Cisplatin, doxorubicin and ifosfamide in carcinosarcoma of the female genital tract. A phase II study of the European Organization for Research and Treatment of Cancer Gynaecological Cancer Group (EORTC 55923)

Spotlight on Carcinosarcoma of the Ovary: A Scoping Review

Ovarian carcinosarcoma, also referred as malignant mixed Mullerian tumour, is an uncommon, highly aggressive and malignant neoplasm which makes up 1 to 4% of all ovarian tumours. It is biphasic involving both malignant sarcomatous (mesenchymal) and carcinomatous (epithelial) cells. There are various subtypes such as serous and endometrioid. However, the mesenchymal part is sarcomatous. About 90% of cases of ovarian carcinosarcoma spread outside the ovary. The two most accepted theories of origin for carcinosarcoma of the ovary are the collision and conversion theories. A third theory is the combination theory. Prognosis remains poor even when still localised in the ovary. In the last few years, there has been no change in the survival rate. The median survival rate is lower than 2 years. Clinical features mainly include lower abdominal pain and a palpable abdominal mass. Ovarian carcinosarcoma remains poorly understood and understudied. Being a rare tumour, elaborate therapeutic consensus is not available for ovarian carcinosarcoma. The main treatment involves cytoreductive surgery and then chemotherapy. The type of chemotherapy, role of radiotherapy and novel therapies need to be further studied. The main objective of this article is to review the current literature on carcinosarcoma of the ovary.

Endometrial carcinosarcoma

Endometrial carcinosarcoma is a rare and aggressive high-grade endometrial carcinoma with secondary sarcomatous trans-differentiation (conversion theory). The clinical presentation and diagnostic work-up roughly align with those of the more common endometrioid counterpart, although endometrial carcinosarcoma is more frequently diagnosed at an advanced stage. Endometrial carcinosarcoma is not a single entity but encompasses different histological subtypes, depending on the type of carcinomatous and sarcomatous elements. The majority of endometrial carcinosarcomas are characterized by p53 abnormalities. The proportion of POLE and microsatellite instablity-high (MSI-H) is directly related to the epithelial component, being approximately 25% and 3% in endometrioid and non-endometrioid components.The management of non-metastatic disease is based on a multimodal approach with optimal surgery followed by (concomitant or sequential) chemotherapy and radiotherapy, even for early stages. Palliative chemotherapy is recommended in the metastatic or recurrent setting, with carboplatin/paclitaxel doublet being the first-line regimen. Although the introduction of immunotherapy plus/minus a tyrosine kinase inhibitor shifted the paradigm of treatment of patients with recurrent endometrial cancer, patients with endometrial carcinosarcoma were excluded from most studies evaluating single-agent immunotherapy or the combination. However, the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) approved the use of pembrolizumab and lenvatinib in endometrial cancer (all histotypes) after progression on chemotherapy and single-agent immunotherapy in MSI-H cancers. In the era of precision medicine, emerging knowledge on molecular endometrial carcinosarcoma is opening new promising therapeutic options for more personalized treatment. The present review outlines state-of-the-art knowledge and future directions for patients with endometrial carcinosarcoma.

Fluid shear stress in a logarithmic microfluidic device enhances cancer cell stemness marker expression

Fluid shear stress (FSS) is crucial in cancer cell survival and tumor development. Noteworthily, cancer cells are exposed to several degrees of FSS in the tumor microenvironment and during metastasis. Consequently, the stemness marker expression in cancer cells changes with the FSS signal, although it is unclear how it varies with different magnitudes and during metastasis. The current work explores the stemness and drug resistance characteristics of the cervical cancer cell line HeLa in a microfluidic device with a wide range of physiological FSS. Hence, the microfluidic device was designed to achieve a logarithmic flow distribution in four culture chambers, realizing four orders of biological shear stress on a single chip. The cell cycle analysis demonstrated altered cell proliferation and mitotic arrest after FSS treatment. In addition, EdU staining revealed increased cell proliferation with medium to low FSS, whereas high shear had a suppressing effect. FSS increased competence to withstand higher intracellular ROS and mitochondrial membrane potential in HeLa. Furthermore, stemness-related gene (Sox2, N-cadherin) and cell surface marker (CD44, CD33, CD117) expressions were enhanced by FSS mechanotransduction in a magnitude-dependent manner. In summary, these stemness-like properties were concurrent with the drug resistance capability of HeLa towards doxorubicin. Overall, our microfluidic device elucidates cancer cell survival and drug resistance mechanisms during metastasis and in cancer relapse patients.

