Malignant mixed mesodermal tumours: biology and clinical aspects

Cervical Carcinosarcoma: Current Understanding on Pathogenesis, Diagnosis, Management and Future Perspectives

Cervical carcinosarcoma (CCS) is a rare aggressive tumor which was referred to as a sarcoma initially with its morbidity less than 1% of all cervical cancers. Four theories have been proposed for the pathogenesis of CCS. The “metaplastic theory,” also called “monoclonal theory,” has been widely accepted so far. The most common clinical symptom of CCS is abnormal vaginal bleeding. CCS is much less common than the counterparts in uterine corpus and usually confused with uterine carcinosarcoma (UCS) or common cervical cancer. The management for CCS has been mainly extrapolated from studies of UCS or cervical cancers. However, CCS has its special anatomical position and biological behaviors and is usually diagnosed at an early stage than UCS. Currently, there is no consensus on the survival, management and prognosis factors of CCS. We reviewed and summarized the literatures regarding to the epidemiology, clinical presentations, pathogenesis, diagnosis and treatment of CCS for providing clinicians with comprehensive information to diagnose and treat this malignancy.

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.

Prognostic significance of lymph node metastasis and lymphadenectomy in early-stage ovarian carcinosarcoma

Background

The role that lymph node dissection (LND) plays in the management of ovarian carcinosarcoma (OCS) is unclear due to its rarity. This study investigated lymph node metastasis (LNM) prevalence in women with early OCS and effects of LND and LNM on survival.

Methods

Data of women diagnosed with OCS, whose primary tumor was confined to ovaries (American Joint Committee on Cancer [AJCC] T1) or pelvic cavity (AJCC T2), between 1988 and 2010 were collected from the Surveillance, Epidemiology, and End Results (SEER) database. Patients were classified into lymphadenectomy (LND [+]) and no lymphadenectomy (LND [−]) groups.

Results

A total of 363 women were included. The prevalence of LNM was 9.6% in AJCC T1 and 16.3% in AJCC T2. Multivariate analysis showed that LND and AJCC T categories were independent prognostic variables, irrespective of cancer-specific survival (CSS) or overall survival (OS). Subgroup analysis by AJCC T categories revealed that LND (+) group in AJCC T2 had a better survival outcome compared to LND (−) group (CSS, HR [95% CI] = 0.61 [0.43–0.87]; OS, HR [95% CI] = 0.59 [0.42–0.83]). There was no survival difference between groups in AJCC T1 (CSS, HR [95% CI] = 0.96 [0.56–1.65]; OS, HR [95% CI] = 0.88 [0.56–1.38]). Multivariate analysis was further carried out in LND (+) group and demonstrated that LNM and AJCC T2 had poor CSS and OS. Subgroup analysis by AJCC T categories showed that worse survival was observed in LNM (+) group compared to LNM (−) group in AJCC T2 (CSS, HR [95% CI] = 3.62 [1.50–8.73]; OS, HR [95% CI] = 3.71 [1.59–8.68]) but not in AJCC T1 (CSS, HR [95% CI] = 1.78 [0.50–6.37]; OS, HR [95% CI] = 1.97 [0.61–6.39]).

Conclusion

Regional lymphadenectomy should be performed in patients with AJCC T2 OCS. LND and LNM were not significantly associated with prognosis in AJCC T1 while LNM had a trend toward worse survival.

Concurrent diagnosis of pulmonary metastasis of malignant mixed müllerian tumor and small cell lung cancer

A patient who has multiple lung masses with a history of malignancy in organs other than the lung is more likely to be diagnosed with metastatic rather than primary lung cancer. Rarely, metastatic cancer can coexist with primary. We experienced a case of concurrent diagnosis of primary small cell lung cancer and pulmonary metastasis of uterine malignant mixed Müllerian tumor (MMMT). The patient was a 52-year-old female with femur fracture and multiple lung masses with a history of an operation for uterine MMMT. The small cell lung cancer was diagnosed by bronchoscopic biopsy. The central lung mass decreased after chemotherapy for small cell lung cancer but multiple peripheral masses increased. A percutaneous biopsy for one of peripheral masses revealed metastatic uterine MMMT. We suggest that we have to consider the possible presence of concomitant malignancies of different origins in one organ especially with patients who had a history of malignancy in another organ.

