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Tang LS, Zhou YW, Wang JL, Zhang GX, Xu CH, Liu JY, Qiu M. Epidemiology, site-specific characteristics and survival of carcinosarcoma: a retrospective study based on SEER database. BMJ Open 2023; 13:e077974. [PMID: 38101828 PMCID: PMC10729011 DOI: 10.1136/bmjopen-2023-077974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 12/01/2023] [Indexed: 12/17/2023] Open
Abstract
OBJECTIVES Carcinosarcoma (CS) is a rare and biphasic malignancy characterised by a highly invasive biological nature and poor prognosis. This study explored the epidemiology, site-specific characteristics and survival outcome of CS. DESIGN We conducted a retrospective study in the Surveillance, Epidemiology and End Results (SEER) database (1975-2018) for primary CS. SETTING AND PARTICIPANTS SEER database includes publicly available information from regional and state cancer registries in the US centres. A total of 5042 CS patients were identified. We selected the top five anatomic CS (uterus, double adnexa, lung, bladder and breast) patients for further analysis. PRIMARY OUTCOME MEASURES Incidence was estimated by geographical region, age, sex, race, stage and primary site. Trends were calculated using joinpoint regression. The cancer-specific survival (CSS) rate and initial treatment were summarised. RESULTS Nearly 80% of CS occurred in the uterus and double adnexa, followed by lung, bladder and breast. The elderly and black population presented the highest age-adjusted rate of CS. The rates of distant metastasis in CS progressively increased from 1989 to 2018. Atlanta was the area with the highest incidence at 0.7 per 100 000. Pulmonary and bladder CS more frequently occurred in men and were diagnosed with regional stage. Distant metastasis was mostly found in ovary/fallopian tube CS. Radiotherapy was more commonly applied in uterine CS, while adnexa CS cases were more likely to receive chemotherapy. Multiple treatments were more used in breast CS. Pulmonary CS seemed to suffer worse CSS (median: 9.92 months), for which radiotherapy might not provide survival benefits (HR 0.60, 95% CI 0.42 to 0.86). Compared with the common histological types in each site, CS had the shortest survival. CONCLUSIONS CS has unique clinical features in each primary site. Substantial prognosis variances exist based on tumour locations. The aggressive course is the common feature in CS at all sites.
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Affiliation(s)
- Lian-Sha Tang
- West China Hospital of Sichuan University, Chengdu, China
| | - Yu-Wen Zhou
- Department of Biotherapy, West China Hospital of Sichuan University, Chengdu, China
| | - Jia-Ling Wang
- West China Hospital of Sichuan University, Chengdu, China
| | - Guo-Xu Zhang
- West China Hospital of Sichuan University, Chengdu, China
| | - Chen-Hao Xu
- West China Hospital of Sichuan University, Chengdu, China
| | - Ji-Yan Liu
- Department of Biotherapy, West China Hospital of Sichuan University, Chengdu, China
| | - Meng Qiu
- Department of Abdominal Oncology, West China Hospital of Sichuan University, Chengdu, China
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Ismail A, Choi S, Boussios S. Frontiers of Ovarian Carcinosarcoma. Curr Treat Options Oncol 2023; 24:1667-1682. [PMID: 37938504 PMCID: PMC10781844 DOI: 10.1007/s11864-023-01138-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 11/09/2023]
Abstract
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.
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Affiliation(s)
- Ayden Ismail
- GKT School of Medicine, King's College London, London, SE1 9RT, UK
| | - Sunyoung Choi
- GKT School of Medicine, King's College London, London, SE1 9RT, UK
| | - Stergios Boussios
- Department of Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Kent, Gillingham, ME7 5NY, UK.
- Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, King's College London, London, SE1 9RT, UK.
- Kent Medway Medical School, University of Kent, Kent, Canterbury, CT2 7LX, UK.
- AELIA Organization, 9Th Km Thessaloniki-Thermi, 57001, Thessaloniki, Greece.
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3
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Hollis RL. Molecular characteristics and clinical behaviour of epithelial ovarian cancers. Cancer Lett 2023; 555:216057. [PMID: 36627048 DOI: 10.1016/j.canlet.2023.216057] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Robert L Hollis
- Nicola Murray Centre for Ovarian Cancer Research, Cancer Research UK Scotland Centre, Institute of Genetics and Cancer, University of Edinburgh, UK.
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4
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Gilks CB, Selinger CI, Davidson B, Köbel M, Ledermann JA, Lim D, Malpica A, Mikami Y, Singh N, Srinivasan R, Vang R, Lax SF, McCluggage WG. Data Set for the Reporting of Ovarian, Fallopian Tube and Primary Peritoneal Carcinoma: Recommendations From the International Collaboration on Cancer Reporting (ICCR). Int J Gynecol Pathol 2022; 41:S119-S142. [PMID: 36305537 DOI: 10.1097/pgp.0000000000000908] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The move toward consistent and comprehensive surgical pathology reports for cancer resection specimens has been a key development in supporting evidence-based patient management and consistent cancer staging. The International Collaboration on Cancer Reporting (ICCR) previously developed a data set for reporting of the ovarian, fallopian tube and primary peritoneal carcinomas which was published in 2015. In this paper, we provide an update on this data set, as a second edition, that reflects changes in the 2020 World Health Organization (WHO) Classification of Female Genital Tumours as well as some other minor modifications. The data set has been developed by a panel of internationally recognized expert pathologists and a clinician and consists of "core" and "noncore" elements to be included in surgical pathology reports, with detailed commentary to guide users, including references. This data set replaces the widely used first edition, and will facilitate consistent and accurate case reporting, data collection for quality assurance and research, and allow for comparison of epidemiological and pathologic parameters between different populations.
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Wang X, Wang S, Yao S, Shi W, Ma K. The clinical characteristics and treatment of ovarian malignant mesoderm mixed tumor: a systematic review. J Ovarian Res 2022; 15:104. [PMID: 36114551 PMCID: PMC9482291 DOI: 10.1186/s13048-022-01037-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/30/2022] [Indexed: 12/02/2022] Open
Abstract
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.
