Uterine sarcoma: clinicopathological characteristics, treatment and outcome in Iran

OBJECTIVE

Uterine sarcomas are rare and heterogeneous tumors with histopathological diversity characterized by rapid clinical progression and a poor prognosis. The aim of this study was to investigate clinical and histopathological characteristics together with treatment and outcome of Iranian patients with uterine sarcomas.

MATERIALS AND METHODS

Records of 57 patients with histologically verified uterine sarcoma treated at the Vali-e-Asr Hospital were reviewed (1999-2004).

RESULTS

The lesions were 19 leomyosarcoma (LMSs), 17 malignant mixed Mullerian tumors (MMMT), 16 endometrial stromal sarcomas (ESSs), 3 unspecified sarcomas, 2 rabdomyosarcomas. Median age at diagnosis was 50 (17-81) years. Clinical stages (based on FIGO) were 30 with stage I disease, 9 with stage II, 12 with stage III and 6 with stage IV. Only one patient did not undergo surgery and most cases with LMS and ESS were treated with simple total hysterectomy (STH). Forty patients (out of 57) received adjuvant radiotherapy. The median follow-up period was 19 (2-96) months and median disease free period was 16 (1-86) months. The overall survival rates after 1, 2, and 5 years were 71%, 58% and 52%, respectively. Survival was related to histological type of ESS (p=0.0018), grade I (p=0.0032) and early stage (p=0.045) significantly, but was not linked to postoperative irradiation. However, local recurrence rate was significantly improved after adjuvant radiotherapy. Twenty-one patients had relapse, 16 in the pelvic and 5 in extrapelvic sites.

CONCLUSION

Based on the findings in this series, prognosis is dependent on histopathological subtype, grade and tumor stage. Adjuvant radiotherapy decreases local recurrence rate, but without significant impact on survival.

[Morphological structure and classification of Muller mixed uterine tumors]

A review of the literature is presented which deals with modern aspects of Muller mixed tumors (MMT) classification and problems of their histo- and morphogenesis, immunohistochemical, ultrastructural and molecular-genetic peculiarities. Prognostic factors and survival rates are considered. Further study of MMT is necessary for verification of their histo- and morphogenesis and for development of their classification.

Malignant mixed mullerian tumors of the ovary: experience with cytoreductive surgery and platinum-based combination chemotherapy

This study reviews the clinical outcome and prognosis of patients with malignant mixed müllerian tumors (MMMTs) of the ovary treated with optimal cytoreductive surgery, leaving no residual disease, and platinum-based chemotherapy. Ten patients diagnosed with MMMT of the ovary after complete surgical staging from February 1993 to February 2004 at Asan Medical Center in Korea were studied retrospectively. All ten patients were treated with optimal cytoreductive surgery, leaving no gross residual disease. Seven patients received ifosfamide/cisplatin chemotherapy, and the remaining three patients received other platinum-based combination chemotherapy. Demographic data, pathologic findings, treatments, and survival time were reviewed. Of the ten patients, two were scored at FIGO stage IIC, seven were at stage IIIC, and one was at stage IV. The median survival time of all ten patients was 46 months. The overall survival rate was 60.0% at 1 year, 40.0% at 2 years, and 20.0% at 5 years. Platinum-based combination chemotherapy after optimal cytoreductive surgery may be effective in the treatment of ovarian MMMT.

On the apparent failure of adjuvant pelvic radiotherapy to improve survival for women with uterine sarcomas confined to the uterus