Angiogenesis and expression of angiogenic agents in uterine and ovarian carcinosarcomas

Carcinosarcomas of the female genital tract are a heterogeneous group of aggressive malignant neoplasms characterized by poor prognosis that contain elements expressing both carcinomatous and sarcomatous characteristics. In this study specimens from 25 patients were treated with labeled antibodies to vascular endothelium (FVIII), and to vascular endothelial growth factor (VEGF) for analysis of angiogenesis, and to vascular endothelial growth factor receptor 3 (VEGFR-3) for analysis of lymphangiogenesis, in 11,099 vessels. Automated quantitative image analysis was used and the results were compared with clinical data. Microvessel density increased from a median value of 18.32 vessels/mm(2) in non-neoplastic stroma to 131.25 vessels/mm(2) in neoplasms. In areas around tumor islets expressing predominantly epithelial carcinomatous characteristics, microvessel density was increased three-fold compared with the islets themselves. Vessels were arranged in a garland-type pattern, or in bursts, and they exhibited directional angiogenesis. Clinical indicators of poor survival were high tumor stage (p=0.002) and age above 65 (p=0.0769). A high number of small vessels (16-300 mum(2) in cross-sectional area) predicted poor survival (p=0.0149), and more so in tumors exhibiting predominantly sarcomatous characteristics (p=0.0087). Tumor tissue area above the median exhibiting VEGF expression was also a sign of poor survival (p=0.0267), as was an area of positive staining for VEGFR-3 exceeding the median (p=0.00487). In this study, active angiogenesis (increased number of vessels, variable in shape and exhibiting decreased antibody staining intensity) was a distinct feature of carcinosarcomas, its extent and distribution depending upon neoplasm morphology. Increased vessel numbers and increased VEGF and VEGFR-3 expression indicated poor survival.

Current management of ovarian carcinosarcoma

Ovarian carcinosarcomas (OCS), also known as malignant mixed müllerian tumors, are uncommon malignancies that carry a poor prognosis. The presentation of OCS is usually indistinguishable from that of epithelial ovarian cancer. Due to its low frequency, prospective trials have been difficult to perform, but there is evidence that OCS are sensitive to platinum-based chemotherapy. Recent studies have shown encouraging results with platinum-ifosfamide and platinum-taxane schedules, which are usually considered the treatment of choice. However, poor performance status at presentation is also a common problem, so that many patients may be unsuitable for combination chemotherapy but may still benefit from single-agent platinum or ifosfamide or, occasionally, from nonplatinum schedules such as ifosfamide plus paclitaxel. Aggressive cytoreductive surgery appears to have a positive impact on outcome and should probably be offered to most patients. However, this procedure has been associated with higher rates of complication in OCS and should only be attempted by experienced (gynecological) surgeons in centers with expertise in the management of gynecological malignancies.

The effect of epithelial and stromal tumor components on FIGO stages III and IV ovarian carcinosarcomas treated with primary surgery and chemotherapy

The aim of this study is to assess the effect of epithelial and stromal tumor components on survival outcomes in FIGO stage III or IV ovarian carcinosarcomas (OCS) treated with primary surgery and adjuvant chemotherapy at the Northern Gynaecological Oncology Centre (NGOC), Gateshead. Women were identified from the histopathology/NGOC databases. Age, FIGO stage, details of histology, treatment, and overall survival were recorded. Of 34 cases (1994-2006, all FIGO stages), 17 were treated with primary surgery followed by adjuvant chemotherapy for FIGO stage III or IV. The median age was 66 years (52-85 years). Cytoreduction was optimal (n= 9) or complete (n= 1) in 10/17 (59%) cases. Epithelial predominant (EP) or stromal predominant (SP) tumor (defined as >50% of either component in the primary tumor) was noted in 12 and 5 cases, respectively. Epithelial types included serous (n= 9), endometrioid (n= 5), and mixed types (n= 3). Twelve women have died of disease. The median overall survival was 11.0 months (3-74 months). On univariate analysis, survival was not affected by optimal/suboptimal debulking, platinum/doxorubicin-containing chemotherapy, or homologous/heterologous stromal components. Stromal components (>25%) adversely affected survival (P= 0.02), and there was a trend to worse survival with serous compared with nonserous epithelial components (P= 0.07). Cox regression (multivariate analysis) showed that SP tumors (P= 0.04), suboptimal debulking (P= 0.01), age (P= 0.01), and tumors with serous epithelial component (P= 0.05) were adverse independent prognostic factors. Type of chemotherapy and homologous/heterologous components (P= 0.24) did not affect overall survival. In conclusion, our study suggests that SP-OCS have a worse survival outcome than EP tumors. Tumors with serous epithelial components adversely affected the survival compared with nonserous components. Larger studies are required to confirm these effects and to identify the optimum chemotherapy regimen for OCS.