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Fu J. Management of a rare ovarian carcinosarcoma: A case report and literature review. Exp Ther Med 2022; 24:583. [PMID: 35949347 PMCID: PMC9353508 DOI: 10.3892/etm.2022.11520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/23/2022] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Jun Fu
- Department of Gynecology and Obstetrics, Ningbo Women and Children's Hospital, Haishu, Ningbo, Zhejiang 315012, P.R. China
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Hollis RL, Croy I, Churchman M, Bartos C, Rye T, Gourley C, Herrington CS. Ovarian carcinosarcoma is a distinct form of ovarian cancer with poorer survival compared to tubo-ovarian high-grade serous carcinoma. Br J Cancer 2022; 127:1034-1042. [PMID: 35715633 PMCID: PMC9470739 DOI: 10.1038/s41416-022-01874-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 05/18/2022] [Accepted: 05/30/2022] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Robert L Hollis
- The Nicola Murray Centre for Ovarian Cancer Research, Cancer Research UK Scotland Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland, UK.
| | - Ian Croy
- The Nicola Murray Centre for Ovarian Cancer Research, Cancer Research UK Scotland Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland, UK
| | - Michael Churchman
- The Nicola Murray Centre for Ovarian Cancer Research, Cancer Research UK Scotland Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland, UK
| | - Clare Bartos
- The Nicola Murray Centre for Ovarian Cancer Research, Cancer Research UK Scotland Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland, UK
| | - Tzyvia Rye
- The Nicola Murray Centre for Ovarian Cancer Research, Cancer Research UK Scotland Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland, UK
| | - Charlie Gourley
- The Nicola Murray Centre for Ovarian Cancer Research, Cancer Research UK Scotland Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland, UK
| | - C Simon Herrington
- The Nicola Murray Centre for Ovarian Cancer Research, Cancer Research UK Scotland Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland, UK
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8
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Kostov S, Kornovski Y, Ivanova Y, Dzhenkov D, Stoyanov G, Stoilov S, Slavchev S, Trendafilova E, Yordanov A. Ovarian Carcinosarcoma with Retroperitoneal Para-Aortic Lymph Node Dissemination Followed by an Unusual Postoperative Complication: A Case Report with a Brief Literature Review. Diagnostics (Basel) 2020; 10:E1073. [PMID: 33322259 PMCID: PMC7763638 DOI: 10.3390/diagnostics10121073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/03/2020] [Accepted: 12/09/2020] [Indexed: 01/12/2023] Open
Abstract
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.
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Affiliation(s)
- Stoyan Kostov
- Department of Gynecology, Medical University of Varna “Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (S.K.); (S.S.)
| | - Yavor Kornovski
- Department of Obstetrics and Gynecology, Medical University of Varna “Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (Y.K.); (Y.I.); (S.S.); (E.T.)
| | - Yonka Ivanova
- Department of Obstetrics and Gynecology, Medical University of Varna “Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (Y.K.); (Y.I.); (S.S.); (E.T.)
| | - Deyan Dzhenkov
- Department of General and Clinical Pathology, Forensic Medicine and Deontology, Faculty of Medicine, Medical University of Varna “Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (D.D.); (G.S.)
| | - George Stoyanov
- Department of General and Clinical Pathology, Forensic Medicine and Deontology, Faculty of Medicine, Medical University of Varna “Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (D.D.); (G.S.)
| | - Stanislav Stoilov
- Department of Gynecology, Medical University of Varna “Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (S.K.); (S.S.)
| | - Stanislav Slavchev
- Department of Obstetrics and Gynecology, Medical University of Varna “Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (Y.K.); (Y.I.); (S.S.); (E.T.)
| | - Ekaterina Trendafilova
- Department of Obstetrics and Gynecology, Medical University of Varna “Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (Y.K.); (Y.I.); (S.S.); (E.T.)
| | - Angel Yordanov
- Department of Gynecologic Oncology, Medical University Pleven, 5800 Pleven, Bulgaria
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Saida T, Mori K, Tanaka YO, Sakai M, Amano T, Kikuchi S, Masuoka S, Yoshida M, Masumoto T, Satoh T, Minami M. Carcinosarcoma of the ovary: MR and clinical findings compared with high-grade serous carcinoma. Jpn J Radiol 2020; 39:357-366. [PMID: 33216290 DOI: 10.1007/s11604-020-01072-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/04/2020] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Tsukasa Saida
- Department of Radiology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Kensaku Mori
- Department of Radiology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yumiko Oishi Tanaka
- Department of Diagnostic Imaging, The Cancer Institute Hospital Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan
| | - Masafumi Sakai
- Department of Radiology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Taishi Amano
- Department of Radiology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Shunsuke Kikuchi
- Department of Radiology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Souta Masuoka
- Department of Radiology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Miki Yoshida
- Department of Radiology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tomohiko Masumoto
- Department of Radiology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Toyomi Satoh
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Manabu Minami
- Department of Radiology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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Xu Q, Zhang X, Zou Y. Primitive ovarian carcinosarcoma: a clinical and radiological analysis of five cases. J Ovarian Res 2020; 13:129. [PMID: 33115531 PMCID: PMC7592589 DOI: 10.1186/s13048-020-00728-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 10/07/2020] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Qiong Xu
- Department of Radiology, Women's Hospital School of Medicine Zhejiang University, No. 1 Xueshi Road, Hangzhou, 310006, Zhejiang Province, China
| | - Xiaofei Zhang
- Department of Pathology, Women's Hospital School of Medicine Zhejiang University, No. 1 Xueshi Road, Hangzhou, 310006, Zhejiang Province, China
| | - Yu Zou
- Department of Radiology, Women's Hospital School of Medicine Zhejiang University, No. 1 Xueshi Road, Hangzhou, 310006, Zhejiang Province, China.
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Mutational and Immunophenotypic Profiling of a Series of 8 Tubo-ovarian Carcinosarcomas Revealed a Monoclonal Origin of the Disease. Int J Gynecol Pathol 2019; 39:305-312. [PMID: 31688243 DOI: 10.1097/pgp.0000000000000645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Carcinosarcomas are rare, highly aggressive neoplasms composed of a combination of carcinomatous and sarcomatous elements. These tumors represent a paradigmatic field for the study of intratumor heterogeneity. A series of 8 tubo-ovarian carcinosarcomas was characterized for the following: (i) immunohistochemical expression of MNF116, epithelial membrane antigen, vimentin, S100, chromogranin, synaptophysin, desmin, myogenin (MYF4), and p53; (ii) mutational profiling of KRAS, BRAF, PIK3CA, NRAS, TP53, and DICER1 genes. Heterologous differentiation was present in 6 of 8 tumors. Cytokeratin MNF116 and epithelial membrane antigen were positive in all the carcinomatous components and in 87.5% and 50.0% of the sarcomatous components, respectively. The sarcomatous components showed positive staining for vimentin in all cases. Two cases demonstrated positivity for neuroendocrine markers in their carcinomatous components. All rhabdomyosarcomas were positive for desmin and MYF-4. Chondrosarcomas were positive for S100. All but one tumor showed similar p53 immunoreactivity in both the carcinomatous and sarcomatous components, and one case showed cytoplasmic p53 expression. Three of 8 cases (37.5%) showed TP53 mutations, and, in 2 cases, the TP53 mutation was shared by both epithelial and mesenchymal components. DICER1 mutation was found in all components of one case. Mutations in KRAS, NRAS, BRAF, and PIK3CA genes were not found in the study cohort. Our results highlight the heterogeneity of ovarian carcinosarcomas at the phenotypic level. A common mutational signature was observed in both components in 3 of 4 informative tumors. More studies are required to dissect different levels of ovarian carcinosarcomas' heterogeneity in order to define the best therapeutic approaches to these aggressive neoplasms.