Despite numerous studies documenting reduction of pelvic relapses after adjuvant pelvic radiotherapy stage I and II uterine sarcomas, improved survival remains unproven. This retrospective report analyzes patterns of failure, survival, and toxicity in 42 women with stage I and 7 patients with stage II uterine sarcomas treated from 1972 through 1998 to identify patients likely to benefit from pelvic or abdominal radiotherapy and chemotherapy. Four of these patients also received adjuvant chemotherapy. There were 20 leiomyosarcomas, 18 homologous mixed mullerian tumors, and 11 heterologous mixed mullerian tumors. Disease-free survivals for mixed mullerian tumors were 65% at 5 years and 61% at 15 years. Disease-free survivals for leiomyosarcomas were 40% at 5 years and 40% at 15 years. There were 14 distant only, 5 distant and abdominal, 1 abdominal, 1 distant and pelvic, and 2 unknown initial sites of failure. Acute toxicity was acceptable as measured by a median 1-kg weight loss from radiotherapy and a 2% rate of failure to complete therapy. Chronic toxicity consisted of 3 small bowel obstructions and 1 sigmoid colon obstruction. In conclusion, the efficacy of adjuvant pelvic radiation is demonstrated by the absence of any isolated pelvic failures. Although the frequent occurrence of peritoneal failures suggests a role for prophylactic abdominal radiation for mixed mullerian tumors, more effective systemic therapy is necessary to substantially increase the chance of cure for women with early-stage uterine sarcomas.

Malignant mixed mullerian sarcomas of the uterus--the LSUHSC Shreveport experience

OBJECTIVE

To evaluate our experience with malignant mixed mullerian sarcomas of the uterus (MMMT) and the clinical factors affecting survival.

STUDY DESIGN

The records of 18 women with MMMT who received treatment at our hospital between 1989-2002 were reviewed. We analyzed factors influencing survival such as stage, presence of heterologous components, and post-operative radiation. Survival analysis was performed using Kaplan-Meier survival curve.

RESULTS

All women underwent surgical tumor debulking. Eleven women were Stage I, three were Stage II, two were Stage III, and two were Stage IV. Five women had tumors with heterologous elements. As expected, survival was most influenced by stage of disease, with the best overall survival in women with Stage I tumors, P < 0.001. Cumulative 5-year survival was 60% for Stage I disease, for Stage II, 34%, and 0% for Stage III and Stage IV.

CONCLUSIONS

The initial stage of women presenting with MMMTs is the most important predictive factor for survival.

Does Tamoxifen Use Affect Prognosis in Breast Cancer Patients Who Develop Endometrial Cancer?

OBJECTIVE

The use of tamoxifen to prevent breast cancer and decrease recurrence is not controversial. However, the effect that tamoxifen may have in women with a history of breast cancer in whom endometrial cancer develops is unclear. The purpose of this study was to estimate whether a history of tamoxifen use is a prognostic factor for such patients.

METHODS

Between 1990 and 2002, patients seen at The University of Texas M. D. Anderson Cancer Center with a history of breast cancer who developed endometrial cancer were identified. Medical records were reviewed to identify clinical, pathologic, and outcome information.

RESULTS

Eighty-nine patients with a history of breast cancer in whom endometrial carcinoma developed were identified. Fifty-two percent (46/89) had a history of tamoxifen use (median duration 48 months; range 2-120 months). There were no significant differences in the clinical or pathologic features between tamoxifen users and nonusers. A history of tamoxifen use was associated with a shorter interval from breast cancer to endometrial cancer diagnosis (77.2 versus 121.3 months for nonusers; P =.01). There was no significant difference in overall survival between tamoxifen users and nonusers (39.2 months versus 48.3 months, P =.27), and there was no difference in endometrial cancer-specific survival duration between tamoxifen users and nonusers (55.7 versus 51.0 months, P =.92).

CONCLUSION

Among tamoxifen users, the interval from breast cancer to endometrial cancer diagnosis was significantly shorter than that in nonusers. In this cohort, a history of tamoxifen use was not associated with a worse overall or disease-specific survival.

Survival of women diagnosed with malignant, mixed mullerian tumors of the ovary (OMMMT)

OBJECTIVE

To analyze the survival of women with malignant, mixed mullerian tumors of the ovary (OMMMT) compared to women with epithelial ovarian cancer (EOC).

METHODS

Data from the Surveillance, Epidemiology and End Results (SEER) Program on 14025 women diagnosed with primary invasive ovarian cancer between 1988 and 1997 were used for this analysis (382 had OMMMT). Differences in distribution of prognostic variables by histological type were compared using a chi-square test. Multivariable survival models were fit using Cox proportional hazards regression analysis to compare risk of death for OMMMT compared to EOC. Analyses were also performed using cases with OMMMT compared to high-grade EOC only.