Carcinosarcomas and Related Cancers: Tumors Caught in the Act of Epithelial-Mesenchymal Transition

In this review, we outline the biology and management of patients with carcinosarcomas and related malignancies, which are often included under the broader concept of sarcomatoid carcinomas. Carcinosarcomas are unusual tumors that are commonly gynecologic in origin, where they are referred to as malignant mixed Müllerian tumors, but may appear in any anatomic site. Although a variety of hypotheses have been presented as to the biphasic nature of these tumors, carcinosarcomas seem to represent the best example in human cancers of the concept of epithelial-mesenchymal transition (EMT), in which the two parts of the tumor are genomically related to one another, as opposed to the mesenchymal component that represents a second neoplasm or (benign) reactive process. In general, patients with carcinosarcomas fare worse than patients with carcinomas of the same anatomic site. Treatment paradigms for carcinosarcomas generally follow those of carcinomas of the same organ site, except where clinical trials provide more specific options. Agents that block or reverse EMT are worth examination in patients with carcinosarcoma and arguably may be even more effective in carcinomas, given evidence of dependence on EMT to generate successful metastases. Information about EMT may also inform other phase transitions in cancer, such as those between prostate or lung carcinoma and more aggressive tumors with neuroendocrine differentiation.

Review of Recommended Treatment of Uterine Carcinosarcoma

Surgery is the primary treatment for uterine carcinosarcoma (UCS). Lymphadenectomy should be performed for staging purposes in tumors apparently confined to the uterus. Most studies found that lymphadenectomy is of therapeutic value. The therapeutic value of cytoreduction to no residual macroscopic disease in advanced UCS is based mostly on small retrospective uncontrolled studies. Postoperative adjuvant therapy should be considered for all stages of UCS. Adjuvant pelvic radiotherapy may reduce locoregional recurrences. However, this does not translate into improved overall survival since most recurrences are distant outside the irradiated field, and the survival rates remain poor, the 5-year overall survival being about 50%. Several adjuvant platin-based combination chemotherapy schedules such as cisplatin/ifosfamide, ifosfamide/paclitaxel, and paclitaxel/carboplatin have been found to be an effective mode of adjuvant treatment. Multimodal therapy (i.e., adjuvant chemotherapy plus radiotherapy) has also been shown to be effective. Most studies dealing with adjuvant treatment are retrospective and prospective randomized controlled trials (i.e., phase III studies) comparing that between the various adjuvant chemotherapy schedules and between them and multimodal treatment are lacking. Quality of life with the various treatment modalities needs also to be assessed. An effective targeted therapy has so far not been found. In spite of the multiple studies with regard to the treatment of UCS published during the last 15 years, the optimal management of UCS is still not established.

Uterine and ovary carcinosarcomas: outcome, prognosis factors, and adjuvant therapy

OBJECTIVES

The aim of this study was to assess the outcome and the prognosis factors of uterine and ovarian carcinosarcomas.

METHODS

From January 1993 to January 2010, data from 68 consecutively treated patients with uterine (n=59) and ovarian (n=9) carcinosarcomas were retrospectively analyzed in a single French comprehensive cancer center.

RESULTS

The median follow-up was 24.2 months (interquartile range [IQR]: 13.5 to 54.6). The median age was 69 years (IQR: 63 to 77). Patients were classified as FIGO stage I (n=28; 41%) and FIGO stage II to IV (n=40; 59%), respectively. There were 33 (49%) and 29 (43%) homologous and heterologous type, respectively. The median disease-free survival and overall survival were 21.9 months (IQR: 7.9 to 22.3) and 27.1 months (IQR: 14.5 to 72), respectively. No statistical differences of survival were reported concerning the initial location of the carcinosarcoma (uterine vs. ovarian). Radiation therapy (hazards ratio [HR]=0.3; 95% confidence interval [CI], 0.16-0.67) and FIGO stage I (HR=0.4; 95% CI, 0.17-0.9) were associated with an increased disease-free survival. Homologous type (HR=3; 95% CI, 1.4-6.3) and FIGO stage II to IV (HR=2.64; 95% CI, 1.3-5.4) were associated with a decreased overall survival. There was no survival improvement for the 12% of patients receiving a multimodal adjuvant therapy.

CONCLUSIONS

Uterine and ovary carcinosarcomas present a worse prognosis. On the basis of the present study data, although it should be prospectively confirmed, a sequential or multimodal adjuvant therapy should be proposed to patients with early-stage uterine and ovary carcinosarcomas.