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Jain V, Pundir S, Sekhon R, Mishra A, Nayyar N, Vishwakarma G, Kamboj M, Rawal S. Carcinosarcoma of the Ovary: A Single-Institute Experience with Surgical Cytoreduction and Platinum-Based Chemotherapy. J Gynecol Surg 2019. [DOI: 10.1089/gyn.2018.0045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Vandana Jain
- Department of Uro-Gynae Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | | | - Rupinder Sekhon
- Department of Uro-Gynae Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - Amita Mishra
- Department of Uro-Gynae Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - Nidhi Nayyar
- Department of Uro-Gynae Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - Gayatri Vishwakarma
- Department of Research, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - Meenakshi Kamboj
- Department of Histopathology and Cytology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - Sudhir Rawal
- Department of Uro-Gynae Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
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Boussios S, Karathanasi A, Zakynthinakis-Kyriakou N, Tsiouris AK, Chatziantoniou AA, Kanellos FS, Tatsi K. Ovarian carcinosarcoma: Current developments and future perspectives. Crit Rev Oncol Hematol 2018; 134:46-55. [PMID: 30771873 DOI: 10.1016/j.critrevonc.2018.12.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 09/16/2018] [Accepted: 12/18/2018] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Stergios Boussios
- Acute Oncology Assessment Unit, Medway NHS Foundation Trust, Windmill Road, ME7 5NY, Gillingham, Kent, UK; AELIA Organization, 9th Km Thessaloniki - Thermi, 57001, Thessaloniki, Greece.
| | - Afroditi Karathanasi
- Acute Oncology Assessment Unit, Medway NHS Foundation Trust, Windmill Road, ME7 5NY, Gillingham, Kent, UK
| | | | - Alexandros K Tsiouris
- Department of Biological Applications & Technology, University of Ioannina, Stavros Niarchou Avenue, 45110, Ioannina, Greece
| | | | - Foivos S Kanellos
- Department of Biological Applications & Technology, University of Ioannina, Stavros Niarchou Avenue, 45110, Ioannina, Greece
| | - Konstantina Tatsi
- Gynaecology Unit, General Hospital "G. Hatzikosta", Makrigianni Avenue, 45001, Ioannina, Greece
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Carcinosarcoma of the ovary compared to ovarian high-grade serous carcinoma: impact of optimal cytoreduction and standard adjuvant treatment. Int J Clin Oncol 2017; 23:329-337. [PMID: 29143144 DOI: 10.1007/s10147-017-1215-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 11/09/2017] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The purpose of this retrospective study was to compare the prognoses of women with ovarian carcinosarcoma (OCS) who had optimal cytoreductive surgery followed by platinum plus taxane combination chemotherapy to those of women with ovarian high-grade serous carcinoma (HGSC) treated in the same manner. METHODS A multicenter, retrospective department database review was performed to identify patients with OCS at eight gynecologic oncology centers in Turkey. A total of 54 women with OCS who had undergone optimal cytoreductive surgery followed by platinum plus taxane combination chemotherapy between 1999 and 2017 were included in this case-control study. Each case was matched to two women with ovarian HGSC who had undergone optimal cytoreductive surgery followed by platinum plus taxane combination chemotherapy. The Kaplan-Meier method was used to generate survival data. Factors predictive of outcome were analysed using Cox proportional hazards models. RESULTS Median disease-free survival (DFS) was 29 months [95% confidence interval (CI) 0-59, standard error (SE) 15.35] versus 27 months (95% CI 22.6-31.3, SE 2.22; p = 0.765) and median overall survival (OS) was 62 versus 82 months (p = 0.53) for cases and controls, respectively. For the entire cohort, the presence of ascites [hazard ratio (HR) 2.32; 95% CI 1.02-5.25, p = 0.04] and platinum resistance [HR 5.05; 95% CI 2.32-11, p < 0.001] were found to be independent risk factors for decreased OS. CONCLUSION DFS and OS rates of patients with OCS and HGSC seem to be similar whenever optimal cytoreduction is achieved and followed by platinum plus taxane combination chemotherapy.
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Cicin İ, Özatlı T, Türkmen E, Özturk T, Özçelik M, Çabuk D, Gökdurnalı A, Balvan Ö, Yıldız Y, Şeker M, Özdemir N, Yapar B, Tanrıverdi Ö, Günaydin Y, Menekşe S, Öksüzoğlu B, Aksoy A, Erdogan B, Bekir Hacıoglu M, Arpaci E, Sevinç A. Predictive and Prognostic Factors in Ovarian and Uterine Carcinosarcomas. Balkan Med J 2016; 33:517-524. [PMID: 27761279 DOI: 10.5152/balkanmedj.2016.151268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 04/18/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Prognostic factors and the standard treatment approach for gynaecological carcinosarcomas have not yet been clearly defined. Although carcinosarcomas are more aggressive than pure epithelial tumours, they are treated similarly. Serous/clear cell and endometrioid components may be predictive factors for the efficacy of adjuvant chemotherapy (CT) or radiotherapy (RT) or RT in patients with uterine and ovarian carcinosarcomas. Heterologous carcinosarcomas may benefit more from adjuvant CT. AIMS We aimed to define the prognostic and predictive factors associated with treatment options in ovarian (OCS) and uterine carcinosarcoma (UCS). STUDY DESIGN Retrospective cross-sectional study. METHODS We retrospectively reviewed the medical records of patients with ovarian and uterine carcinosarcoma from 2000 to 2013, and 127 women were included in this study (24 ovarian and 103 uterine). Patients admitted to seventeen oncology centres in Turkey between 2000 and December 2013 with a histologically proven diagnosis of uterine carcinosarcoma with FIGO 2009 stage I-III and patients with sufficient data obtained from well-kept medical records were included in this study. Stage IV tumours were excluded. The patient records were retrospectively reviewed. Data from 104 patients were evaluated for this study. RESULTS Age (≥70 years) was a poor prognostic factor for UCS (p=0.036). Pelvic±para aortic lymph node dissection did not affect overall survival (OS) (p=0.35). Macroscopic residual disease was related with OS (p<0.01). The median OS was significantly longer in stage I-II patients than stage III patients (p=0.03). Adjuvant treatment improved OS (p=0.013). Adjuvant radiotherapy tended to increase the median OS (p=0.075). However, this tendency was observed in UCS (p=0.08) rather than OCS (p=0.6).Adjuvant chemotherapy had no effect on OS (p=0.15).Adjuvant radiotherapy significantly prolonged the median OS in patients with endometrioid component (p=0.034). A serous/clear cell component was a negative prognostic factor (p=0.035). Patients with serous/clear cell histology for whom adjuvant chemotherapy was applied had significantly longer OS (p=0.019), and there was no beneficial effect of adjuvant radiotherapy (p=0.4). Adjuvant chemotherapy was effective in heterologous tumours (p=0.026). In multivariate analysis, the stage and chemotherapy were prognostic factors for all patients. Age was an independent prognostic factor for UCS. However, serous/clear cell histology and radiotherapy tended to be significant prognostic factors. CONCLUSION The primary location, the histological type of sarcomatous and the epithelial component may be predictive factors for the efficacy of chemotherapy or radiotherapy in UCS and OCS.