RESULTS

Women with OMMMT were older at diagnosis and were more likely to have primary surgery compared to women with EOC. The majority of women in either histological group had advanced-stage disease at diagnosis. Women with OMMMT had a significant increased risk of death from any cause whether being compared to all women with EOC (HR = 1.69, 95% CI = 1.50,1.90) or to women with high-grade EOC only (HR = 1.58, 95% CI = 1.40,1.79). Women with advanced-stage OMMMT were at a 60% increased risk of death compared to women with advanced-stage, high-grade EOC, after adjustment for other variables of interest (adjusted HR = 1.60, 95% CI = 1.40,1.84). There was no difference in risk of death for these two groups of women with early-stage disease.

CONCLUSION

OMMMT is a rare malignancy compared to EOC and had a significantly worse prognosis compared to EOC.

Malignant mixed müllerian tumors of the uterus: Analysis of patterns of failure, prognostic factors, and treatment outcome

PURPOSE

To determine the survival outcomes, prognostic factors, and patterns of failure in patients with malignant mixed Müllerian tumor (MMMT) of the uterus.

METHODS AND MATERIALS

Between 1954 and 1998, 300 patients with clinical Stage I-III MMMT of the uterus were treated with curative intent at The University of Texas M. D. Anderson Cancer Center. Their hospital records were reviewed to obtain patient and tumor characteristics; details of surgery, radiotherapy (RT), and chemotherapy; and long-term outcome. Surviving patients were followed for a median of 109 months (range 15-138). Survival rates were calculated using the Kaplan-Meier method, with differences assessed by log-rank tests.

RESULTS

Of the 300 patients, 113 (38%) were treated with surgery alone, 160 (53%) with surgery plus adjuvant EBRT or ICRT, and 27 (9%) with RT alone. Forty-eight patients received adjuvant chemotherapy. At 5 years, the overall rates of survival and cause-specific survival were 31% and 33%, respectively. Women who were postmenopausal or had a history of prior pelvic RT, pain at presentation, clinical Stage II-III disease, uterine enlargement (>/=12 weeks), or an abnormal Papanicolaou smear finding had a significantly poorer prognosis than the other patients in the series. Of the 273 patients who underwent surgery, those who had positive abdominal washings, uterine length >10 cm, or extrauterine spread of disease to the cervix, adnexa, or peritoneum had a significantly worse prognosis than the other patients. Factors found on multivariate analysis to have an independent adverse influence on cause-specific survival included postmenopausal status (p = 0.0007, relative risk [RR] 3.3), uterine length >10 cm (p = 0.0001, RR 2.2), cervical involvement (p = 0.002, RR 1.8), and peritoneal involvement (p = 0.0001, RR 4.3). At 5 years, the rates of pelvic and distant disease recurrence for the entire group of 300 patients were 38% and 57%, respectively. The most common site of distant recurrence was the peritoneal cavity. Patients treated with pelvic RT had a lower rate of pelvic recurrence than patients treated with surgery alone (28% vs. 48%, p = 0.0002), but the overall survival rates (36% vs. 27%, p = 0.10) and distant metastasis rates (57% vs. 54%, p = 0.96) were not significantly different. However, patients treated with pelvic RT had a longer mean time to any distant relapse (17.3 vs. 7.0 months, p = 0.001) than patients treated with surgery alone. The use of adjuvant chemotherapy did not correlate with the survival rate or rate of distant metastasis.

CONCLUSION

Adjuvant pelvic RT decreased the risk of pelvic recurrence and may delay the appearance of distant metastases after hysterectomy for MMMT. However, the survival rates remain poor because of a high rate of distant recurrence. As more effective systemic chemotherapy is developed to control microscopic distant disease, the role of RT in controlling locoregional disease in the pelvis and abdomen may become more important. Future research should consider programs that integrate surgery, RT, and chemotherapy to maximize the probability of cure.

Uterine sarcoma: twenty-seven years of experience

PURPOSE

A correlation of treatment for uterine sarcoma with outcome, prognostic importance of pathology, and clinical parameters.

