometrioid carcinomas with small papillary buds lacking fibrovascular cores that could be confused with the small cellular papillae of serous papillary carcinoma (SPC). We have designated these tumors "endometrioid carcinoma with small nonvillous papillae" (ECSP). Because they have not been investigated previously we analyzed 26 examples and compared their features with those of 21 SPCs of the uterus. Three hundred and ninety consecutive cases of endometrial carcinoma diagnosed between January, 1989, and January, 1994, were retrieved from our hospital files; 26 (6.7%) of them, (8% of the endometrioid carcinomas) were identified as ECSP, and 21 (5.4%) as SPC. Tumors were classified as ECSP when the small papillae were present within the glands of otherwise typical endometrioid carcinoma or on the villous projections of villoglandular endometrioid carcinoma. Most of the papillae were in the form of buds of cells with ample eosinophilic cytoplasm and a low nuclear-to-cytoplasmic ratio, but some papillae had a more complex pattern. The papillae arose on a background of International Federation of Gynecology and Obstetrics (FIGO) grade 1 or 2 endometrioid carcinomas, which showed squamous differentiation in half the cases. SPCs were identified according to generally accepted criteria. The mean age of the patients with ECSP was 67 years, intermediate between that of the patients with endometrioid carcinoma lacking small nonvillous papillae (62 years) and that of the patients with SPC (71 years). Patients with ECSP more frequently presented at an earlier stage (73% stage I/II) than those with SPC (29% stage I/II). The overall 5-year survival of patients with ECSP was 84% (95%CI: 0.68-1), more than double that of patients with SPC, 33% (95%CI: 0.10-0.56). ECSP may be confused with SPC on microscopic examination but has clinical and pathological features similar to those of endometrioid carcinoma lacking small nonvillous papillae, and unlike SPC, should be treated in the same manner as the former. Int J Surg Pathol 8(4):279-289, 2000

Minimal uterine serous carcinoma: diagnosis and clinicopathologic correlation

The clinicopathologic features of uterine serous carcinoma (USC) lacking myometrial invasion, including its putative precursor lesion endometrial intraepithelial carcinoma (EIC), have not been studied extensively. Some USCs may prove fatal even when myometrial invasion is apparently absent, whereas others may be cured with surgery alone. Accordingly, the authors studied eight cases of pure EIC (no invasion identified) and 13 superficial serous carcinomas (SSCs) in which invasion was limited to the endometrial stroma to clarify the behavior of these lesions. The review demonstrated that the most important feature in assessing prognosis is the presence or absence of extrauterine disease at presentation. Thirteen of 14 patients (93%) with EIC or SSC confined to the uterus (stage I or IIA) were disease free and one was dead of unrelated causes at 52 months, whereas seven women who presented with extrauterine disease, even if only microscopic, were either dead of disease or alive with recurrences. Accordingly, patients with EIC or SSC must undergo meticulous surgical staging at the time of hysterectomy. Because the distinction between EIC and SSC based on the identification of stromal invasion is difficult and these lesions share a unique pattern of clinical behavior, the authors regard EIC and SSC measuring 1 cm or less as "minimal uterine serous carcinoma."

The treatment of uterine papillary serous carcinoma (UPSC): are we doing the right thing?

Tay EH, Ward BG. The treatment of uterine papillary serous carcinoma (UPSC): are we doing the right thing? In an earlier study(1) of 21 patients with uterine papillary serous carcinoma (UPSC), Ward et al. found a poor 3-year survival, even for patients with surgically documented localized disease, and a high rate of recurrence outside the field of treatment. Eight years later, we performed a retrospective study on 67 patients who were treated initially by surgery, which included the 21 patients previously reported, to evaluate any changes in the management approach since 1990 and its impact on the survival of such patients. The clinical characteristics of patients treated before and after 1990 were similar. However, after 1990, more patients had omentectomy and complete surgical staging (42% vs. 17%); chemotherapy was more widely used (63% vs. 33%); all chemotherapies were platinum-based regimens and less radiotherapy was administered (47% vs. 83%). The overall 3-year survival was 43% and 5-year survival was 35%, with a median survival period of 31 months. There was no significant difference in the survival outcome between patients managed before and after 1990, after adjusting for stage and spread of disease. Based on the results of this retrospective study, it appears that the current treatment strategy has not resulted in an improvement in the survival of patients with UPSC.

Endometrial cancer

Endometrial cancer is the most common gynecologic malignancy in the United States, with 37,400 new cases and 6400 deaths estimated to occur in 1999. The epidemiology of endometrial cancer has been widely characterized; nevertheless, efforts continue to more precisely define risk factors for the disease. Accurate epidemiologic risk factor profiles or focused screening efforts may ultimately facilitate the primary prevention of endometrial cancer. Currently, standard management of women with endometrial cancer includes surgical exploration with total hysterectomy and bilateral salpingo-oophorectomy. Uterine histopathologic characteristics and intraoperative findings continue to provide the primary indications for surgical staging in endometrial cancer. The addition of serum CA125 and selected imaging techniques (eg, transvaginal sonography with color Doppler and MR imaging) to the preoperative assessment may ultimately improve the sensitivity and specificity with which patients are selected for pathologic nodal evaluation. Various clinicopathologic factors have been evaluated as predictors of the clinical course of endometrial cancer and as selection criteria for patients most likely to benefit from adjuvant therapy. Histologic measurement of the tumor microvessel density is a promising technique for identifying patients at high risk for recurrence. Although uterine papillary serous carcinoma of the endometrium represents only 3% to 4% of endometrial cancer cases, it is of particular interest because of the aggressive clinical course and poor prognosis associated with this disease.