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Affiliation(s)
- İrfan Cicin
- Department of Medical Oncology, Trakya University School of Medicine, Edirne, Turkey
| | - Tahsin Özatlı
- Department of Medical Oncology, Ankara Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, Ankara, Turkey
| | - Esma Türkmen
- Department of Medical Oncology, Trakya University School of Medicine, Edirne, Turkey
| | - Türkan Özturk
- Department of Medical Oncology, Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Melike Özçelik
- Department of Medical Oncology, Dr. Lütfi Kırdar Research and Training Hospital, İstanbul, Turkey
| | - Devrim Çabuk
- Department of Medical Oncology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Ayşe Gökdurnalı
- Department of Medical Oncology, Ankara Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, Ankara, Turkey
| | - Özlem Balvan
- Department of Medical Oncology, Dr. Lütfi Kırdar Research and Training Hospital, İstanbul, Turkey
| | - Yaşar Yıldız
- Department of Medical Oncology, Atatürk Research and Training Hospital, İzmir, Turkey
| | - Metin Şeker
- Department of Medical Oncology, Cumhuriyet University School of Medicine, Sivas, Turkey
| | - Nuriye Özdemir
- Department of Medical Oncology, Ankara Numune Research and Training Hospital, Ankara, Turkey
| | - Burcu Yapar
- Department of Medical Oncology, Pamukkale University School of Medicine, Denizli, Turkey
| | - Özgür Tanrıverdi
- Department of Medical Oncology, Muğla University School of Medicine, Muğla, Turkey
| | - Yusuf Günaydin
- Department of Medical Oncology, Gazi University School of Medicine, Ankara, Turkey
| | - Serkan Menekşe
- Department of Medical Oncology, Celal Bayar University School of Medicine, Manisa, Turkey
| | - Berna Öksüzoğlu
- Department of Medical Oncology, Ankara Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, Ankara, Turkey
| | - Asude Aksoy
- Department of Medical Oncology, İnönü University School of Medicine, Malatya, Turkey
| | - Bülent Erdogan
- Department of Medical Oncology, Trakya University School of Medicine, Edirne, Turkey
| | - M Bekir Hacıoglu
- Department of Medical Oncology, Trakya University School of Medicine, Edirne, Turkey
| | - Erkan Arpaci
- Department of Medical Oncology, Sakarya Research and Training Hospital, Sakarya, Turkey
| | - Alper Sevinç
- Department of Medical Oncology, Gaziantep University School of Medicine, Gaziantep, Turkey
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Rauh-Hain JA, Birrer M, Del Carmen MG. "Carcinosarcoma of the ovary, fallopian tube, and peritoneum: Prognostic factors and treatment modalities". Gynecol Oncol 2016; 142:248-54. [PMID: 27321238 DOI: 10.1016/j.ygyno.2016.06.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 05/31/2016] [Accepted: 06/01/2016] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- J Alejandro Rauh-Hain
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Michael Birrer
- Division of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Lee SY, Shia J, Kingham TP, Jarnagin WR. Carcinosarcoma of the bile duct: a case report and review of literature. Hepatobiliary Surg Nutr 2016; 5:72-8. [PMID: 26904559 DOI: 10.3978/j.issn.2304-3881.2015.06.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Carcinosarcomas of the bile ducts are very rare tumors consisting of both epithelial and mesenchymal elements. We report a case of bile duct carcinosarcoma and its clinical, radiological and pathological features and a brief review on this rare condition.
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Affiliation(s)
- Ser Yee Lee
- 1 Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA ; 2 Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore ; 3 Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Jinru Shia
- 1 Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA ; 2 Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore ; 3 Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - T Peter Kingham
- 1 Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA ; 2 Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore ; 3 Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - William R Jarnagin
- 1 Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA ; 2 Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore ; 3 Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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McCluggage WG, Judge MJ, Clarke BA, Davidson B, Gilks CB, Hollema H, Ledermann JA, Matias-Guiu X, Mikami Y, Stewart CJR, Vang R, Hirschowitz L. Data set for reporting of ovary, fallopian tube and primary peritoneal carcinoma: recommendations from the International Collaboration on Cancer Reporting (ICCR). Mod Pathol 2015; 28:1101-22. [PMID: 26089092 DOI: 10.1038/modpathol.2015.77] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 02/24/2015] [Accepted: 02/25/2015] [Indexed: 12/20/2022]
Abstract
A comprehensive pathological report is essential for optimal patient management, cancer staging and prognostication. In many countries, proforma reports are used but these vary in their content. The International Collaboration on Cancer Reporting (ICCR) is an alliance formed by the Royal College of Pathologists of Australasia, the Royal College of Pathologists of the United Kingdom, the College of American Pathologists, the Canadian Partnership Against Cancer and the European Society of Pathology, with the aim of developing an evidence-based reporting data set for each cancer site. This will reduce the global burden of cancer data set development and reduplication of effort by different international institutions that commission, publish and maintain standardised cancer reporting data sets. The resultant standardisation of cancer reporting will benefit not only those countries directly involved in the collaboration but also others not in a position to develop their own data sets. We describe the development of a cancer data set by the ICCR expert panel for the reporting of primary ovarian, fallopian tube and peritoneal carcinoma and present the 'required' and 'recommended' elements to be included in the report with an explanatory commentary. This data set encompasses the recent International Federation of Obstetricians and Gynaecologists staging system for these neoplasms and the updated World Health Organisation Classification of Tumours of the Female Reproductive Organs. The data set also addresses issues about site assignment of the primary tumour in high-grade serous carcinomas and proposes a scoring system for the assessment of tumour response to neoadjuvant chemotherapy. The widespread implementation of this data set will facilitate consistent and accurate data collection, comparison of epidemiological and pathological parameters between different populations, facilitate research and hopefully will result in improved patient management.
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Affiliation(s)
- W Glenn McCluggage
- Department of Pathology, Belfast Health and Social Care Trust, Belfast, UK
| | - Meagan J Judge
- Royal College of Pathologists of Australasia, Sydney, NSW, Australia
| | - Blaise A Clarke
- Department of Pathology and Laboratory Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ben Davidson
- 1] Department of Pathology, Oslo University Hospital, Norwegian Radium Hospital, Oslo, Norway [2] Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - C Blake Gilks
- Department of Pathology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Harry Hollema
- Department of Pathology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Xavier Matias-Guiu
- Department of Pathology and Molecular Genetics and Research Laboratory, Hospital Universitari Arnau de Vilanova, University of Lleida, IRBLleida, Lleida, Spain
| | - Yoshiki Mikami
- Department of Diagnostic Pathology, Kumamoto University Hospital, Kumamoto, Japan
| | - Colin J R Stewart
- 1] Department of Histopathology, King Edward Memorial Hospital, Perth, WA, Australia [2] School for Women's and Infant's Health, University of Western Australia, Crawley, WA, Australia
| | - Russell Vang
- Department of Pathology (Division of Gynecologic Pathology), The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lynn Hirschowitz
- Department of Cellular Pathology, Birmingham Women's Hospital, Birmingham, UK
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Abstract
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.