PATIENTS AND METHODS

One hundred forty-one patients (median age: 56 years, range: 19-85 years) with a histologically verified uterine sarcoma were identified from a database compiled at the Royal Marsden Hospital and the University of Florence between 1974 and 2001. Seventy-two patients had leiomyosarcoma, 42 had mixed müllerian tumors, 22 had endometrial stromal sarcoma, 1 hemangiopericytoma, 1 rhabdomyosarcoma, and 3 patients had unspecified sarcoma. According to FIGO classification, Stage I, II, III, and IV tumors were identified in 71, 13, 31, and 26 patients, respectively.

RESULTS

At the time of analysis, 73.7% of patients were dead, and 26.3% were alive with a median survival of 2 years from initial diagnosis. Univariate analysis for cause-specific survival demonstrated statistical significance for histology (p = 0.02), grade (p = 0.003), stage (p = 0.007), and age (p = 0.02). Multivariate analysis demonstrated significant prognostic values for stage (p = 0.02) and histology (p = 0.05) only. Postoperative radiotherapy with a total dose higher than 50 Gy seems to be significant (p = 0.001) in reducing local recurrence.

CONCLUSIONS

Our data favor treatment for Stages I, II, and III of uterine sarcoma with radical surgery plus radical dose irradiation comprising both external beam radiotherapy and brachytherapy.

Malignant mixed mullerian tumour of the ovary: prognostic factor and response of adjuvant platinum-based chemotherapy

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.

Analysis of clinicopathologic factors in malignant mixed Müllerian tumors of the uterine corpus

The aim of this study was to retrospectively analyze the clinical and pathologic data of a series of patients presenting to our unit with uterine malignant mixed Müllerian tumors (MMMT) to attempt to identify prognostic factors and relate them to survival. Thirty-seven patients diagnosed with MMMT of the uterus from 1988 through 2000 were identified from the gynecological tumor registry. Data was abstracted and analyzed. The effect of a variety of clinical, histopathologic, and surgical variables on recurrence and survival were analyzed by univariate and multivariate analyses. Patients tended to be postmenopausal, overweight, hypertensive, and presented with abnormal bleeding. Preoperatively 28 (76%) were thought to have clinical stage I-II disease. Nine (32%) were upstaged based on surgical data. Five (56%) of these patients were found to have gross extrauterine disease and four (44%) were found subsequently to have microscopic extrauterine disease. Twenty (54%) patients underwent lymph node dissection and positive nodes were found in seven (35%) patients. Nine patients underwent omentectomy and disease was found in three (33%). Peritoneal washings were positive in three of 16 patients (19%). At the completion of primary surgery, 27 (75%) patients had no residual disease. Twelve (44%) of these patients had recurrence of disease. Median disease-free interval prior to first recurrence was 15 months. Median overall survival was 30 months. Log-rank analysis performed on multiple variables, including stage, age, residual disease, and depth of myometrial invasion showed a statistically significant association with overall survival probability. Only stage remained a significant independent variable predictive of overall survival (P = 0.034). We found that stage was an independent prognostic factor for overall survival in patients with uterine MMMT. Age, depth of myometrial invasion, and residual tumor were significant prognostic factors on univariate analysis. These factors may be a guide in order to select a group of high risk patients that may benefit from adjuvant therapy.

Postoperative pelvic irradiation in early stage uterine mixed mullerian tumors

PURPOSE OF INVESTIGATION

To review our management experience with uterine mixed mullerian tumors (MMTs) in order to evaluate potential prognostic indicators, and assess the efficacy of various treatment modalities.

METHODS

A retrospective, clinicopathologic evaluation of 43 patients presenting for treatment of uterine MMTs between 1982 and 1992 was conducted. Diagnostic criteria for inclusion was the presence of both a malignant glandular or squamous epithelial component, and a homologous or heterologous stromal component.

RESULTS

Overall 2- and 5-year cancer related Kaplan-Meier survival estimates with 95% confidence intervals were 44 (.28, .59) and 26% [.12, .39], respectively. Survivals were 83 [.62, .99] and 58% [.31, .85] when disease was confined to the uterus, and 22 [.03, .41] and 7% [.01, .20] when disease extended beyond the uterus. Clinical staging was often inaccurate, with 29% of clinical stage I or II disease being upstaged at laparotomy. A significant survival advantage was found in patients with stage I or II disease treated with surgery plus pelvic irradiation (p = 0.001), as compared to those treated with surgery alone. The prognosis after disease recurrence was poor, irrespective of secondary therapy, with a median survival of 11 months.