Sensitivities of Uterine Adenocarcinoma, Mixed Mullerian Tumor (MMT) and Sarcoma Cell Lines to Chemotherapeutic Agents and a Flex-Het Drug

The administration and combination of a variety of chemotherapeutic agents for treatment of advanced or recurrent uterine cancer of different histologies is under current debate. Mixed Mullerian Tumors (MMTs), which contain both adenocarcinoma and sarcoma components, are the most rate histologic type and it is therefore difficult to conduct clinical trials to determine if they should be treated like endometrial adenocarinomas or like sarcomas. Flexible Heteroarotionoids (Flex-Hets) are a promising class of anti-cancer drugs with low toxicity that have demonstrated activity against a wide variety of cancer types, but their efficacy in uterine cancers is unknown. The objective of this study was to determine if cell lines established from endometrial carcinoma (HEC-1-A), uterine sarcoma (SK-UT-1) and MMT (MES-SA) cancers exhibit differential sensitivities to cisplatin, carboplatin, paclitaxel, docetaxel, doxorubicin and SHetA2, if SHetA2 can enhance sensitivity to the chemotherapeutic drugs and if SHetA2 exhibits a differential effect on uterine cancer cells in comparison to normal endometrial cells using a cytotoxicity assay. These cell lines did not differ in their sensitivities to platinum or taxel drugs. Doxorubicin was active against the sarcoma but not the adenocarcinoma or MMT cell lines. SHetA2 decreased the survival of all three cell lines, but did not enhance their sensitivities to the chemotherapeutic agents. Two of the three uterine cancer cell lines were more sensitive to SHetA2 in comparison to normal endometrial cells. In conclusion, doxorubicin appears to have a greater effect against sarcoma than other uterine histology types. SHetA2 is affective against uterine cancer cell lines, but does not enhance their sensitivities to chemotherapeutic agents.

Changing concepts in the pathological basis of soft tissue and bone sarcoma treatment

Though soft tissue sarcomas are rare considerable progress has been made in the clinical and biological understanding of these neoplasms. This has led to the launch of a new WHO classification of soft tissue tumours in 2002, which integrate morphological data with tumour specific (cyto-) genetics. Moreover worldwide consensus has grown how to predict clinical behaviour based on a specific grading system and which specific types of tumours seem not to obey these rules. As a consequence entry criteria for multi-institute prospective trials have changed over the last few years. The recent identification of tumour specific drug targets by immunohistochemistry has had impact on specimen requirements and handling as well as laboratory standards. These changes in concepts, classification, and processing of soft tissue sarcomas have had impact on patient selection and treatment and formats of multi-institute trials.

Carcinosarcoma of the ovary

BACKGROUND

A review of clinicopathologic features and outcome in women with carcinosarcoma of the ovary (also known as malignant mixed mesodermal tumor [MMMT]) compared with a group of women with serous adenocarcinoma (SAC) of the ovary was conducted.

METHODS

Between 1984 and 2002, 1568 patients with epithelial ovarian carcinoma and 70 patients with ovarian carcinosarcoma underwent treatment at the Edinburgh Cancer Centre. Analysis was performed on 65 patients with MMMT, and 746 patients with SAC were selected as a group for comparison. Baseline variables were recorded prospectively and response to chemotherapy and progression-free and cause-specific survival between the groups were compared.

RESULTS

Patients with carcinosarcoma had a mean age of 66.6 years, which is significantly older than those with SAC (62.0 years) (P < 0.001). The objective response rate to platinum-based chemotherapy was found to be significantly lower in patients with carcinosarcoma (25% vs. 60%; P = 0.02). Cause-specific survival in the carcinosarcoma group was poor and significantly shorter than that observed in the SAC group (median survival of 8.2 months vs. 20.7 months; P < 0.0001). Progression-free survival in patients with carcinosarcoma also was found to be significantly shorter compared with patients with SAC (median progression-free survival of 6.4 months vs. 12.1 months; P < 0.001). Achieving optimal debulking at the time of initial surgery was found to be a highly significant factor in patients with carcinosarcoma with regard to determining outcome (median survival of 14.8 months for patients with optimally debulked International Federation of Gynecology and Obstetrics Stage III disease vs. 3.1 months for patients with suboptimally/nondebulked Stage III disease; P < 0.001).

CONCLUSIONS

Ovarian carcinosarcoma is a distinct entity with a poor prognosis. Patients with carcinosarcoma differ from those with SAC with regard to having an older mean age of onset, an inferior response to platinum-based chemotherapy, and worse progression-free and cause-specific survival. The extent of benefit from chemotherapy is unclear.