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Sato S, Nishida M, Takebayashi K, Sato H, Ishii T, Nasu K, Narahara H. Carcinosarcoma of the ovary successfully treated with paclitaxel and carboplatin therapy: two cases. Int Cancer Conf J 2015. [DOI: 10.1007/s13691-014-0175-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Doo DW, Erickson BK, Arend RC, Conner MG, Huh WK, Leath CA. Radical surgical cytoreduction in the treatment of ovarian carcinosarcoma. Gynecol Oncol 2014; 133:234-7. [PMID: 24631447 DOI: 10.1016/j.ygyno.2014.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 02/27/2014] [Accepted: 03/01/2014] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- David W Doo
- University of Alabama at Birmingham School of Medicine, USA.
| | - Britt K Erickson
- University of Alabama at Birmingham, Division of Gynecologic Oncology, USA
| | - Rebecca C Arend
- University of Alabama at Birmingham, Division of Gynecologic Oncology, USA
| | - Michael G Conner
- University of Alabama at Birmingham, Division of Anatomic Pathology, USA
| | - Warner K Huh
- University of Alabama at Birmingham, Division of Gynecologic Oncology, USA
| | - Charles A Leath
- University of Alabama at Birmingham, Division of Gynecologic Oncology, USA
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Shylasree TS, Bryant A, Athavale R. Chemotherapy and/or radiotherapy in combination with surgery for ovarian carcinosarcoma. Cochrane Database Syst Rev 2013; 2013:CD006246. [PMID: 23450567 PMCID: PMC6756783 DOI: 10.1002/14651858.cd006246.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Ovarian carcinosarcoma, also known as malignant mixed Mullerian tumour, is a rare malignant gynaecological tumour constituting about 1% or less of all ovarian cancers. In over 80% of cases, there is extra-ovarian intra-abdominal spread at diagnosis. The primary treatment has traditionally been surgical cytoreduction followed by radiotherapy and chemotherapy or chemotherapy alone. Regimes have included cisplatin alone; a combination of doxorubicin, ifosfamide, dacarbazine, cyclophosphamide, taxol; and various other combinations. The effectiveness of these various regimens appears to be mixed. Therefore, there is a need to clarify if there is an optimum neoadjuvant or adjuvant therapy after surgical cytoreduction for this rare tumour. Also, it is important to address quality of life (QoL) issues related to treatment, particularly toxicity, as the overall prognosis appears to be poor. OBJECTIVES To assess the effectiveness and safety of various adjuvant and neoadjuvant chemotherapy and radiotherapy options or chemotherapy alone in combination with surgery in the management of ovarian carcinosarcoma. SEARCH METHODS We searched the Cochrane Gynaecological Cancer Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE up to February 2012. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of review articles and contacted experts in the field. SELECTION CRITERIA We searched for randomised controlled trials (RCTs) that compared neoadjuvant or adjuvant chemotherapy and radiotherapy, or chemotherapy alone, in women with ovarian carcinosarcoma (malignant mixed Mullerian sarcoma of the ovary). We also reviewed non-randomised studies (NRS) for discussion in the absence of RCTs. DATA COLLECTION AND ANALYSIS Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. No trials were found and therefore no data were analysed. MAIN RESULTS The search strategy identified 297 unique references of which all were excluded. AUTHORS' CONCLUSIONS We found no evidence to inform decisions about neoadjuvant and adjuvant chemotherapy and radiotherapy regimens, or chemotherapy alone, for women with ovarian carcinosarcoma. Ideally, an RCT that is multicentre or multinational, or well designed non-randomised studies that use multivariate analysis to adjust for baseline imbalances, are needed to compare treatment modalities and improve current knowledge. Further research in genetic and molecular signalling pathways might improve understanding of this tumour subtype.
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Affiliation(s)
- T S Shylasree
- GynaecologicalOncologyDivision,Department of SurgicalOncology,TataMemorialCentre,Mumbai, India.
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Matsuo K, Sheridan TB, Yoshino K, Miyake T, Hew KE, Im DD, Rosenshein NB, Mabuchi S, Enomoto T, Kimura T, Sood AK, Roman LD. Significance of lymphovascular space invasion in epithelial ovarian cancer. Cancer Med 2012; 1:156-64. [PMID: 23342265 PMCID: PMC3544453 DOI: 10.1002/cam4.31] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 08/21/2012] [Accepted: 08/21/2012] [Indexed: 12/18/2022] Open
Abstract
While the prognostic significance of lymphovascular space invasion (LVSI) is well established in endometrial and cervical cancer, its role in ovarian cancer is not fully understood. First, a training cohort was conducted to explore whether the presence and quantity of LVSI within the ovarian tumor correlated with nodal metastasis and survival (n = 127). Next, the results of the training cohort were applied to a different study population (validation cohort, n = 93). In both cohorts, histopathology slides of epithelial ovarian cancer cases that underwent primary cytoreductive surgery including pelvic and/or aortic lymphadenectomy were examined. In a post hoc analysis, the significance of LVSI was evaluated in apparent stage I cases (n = 53). In the training cohort, the majority of patients had advanced-stage disease (82.7%). LVSI was observed in 79.5% of cases, and nodal metastasis was the strongest variable associated with the presence of LVSI (odds ratio [OR]: 7.99, 95% confidence interval [CI]: 1.98–32.1, P = 0.003) in multivariate analysis. The presence of LVSI correlated with a worsened progression-free survival on multivariate analysis (hazard ratio [HR]: 2.06, 95% CI: 1.01–4.24, P = 0.048). The significance of the presence of LVSI was reproduced in the validation cohort (majority, early stage 61.3%). In apparent stage I cases, the presence of LVSI was associated with a high negative predictive value for nodal metastasis (100%, likelihood ratio, P = 0.034) and with worsened progression-free survival (HR: 5.16, 95% CI: 1.00–26.6, P = 0.028). The presence of LVSI is an independent predictive indicator of nodal metastasis and is associated with worse clinical outcome of patients with epithelial ovarian cancer.
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Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Los Angeles County Medical Center, University of Southern California Los Angeles, CA, USA.
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Pelvic Angiosarcoma Occurring in a Postmenopausal Female: Case Report and Review of the Literature. Pathol Oncol Res 2012; 19:135-9. [DOI: 10.1007/s12253-012-9540-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Accepted: 05/17/2012] [Indexed: 01/18/2023]
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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. Am J Surg Pathol 2012; 36:831-7. [PMID: 22588065 DOI: 10.1097/pas.0b013e31824ee500] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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del Carmen MG, Birrer M, Schorge JO. Carcinosarcoma of the ovary: A review of the literature. Gynecol Oncol 2012; 125:271-7. [DOI: 10.1016/j.ygyno.2011.12.418] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 11/28/2011] [Accepted: 12/02/2011] [Indexed: 01/18/2023]
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Nasser H, Morris RT, Fathallah L. Ovarian malignant mixed mullerian tumor with primitive neuroectodermal differentiation: case report with review of the literature. Pathol Res Pract 2011; 207:202-6. [PMID: 20950943 DOI: 10.1016/j.prp.2010.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 08/06/2010] [Accepted: 08/06/2010] [Indexed: 11/16/2022]
Abstract
Ovarian malignant mixed mullarian tumor (OMMMT) is a rare and aggressive tumor of the female genital tract, occurring mainly in elderly women. Stage of disease is the most important predictor for survival with no prognostic effect, yet, of heterologous elements. Rare case reports described the peculiar presence of primitive neuroectodermal tissue among other heterologous elements in these tumors. Attractive designations, such as teratoid carcinosarcoma, were set by some authors to describe this subset of lesions, where it was considered a primary neuroectodermal tumor capable of multilineage differentiation. We here report a case of OMMMT in an elderly woman with focal primitive neuroectodermal differentiation as the sole heterologous element, and review the controversy on this topic in the literature.