Ovarian carcinosarcoma: effects of cytoreductive status and platinum-based chemotherapy on survival

Objective. To define survival patterns of women with ovarian carcinosarcoma based on patient, tumor, and treatment characteristics. Methods/Materials. A single-institution, retrospective analysis of women diagnosed with ovarian carcinosarcoma from February 1993 to May 2009 was performed. Survival was analyzed with Cox proportional hazards ratios and Kaplan Meier tests. Results. Forty-seven cases of primary ovarian carcinosarcoma were identified. Age conveyed an HR 3.28 (95% CI 1.51–7.11, P = 0.003) for death. Compared to Stages I-II, Stage III carried an HR for death of 4.75 (95% CI 1.16–19.4, P = 0.03) and Stage IV disease an HR of 9.13 (95% CI 1.76–47.45, P = 0.009). Compared to those with microscopic residual, women with >1 cm diameter of residual disease after primary cytoreductive surgery had an HR for death of 4.71 (95% CI 1.84–12.09, P = 0.001). At analysis, 59.1% of those who received platinum-based chemotherapy were alive, compared to 23.1% of those who received nonplatinum-based chemotherapy (P = 0.08). Conclusions. Age, stage, and cytoreduction to no gross residual disease are associated with improved survival in women with ovarian carcinosarcoma. Complete surgical cytoreduction should be the goal of surgical management when possible, but the ideal adjuvant treatment regimen remains unclear.

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.

Combination chemotherapy with carboplatin, paclitaxel and pegylated liposomal doxorubicin for advanced or recurrent carcinosarcoma of the uterus: clinical experience of a single institution

OBJECTIVES

The purpose of this study was to evaluate the activity and toxicity of carboplatin, paclitaxel and pegylated liposomal doxorubicin combination in advanced or recurrent of the uterine carcinosarcoma.

METHODS

Twenty-nine eligible patients with measurable disease were treated with carboplatin [area under the curve (AUC) 5], paclitaxel 175 mg/m(2) and pegylated liposomal doxorubicin 25 mg/m(2) every 3 weeks for 6-8 cycles.

RESULTS

There were 10 complete responses (CRs) (34%) and 8 partial responses (PRs) (28%) for an overall response rate (RR) of 62% (95% confidence interval [CI], 43-81%). The median progression-free survival (PFS) was 8.2 months (95% CI, 4.1-12.2 months) and the median overall survival (OS) was 16.4 months (95% CI, 14.7-18.0 months). There was no statistically significant difference between histology and response to therapy. Patients with PS of 0 or 1 had a higher RR than those with worst PS. Toxicity was generally mild except for myelotoxicity. Neutropenia grade 3/4 was recorded in 52% of patients and 10% experienced febrile neutropenia. Anemia grade 3 or 4 developed in 27% of patients and thrombocytopenia grade 3 or 4 in 31% of patients. Three patients (10%) developed grade 3 sensory neuropathy and only 2 patients (8%) grade 3 palmar-plantar erythrodysesthesias. No treatment-related deaths were recorded in our series.

CONCLUSION

The combination of carboplatin, paclitaxel and pegylated liposomal doxorubicin appears to have activity in advanced, persistent or recurrent endometrial carcinosarcoma with an acceptable toxicity profile.

The management of patients with uterine sarcoma: a debated clinical challenge

Uterine sarcomas include a heterogeneous group of rare tumours that usually have an aggressive clinical behaviour and a poor prognosis. Total abdominal hysterectomy and bilateral salpingo-oophorectomy represents the standard surgical treatment. Pelvic and/or para-aortic lymphadenectomy is indicated for carcinosarcoma, but not for leiomyosarcoma and undifferentiated endometrial sarcoma. Some recent data on low numbers of patients with low-grade endometrial stromal sarcoma appear to show an incidence of nodal involvement higher than previously expected, thus suggesting a role for lymphadenectomy in this malignancy. Carcinosarcoma also requires a comprehensive surgical peritoneal staging. Postoperative treatment of uterine sarcomas has been long debated. Adjuvant pelvic radiotherapy appears to improve local control without any significant impact on overall survival. There is little evidence in the literature supporting the use of adjuvant chemotherapy in any gynaecological sarcomas except for carcinosarcomas. However, uterine sarcomas have a high tendency to develop distant recurrences, and recent data on adjuvant chemotherapy in soft tissue sarcomas are promising. As for the drugs to be used, it is worth noting that in a Swiss study, the combination of ifosfamide (IFO) and doxorubicin (DOX) obtained similar response rates in advanced gynaecological sarcomas and in advanced soft tissue sarcomas of other sites. In our decision-making scheme for early-stage disease, patients with leiomyosarcoma or undifferentiated endometrial sarcoma should receive adjuvant doxorubicin/epidoxorubicin (EPIDX)+ifosfamide, and those with carcinosarcoma should be treated with adjuvant cisplatin (CDDP)-based chemotherapy. The same drug regimens are used for the treatment of advanced disease. Sequential pelvic radiotherapy following chemotherapy could be delivered to selected cases. Recurrent disease often requires the integration of different therapeutic modalities, but no curative option is currently available with the possible exception of surgery for lung metastases and hormone therapy with or without debulking surgery for recurrent low-grade endometrial stromal sarcoma. Patients should be encouraged to enter clinical trials designed to identify new active drugs for these malignancies.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Combined adjuvant cisplatin and ifosfamide chemotherapy and radiotherapy for malignant mixed müllerian tumors of the uterus