CONCLUSIONS

A therapeutic advantage may be gained from postoperative pelvic irradiation in the treatment of surgical stage I or II uterine MMT.

Cluster of uterine mullerian adenosarcoma in the Washington, DC metropolitan area with high incidence of sarcomatous overgrowth

Mullerian adenosarcoma is an uncommon variant of uterine sarcoma. Twelve uterine adenosarcomas were diagnosed during a 42-month period at the Washington Hospital Center in Washington, DC. Based on estimated incidence data derived from the US Department of Defense beneficiary population, an estimated relative risk of 15.4 (95% confidence interval, 7.7-31.0) was calculated, indicating a significantly increased incidence of adenosarcoma in the population studied (p<0.0000001). Among 10 patients who underwent hysterectomy, six (60%) of their tumors had sarcomatous overgrowth. In comparison with the previously reported proportion of adenosarcomas with sarcomatous overgrowth, approximately 16%, the proportion with sarcomatous overgrowth was significantly higher than expected (p<0.01). Mullerian adenosarcoma with sarcomatous overgrowth was first described in 1989 and suggests that the cluster of adenosarcomas reported herein may be due in part to the current classification of some uterine tumors as adenosarcoma with sarcomatous overgrowth that previously would have been classified as other types of uterine sarcoma. Nonetheless, even after reviewing and updating the classification of all sarcomas diagnosed at the Washington Hospital Center from 1985 to 1998, the ratio of adenosarcomas to uterine adenocarcinomas during the 1994-1998 period was 4.7 times (p<0.005) that of the 1985-1993 period, suggesting a more modest but real increase in the occurrence of this tumor. Correct classification of mullerian adenosarcomas with sarcomatous overgrowth is important because the limited available data suggest that the prognosis is notably worse than that for adenosarcomas without sarcomatous overgrowth.

Results of primary and adjuvant radiotherapy in the treatment of mixed Müllerian tumors of the corpus uteri

OBJECTIVE

The benefit of primary or adjuvant irradiation in the treatment of mixed Müllerian tumors is still not clear.

METHODS

During 1981-1997 63 patients were referred for primary (n = 13) or postoperative (n = 50) radiotherapy. Analysis of outcome of primarily and postoperatively irradiated patients was performed separately because of different staging systems. Of 50 patients treated after surgery 29 presented in histopathologic stage I, 4 in stage II, 14 in stage III, and 3 in stage IV. Clinical stage distribution for primary treatment was stage I: n = 9, stage II: n = 1, stage III: n = 3. Forty-four patients in the postoperatively treated group and 6 in the primarily treated group received radiotherapy with a curative intent; external beam therapy was given up to 56 Gy to the pelvis combined with intravaginal or intracavitary brachytherapy.

RESULTS

Five-year actuarial overall survival, disease-specific survival, local control, and distant control for 50 patients receiving adjuvant irradiation was 52.9, 57. 5, 83.4, and 70.8%, in stage I: 68.4, 76.1, 95.2, and 81.7%, in stage II: 50.0, 50.0, 75.0, and 66.7%, and in stage III: 31.3, 34.1%, 70.4, and 47.6%, respectively. Four of 13 patients treated with primary irradiation achieved long-term local control.

CONCLUSION

These data suggest that adjuvant radiotherapy improves local control and disease specific survival in the treatment of mixed Müllerian tumors compared to data in the literature concerning treatment by surgery alone.

Prognostic factors in uterine carcinosarcoma: a clinicopathologic study of 25 patients

BACKGROUND

Carcinosarcoma (malignant mixed mullerian tumor) of the female genital tract is a highly malignant neoplasm. The tumor stage and histologic grade of the carcinomatous component are among the important prognostic indicators cited in the literature for this tumor.