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Affiliation(s)
- Haitham Nasser
- Department of Pathology, St. John Hospital and Medical Center, Detroit, MI 48236, USA.
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Malignant mixed Mullerian tumor of the ovary with two cases and review of the literature. Arch Gynecol Obstet 2011; 283:1363-8. [PMID: 21298439 DOI: 10.1007/s00404-011-1845-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 01/20/2011] [Indexed: 10/18/2022]
Abstract
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.
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WT1 Immunoprofiling and Comparison of Malignant Mullerian Mixed Tumors of The Female Genital Tract. Int J Gynecol Pathol 2010; 29:452-8. [DOI: 10.1097/pgp.0b013e3181d55597] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Becerro A, Ruiz-Díaz I, Elvira A, Aizpitarte I. Carcinosarcoma de ovario: revisión de la literatura médica a propósito de un caso. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2010. [DOI: 10.1016/j.gine.2009.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Qian X, Xi X, Jin Y. The Grading of Lymphovascular Space Invasion in Epithelial Ovarian Carcinoma. Int J Gynecol Cancer 2010; 20:895-9. [DOI: 10.1111/igc.0b013e3181e02fc7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction:To assess the prognostic value of lymphovascular space invasion (LVSI) in epithelial ovarian carcinoma.Methods:We reexamined single representative hematoxylin and eosin-stained sections of 66 patients with epithelial ovarian carcinoma to identify LVSI. A 4-grade system was used to classify LVSI: absent (no LVSI), mild (1-2 foci of LVSI), moderate (3-8 foci of LVSI), and severe (≥9 foci of LVSI). We investigated the possible associations between the grade of LVSI and clinicopathologic factors.Results:Lymphovascular space invasion was present in 36 patients (54.5%) and absent in 30 (45.5%). Statistical analysis indicated that LVSI was significantly associated with advanced clinical stage, poor histological grade, and lymph node metastasis. Follow-up studies indicated that the disease-free survival time for patients without LVSI was significantly longer than that for patients with moderate LVSI (P = 0.01) and severe LVSI (P = 0.001). The overall survival (OS) time for patients with moderate or severe LVSI was significantly shorter than that for patients with mild or no LVSI. The grade of LVSI was found to be significantly associated with OS (P = 0.004). The grade of LVSI showed poor correlation with disease-free survival and OS.Conclusions:The grade of LVSI is an important predictive factor for disease recurrence and poor survival of patients with epithelial ovarian carcinoma.
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López-Olmos J, Navarro P. Carcinosarcoma de ovario. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2009. [DOI: 10.1016/j.gine.2008.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Cicin I, Saip P, Eralp Y, Selam M, Topuz S, Ozluk Y, Aydin Y, Topuz E. Ovarian carcinosarcomas: clinicopathological prognostic factors and evaluation of chemotherapy regimens containing platinum. Gynecol Oncol 2007; 108:136-40. [PMID: 17936342 DOI: 10.1016/j.ygyno.2007.09.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2007] [Revised: 08/27/2007] [Accepted: 09/04/2007] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Irfan Cicin
- Department of Medical Oncology, Faculty of Medicine, Trakya University, Turkey.
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Muller M, Dupre PF, Lucas B, Simon H, Malhaire JP, Guillemet C, Dessogne P, Pradier O. Le carcinosarcome ovarien. ACTA ACUST UNITED AC 2007; 36:399-402. [PMID: 17408876 DOI: 10.1016/j.jgyn.2007.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2006] [Revised: 02/05/2007] [Accepted: 03/01/2007] [Indexed: 11/21/2022]
Abstract
Ovarian carcinosarcoma, also called malignant mixed mesodermal tumour, is a rare ovarian tumour representing less than two per cent of ovarian cancers. Carcinosarcoma is an aggressive tumour, which associates some epithelial elements (carcinoma) with a stromal component (sarcoma). This tumour can be found in the female genital tractus, mostly in the uterus. It can be found even more rarely on the ovaries. The initial stage of the disease at the diagnostic is considered as the only prognostic factor. There is no existing consensus concerning treatment. Nevertheless, surgical treatment is paramount for the survival of patients. Response rates to chemotherapy are about 20%.
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Affiliation(s)
- M Muller
- Institut de cancérologie et d'hématologie, CHU de Brest, 29200 Brest, France.
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Mano MS, Rosa DD, Azambuja E, Ismael G, Braga S, D'Hondt V, Piccart M, Awada A. Current management of ovarian carcinosarcoma. Int J Gynecol Cancer 2007; 17:316-24. [PMID: 17362309 DOI: 10.1111/j.1525-1438.2006.00760.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- M S Mano
- Department of Medical Oncology, Institut Jules Bordet, Brussels, Belgium.
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36
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Lee SJ, Kim HS, Kim HS, Chun YK, Hong SR, Lee JH. Immunohistochemical study of DNA topoisomerase I, p53, and Ki-67 in uterine carcinosarcomas. Hum Pathol 2007; 38:1226-31. [PMID: 17490723 DOI: 10.1016/j.humpath.2007.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2006] [Revised: 01/07/2007] [Accepted: 01/11/2007] [Indexed: 10/23/2022]
Abstract
Uterine carcinosarcomas (UCs) are highly aggressive neoplasms for which no effective adjuvant therapy has been established. The aim of this study was to test potential indicators of UC sensitivity to topoisomerase I (topo I)-targeted drugs. Laboratory studies have shown that the cellular response to topo I-targeted drugs is dependent on topo I expression, DNA replication rate, and activity of the apoptotic pathway. Therefore, this study investigated expression of topo I, a proliferation marker Ki-67, and the apoptosis initiator p53 in 20 cases of UC. Formalin-fixed paraffin-embedded tissue sections were immunostained with monoclonal antibodies against topo I, Ki-67, and p53. The hospital records of all 20 patients with UC were reviewed. Twelve (60%) of 20 cases showed increased expression of topo I. Staining for Ki-67 showed elevated expression in 15 (75%) of 20 cases. Fourteen cases (70%) showed positive staining for p53 in more than 20% of the tumor cells. However, analysis of the relationship between immunohistochemical results and clinical parameters revealed no correlations with topo I expression. There were no significant correlations between the expression of topo I and Ki-67 (P = .704), or topo I and p53 (P = .465). Significantly increased expression of topo I, Ki-67, and p53 in UC tumor cells suggests sensitivity to topo I-targeted drug treatment.