The role of adjuvant therapy for malignant mixed müllerian tumors of the uterus has not been established. Our aim was to review our experience with sequential adjuvant therapy using cisplatin and ifosfamide chemotherapy and radiotherapy after surgical staging. A retrospective study of 43 patients from 1995 to 2004 was undertaken. Survival was calculated using the Kaplan-Meier method and compared by the log-rank test. The Cox proportional hazard regression model was used to assess the effect of treatment on survival after adjustment for age and stage. Twenty-eight patients received adjuvant chemotherapy and 28 patients had adjuvant radiotherapy. Twenty-one patients underwent sequential adjuvant chemotherapy and radiotherapy. Tumor recurrence occurred in 14 patients at a median duration of 10 months. The overall 2- and 5-year survival was 64% and 60%, respectively. The 2- and 5-year survival for stage I and II diseases was both 95%, while the 2-year survival for stage III and IV diseases was 25%. Patients who underwent sequential adjuvant therapy had an improved survival compared with patients who did not follow the protocol (P= 0.024). Our results with sequential adjuvant therapy are encouraging and justify future randomized trials.

Carcinosarcome de la peau

BACKGROUND

Carcinosarcoma of skin is a biphasic tumor composed of intimately admixed malignant epithelial and mesenchymal components. Various terms have been used to designate these tumors (metaplastic carcinoma, pseudosarcoma, spindle cell carcinoma, etc.). However, the histogenetic conception has changed and carcinosarcoma is currently regarded as authentic sarcomatoid carcinoma.

CASE REPORT

The authors report the case of a 32-year-old women initially presenting with a budding and ulcerating tumor at the site of an old cutaneous scar on the right leg. Histopathological and immunohistochemical evaluation led to a diagnosis of cutaneous carcinosarcoma. One month after treatment, the patient developed inguinal lymph node metastasis.

DISCUSSION

Our case and a review of other cases in the literature confirm the dual epithelial and sarcomatous phenotype of sarcomatoid carcinoma. Progressive transition between the cells of the two components on microscopic analysis and their positive immunostaining for anti-p53 antibody suggest a clonal origin of the tumor. The carcinomatous component seems to influence the course of the disease with the development of metastases, particularly at the lymph nodes. It thus seems advisable to combine lymphadenectomy with surgical tumor excision.

Different subtypes of uterine sarcoma require a separate therapeutic approach

Uterine sarcomas include a variety of mono- and biphasic malignancies, whereas tumor biology varies from an indolent and hormone-sensitive growth pattern to an aggressive and nonresponsive disease that is inevitably fatal. Insight into these different entities has only been gained after careful analysis of clinical, pathologic and molecular characteristics during the last few years. Furthermore, the rarity of uterine sarcomas has motivated many to collect data from different subtypes and to report on the collective data in order to report on larger numbers. The current overview aims to provide insights of clinical importance into each type of uterine sarcoma, with a special emphasis on treatment modalities.

Clinical experience with combination paclitaxel and carboplatin therapy for advanced or recurrent carcinosarcoma of the uterus

OBJECTIVE

The purpose of the study was to evaluate the efficacy of combination chemotherapy with paclitaxel and carboplatin in patients with advanced or recurrent carcinosarcoma of the uterus.

METHODS

A retrospective review was carried out at Miyagi Prefecture Cancer Research Center Hospital. Six patients pathologically diagnosed with uterine carcinosarcoma were treated with paclitaxel (175 mg/m(2) given intravenously over 3 h) and carboplatin (dosed at AUC 6) every 3 weeks at our center between 1997 and 2003. Responses and adverse effects were assessed according to Response Evaluation Criteria in Solid Tumors and National Cancer Institute-Common Toxic Criteria, respectively.

RESULTS

All six patients were evaluable for toxicity, and no unacceptably severe toxicities were reported. Grades 3 and 4 hematologic toxicities occurred, but all of them were overcome by adequate treatment with granulocyte colony-stimulating factor and blood transfusions. Five of six patients had measurable disease and thus were evaluable for response: Four patients had a complete response (CR) and the remaining patient had progressive disease (PD). The median progression-free interval (PFI) for all six cases was 18 months, with a median overall survival of 25 months.

CONCLUSIONS

Although the number of cases was small, the regimen evaluated in the current study demonstrated higher activity and lesser toxicity than those found in previous studies in patients with advanced or recurrent uterine carcinosarcoma. Additional phase II clinical studies are necessary to evaluate fully the benefits of this regimen.