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Affiliation(s)
- Sun-Joo Lee
- Department of Obstetrics and Gynecology, Konkuk University Hospital, Konkuk University School of Medicine, Seoul 143-729, South Korea
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Athavale R, Thomakos N, Godfrey K, Kew F, Cross P, de Barros Lopes A, Hatem MH, Naik R. The effect of epithelial and stromal tumor components on FIGO stages III and IV ovarian carcinosarcomas treated with primary surgery and chemotherapy. Int J Gynecol Cancer 2007; 17:1025-30. [PMID: 17466043 DOI: 10.1111/j.1525-1438.2007.00919.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- R Athavale
- Department of Gynaecological Oncology, Queen Elizabeth Hospital, Gateshead, United Kingdom.
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Corakci A, Filiz S, Caliskan E, Dalcik C, Ozeren S, Dalcik H. The effects of ovulation induction on ovarian epithelium dysplasia scores and Ki67 expression: an experimental study on rats. Int J Gynecol Cancer 2005; 15:866-71. [PMID: 16174237 DOI: 10.1111/j.1525-1438.2005.00149.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
We aimed to evaluate the effects of ovulation induction on Ki67 expression and dysplasia scores of female rat ovaries. Twenty female Wistar rats were randomized either to receive 150 IU/kg human menopausal gonadotropin on estrous day 2 and 75 IU/kg human chorionic gonadotropin on the day of preestrous (induction group, n= 10) or saline as placebo on the corresponding days (control group, n= 10). After five estrous cycles bilateral oophorectomy was performed to compare the Ki67 expression and dysplasia score of the ovarian epithelium. The mean number of the cells that stained positive for Ki67 was 159.6 +/- 101.92 in the follicles, 283.4 +/- 42 in the corpus luteum, and 151 +/- 75.1 in the stroma of the study group compared to 41.8 +/- 35.6 (P= 0.03), 43.2 +/- 28.3 (P= 0.007), and 55.6 +/- 18.6 (P= 0.01), respectively, in the control group. The mean number and rate of cells that stained positive for Ki67 in the epithelium was significantly higher in the ovulation induction group (758 +/- 71 and 63 +/- 1.6%, respectively) compared to the control group (386 +/- 23, P < 0.001; and 60 +/- 1.1%, P < 0.001; respectively). The mean dysplasia score was significantly higher (9.6 +/- 1.3) in the study group compared to the control group (5.08 +/- 0.9, P < 0.001). Ovulation induction in rats resulted in increased Ki67 expression and dysplastic features in the ovarian epithelial cells.
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Affiliation(s)
- A Corakci
- Department of Obstetrics and Gynecology, School of Medicine, Kocaeli University, Kocaeli, Turkey
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Ikeda K, Tate G, Suzuki T, Mitsuya T. Effusion cytodiagnosis of carcinosarcoma derived from the female genital tract: immunohistochemical features of MMP-7 and Ki-67 and immunofluorescence double staining analyses of eight cases. Gynecol Oncol 2005; 97:323-9. [PMID: 15863125 DOI: 10.1016/j.ygyno.2004.12.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2004] [Revised: 12/04/2004] [Accepted: 12/08/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Expression of Matrix metalloproteinase 7 (MMP-7) and Ki-67 by carcinoma components (CCs) and sarcoma components (SCs) in carcinosarcoma of the female reproductive organs has been investigated by conventional methods, but analysis with immunohistochemical staining of multiple antigens has not been reported. We report the profiles of expression of MMP-7 and Ki-67 in carcinosarcoma determined with immunohistochemical staining techniques. METHODS We used antibodies against epithelial antigen (EA), epithelial membrane antigen (EMA), and vimentin for immunofluorescence double staining of ascitic fluid in eight cases of carcinosarcoma of female reproductive organs. We also used immunohistochemical triple staining to compare MMP-7 and Ki-67 expression between CCs and SCs in the primary site of carcinosarcoma. RESULTS Immunofluorescence analysis revealed that all neoplastic cells in the ascitic fluid were positive for EA or EMA, indicating that these cells were CCs. Immunohistochemical analyses of the primary organ of carcinosarcoma revealed that MMP-7 was expressed on CCs in four of eight cases of carcinosarcoma, whereas MMP-7 was not expressed on SCs. The average Ki-67 labeling index (LI) in CCs and SCs was 51.8% and 28.6%, respectively. The difference in Ki-67 LI between CCs and SCs was statistically significant (t test for paired samples, P = 0.0173). CONCLUSIONS This is the first study to examine carcinosarcoma of the female reproductive organ by immunohistochemical staining for multiple antigens, which allows analysis of mixed tumor elements. In addition, we found that expression of MMP-7 and the average Ki-67 LI differ between CCs and SCs in carcinosarcoma. The predominance of CCs as the malignant cells in the ascitic fluid may be due to cytological differences between CCs and SCs of carcinosarcoma.
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Affiliation(s)
- Katsuhide Ikeda
- Department of Pathology, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Yokohama 227-8501, Japan.
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Nishimura N, Hachisuga T, Yokoyama M, Iwasaka T, Kawarabayashi T. Clinicopathologic analysis of the prognostic factors in women with coexistence of endometrioid adenocarcinoma in the endometrium and ovary. J Obstet Gynaecol Res 2005; 31:120-6. [PMID: 15771637 DOI: 10.1111/j.1447-0756.2005.00256.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To compare the survival and prognostic factors of patients with dual primary ovarian and endometrial cancers (primary group), and endometrial cancers metastatic to the ovaries (metastatic group). METHODS Thirty-six patients with gross tumors confined to the pelvis and of endometrioid adenocarcinoma subtype in both the endometrium and ovary were selected from our file of 546 Japanese women with endometrial carcinoma. The patients were divided into two groups. Eleven were classified into the primary group. Twenty-five were classified into the metastatic group. Both univariate and multivariate regression analyses were carried out. RESULTS The mean age of the primary group was significantly younger than that of the metastatic group (45.2 years vs 51.2 years; P < 0.01). The cumulative 10-year survival of the primary group was significantly better than that of the metastatic group (90.9%vs 46.6%; P < 0.05). Univariate analyses showed that older age (P < 0.05) and the presence of lymphovascular space invasion (LVSI; P < 0.004) of the tumor of the uterus were significantly associated with a poor prognosis in the metastatic group. Multivariate analysis including the above variables showed no independent prognostic factor (older age, P < 0.60 and LVSI, P < 0.06). CONCLUSION When encountering women with coexisting endometrioid carcinoma in the endometrium and ovary with gross tumor limited to the pelvis, more attention should be paid to LVSI of the tumor of the uterus as a poor prognostic indicator.
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Affiliation(s)
- Noriko Nishimura
- Department of Obstetrics and Gynecology, School of Medicine, Fukuoaka University, Nanakuma, Fukuoka, Japan
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Zorzou MP, Markaki S, Rodolakis A, Kastritis E, Bozas G, Dimopoulos MA, Papadimitriou CA. Clinicopathological features of ovarian carcinosarcomas: a single institution experience. Gynecol Oncol 2005; 96:136-42. [PMID: 15589592 DOI: 10.1016/j.ygyno.2004.09.051] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2004] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The aim of this study was to elucidate the clinicopathological and immunohistochemical prognostic factors of patients with ovarian carcinosarcoma treated with radical surgery and postoperative chemotherapy. METHODS During a 6-year period, nine patients with ovarian carcinosarcoma were referred to our institution. Tissue blocks were reviewed and sections containing both carcinomatous and sarcomatous elements were stained for epithelial membrane antigen (EMA), vimentin, vascular endothelial growth factor (VEGF), CD45RO, c-erbB-2, p53, CD34, Ki67, S100, estrogen, and progesterone receptors. Histological and immunohistochemical findings as well as clinical characteristics were then correlated with progression-free interval and overall survival. RESULTS There were four homologous and five heterologous carcinosarcomas. Five patients had early stage disease. Seven of the patients were optimally debulked. All patients were treated with anthracycline-based chemotherapy following surgery. With regard to immunohistochemistry, all specimens were negative for CD34, c-erbB-2, estrogen, and progesterone receptor expression. Five tumors overexpressed p53 and four specimens demonstrated a positive staining for Ki67. Reactivity for VEGF and CD45RO was observed in four and two tumor specimens, respectively. The median overall survival was 32.9 months with no statistical difference between early and advanced stages, while median time to progression was 13.5 months. p53 overexpression demonstrated a trend for better overall survival. CONCLUSIONS Only p53 overexpression seems to influence overall survival although, due to the small number of patients studied, no safe conclusions can be drawn. Despite the predominance of early stage patients that favorably influenced overall survival, aggressive surgical cytoreduction followed by anthracycline-based treatment were the cornerstone in our multimodality approach.
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Affiliation(s)
- Markella-P Zorzou
- Department of Clinical Therapeutics, Alexandra Hospital, University of Athens, School of Medicine, 14671 Nea Erythrea, Athens, Greece
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Amant F, Vloeberghs V, Woestenborghs H, Moerman P, Vergote I. Transition of epithelial toward mesenchymal differentiation during ovarian carcinosarcoma tumorigenesis. Gynecol Oncol 2003; 90:372-7. [PMID: 12893202 DOI: 10.1016/s0090-8258(03)00326-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND It was the purpose of this study to test the monoclonal theory in ovarian carcinosarcoma. METHODS Twenty-six women with a diagnosis of ovarian carcinosarcoma were subjected to a clinicopathologic analysis. Biopsies from metastatic lesions obtained at primary surgery and surgery for recurrent disease were reviewed. Special attention was paid to the composition of metastatic lesions and to florid desmoplastic reaction as a potential pitfall for the detection of sarcomatous areas. RESULTS Biopsies derived from metastatic disease at primary surgery (n = 107) consisted of carcinoma cells only (n = 71, 66%), >50% carcinoma cells (n = 21, 20%), >50% sarcoma cells (n = 13, 12%), or sarcoma cells only (n = 2, 2%). The microscopic analysis demonstrated a preponderance of epithelial cells in the primary setting and suggested the epithelial component to drive the tumor, a finding consistent with the monoclonal theory. Biopsies derived from surgery for recurrent disease (n = 8) consisted of carcinoma cells only (0%), >50% carcinoma cells (n = 1, 13%), >50% sarcoma cells (n = 4, 50%), or sarcoma cells only (37%). Since sarcomatous cells dominated the tumorigenic cell population in the recurrent setting, this analysis revealed a change of the composition of metastatic lesions in time when compared to the data in the primary setting. This change was supported by the observation of a threefold higher incidence of sarcoma-dominated metastatic lesions at interval debulking when compared to primary debulking (24 vs 8%, respectively). The potential of a phenotypic change during ovarian cancer progression was further highlighted by the detection of two cases of carcinosarcoma that presented as a recurrence of epithelial ovarian carcinoma. CONCLUSION Our results are consistent with the monoclonal theory of ovarian carcinosarcoma histogenesis, but suggest that there is a tendency toward a sarcomatous differentiation during disease progression. These data are important to understand the tumor biology and might have implications for a tailored treatment of ovarian carcinosarcoma.
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Affiliation(s)
- Frederic Amant
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium.
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Inthasorn P, Beale P, Dalrymple C, Carter J. Malignant mixed mullerian tumour of the ovary: prognostic factor and response of adjuvant platinum-based chemotherapy. Aust N Z J Obstet Gynaecol 2003; 43:61-4. [PMID: 12755351 DOI: 10.1046/j.0004-8666.2003.00003.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The purpose of the present study was to analyse retrospectively the data of a series of patients presenting to our unit with malignant mixed mullerian tumour (MMMT) of the ovary to identify the prognostic factors and relate them to survival. The role of platinum-based chemotherapy in the adjuvant treatment of this tumour was also evaluated. METHODS All patients diagnosed with MMMT of the ovary from 1987 to 2000 were identified from the gynaecological tumour registry of King George V Hospital, Australia. The effect of clinical and histopathological variables on survival was analysed. The response of platinum-based adjuvant chemotherapy after surgery was also evaluated. RESULTS Twenty patients with MMMT of the ovary were identified. Of the six patients with measurable disease, two (33%) had complete response after adjuvant platinum-based chemotherapy. The median survival of all patients was 8 months, while that of the patients receiving adjuvant platinum-based chemotherapy was 23 months. Women who were older (> 65 years) had a significantly worse survival rate than those who were younger (P = 0.02). The patients with optimal debulking had a better median survival than those with suboptimal debulking, but this difference was not statistically significant (P = 0.21). Sarcomatous component (homologous vs heterologous) was not found to be a significant prognostic factor for predicting survival. CONCLUSIONS Malignant mixed mullerian tumour of the ovary is a rare and aggressive gynaecological tumour. The current study indicates that patient age was a significant prognostic factor for survival and surgical cytoreduction combined with platinum-based chemotherapy is the most effective management regimen identified to date to treat MMMT of the ovary.
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Pillay K, Essa AS, Chetty R. Borderline serous cystadenocarcinoma with coexistent angiosarcoma: an unusual form of ovarian carcinosarcoma. Int J Surg Pathol 2001; 9:317-21. [PMID: 12574850 DOI: 10.1177/106689690100900411] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 45-year-old woman presented with a short history of abdominal distension and features of intestinal obstruction. Computed tomography examination of the abdomen revealed a solid and cystic mass in the region of the left ovary, but spread within the abdomen was also noted. The ovarian tumor was removed, and an omentectomy was also performed. Microscopic examination of the ovarian tumor and metastases within the omentum showed a carcinosarcoma composed of borderline serous papillary cystadenocarcinoma and angiosarcoma. The angiosarcomatous component was the dominant tumor within the omentum. This case documents an unusual combination of epithelial and sarcomatous elements in an ovarian carcinosarcoma. The tumor behaved aggressively because of the angiosarcomatous component, and since the patient was assessed as having stage IV disease, no further treatment was offered.
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Affiliation(s)
- K Pillay
- Department of Pathology, Nelson R. Mandela School of Medicine, Faculty of Health Sciences, University of Natal, Congella, Durban, South Africa
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Tumores müllerianos mixtos. Revisión bibliográfica. A propósito de tres casos de localización diferente: vaginal, uterina y ovárica. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2001. [DOI: 10.1016/s0210-573x(01)77084-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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