METHODS

Twenty-five patients with uterine carcinosarcoma at 4 hospitals in the Kyoto and Nara areas of Japan were studied retrospectively. The clinicopathologic and immunohistochemical data including p53, bcl-2, Ki-67, and proliferating cell nuclear antigen (PCNA) staining were analyzed using univariate and multivariate analysis with the Cox proportional hazards model to investigate potential prognostic indicators for this neoplasm.

RESULTS

The 5-year survival rate was 36.4% for all stages, 62.3% for Stage I, and 0% for Stages II-IV. From the univariate analysis, stage (P = 0.0001), endometrioid adenocarcinoma as a carcinomatous component (P = 0.0006), age (P = 0.0355), and a heterologous sarcomatous component (P = 0.0421) were found to be prognostically significant for patient survival. Stage was the only independent significant factor in the multivariate analysis (t = 2.212). None of the other factors (history of pregnancy and gestation, gross appearance of the tumors, grade of the carcinomatous component, mitotic count of the sarcomatous component, Ki-67 and PCNA reactivity, or p53 or bcl-2 positive staining) was found to be a significant prognostic indicator.

CONCLUSIONS

Stage appears to be the only definite independent prognostic indicator of survival in patients with uterine carcinosarcoma. It is uncertain whether age, endometrioid adenocarcinoma as a carcinomatous component, or absence of a heterologous component in the sarcomatous area are prognostic factors. Immunohistochemical expression of p53, bcl-2, Ki-67, or PCNA is not a prognostic indicator. The immunohistochemical results of the current study may support the hypothesis of a common stem cell origin of this tumor.

Increased expression of fatty acid synthase (OA-519) in ovarian neoplasms predicts shorter survival

Certain cancers exhibit derangement of de novo fatty acid biosynthesis, manifested as overexpression and hyperactivity of the lipogenic enzyme fatty acid synthase (FAS). Correlation of elevated FAS with high tumor grade and advanced stage in primary breast, prostate, and colorectal cancers has drawn attention to the enzyme as a possible marker of poor prognosis. To find a similar utility of FAS in ovarian neoplasms, we compared FAS expression in 68 ovarian tumors with their histological features and clinical outcome. Immunohistochemical localization of FAS was observed in 48 (71%) cases in which staining was either focal (defined as positive staining in 1% to 20% of cells) or multifocal/diffuse (positive staining in >20% of cells). Most (83%) of the 48 cases were represented by endometrioid, serous, or mucinous carcinomas and malignant mixed mullerian tumors (MMMTs). In contrast, ovarian adenomas and tumors of low malignant potential (LMPs) contained little or no FAS. Association between FAS expression and histological diagnosis was statistically significant. The extent of FAS immunostaining was also predictive of prognosis. Among all patients with ovarian malignancies (including LMPs), median survival was 64.8 months, when their tumors exhibited no or focal immunostaining for FAS, as opposed to 31.2 months, when staining was multifocal/diffuse (P = .005). Similar median survival values were obtained when cases were limited to endometrioid, serous, and mucinous carcinomas. Short-term survival at 1 and 2 years was significantly higher in patients whose tumors showed no or focal expression of FAS compared with multifocal/diffuse expression. Thus, elevated FAS may serve as an independent marker for predicting poor clinical outcome in patients with ovarian cancer.

Epidermal growth factor receptor and c-erbB-2 oncoprotein expression in female genital tract carcinosarcomas (malignant mixed müllerian tumors). Clinicopathologic study of 82 cases

BACKGROUND

Epidermal growth factor receptor (EGFR) and c-erbB-2 (also known as HER-2/neu) oncoprotein (p185erbB-2) are members of the subfamily of tyrosine kinase, transmembrane receptors often implicated in human carcinogenesis. We hypothesize that expression of EGFR and p185erbB-2 adds useful prognostic and histogenetic information regarding female genital tract carcinosarcomas (FGTCSs).

METHODS

Paraffin sections from 82 FGTCS (61 endometrium, 14 ovary, 5 cervix, and 2 fallopian tube), 56% of which exhibited heterologous elements, were stained using anti-EGFR (clone 31G7, Triton Diagnostics, Alameda, CA) and anti-p185erbB-2 (clone CB11, Novocastra Labs, UK).

RESULTS

EGFR reactivity was present in 11 (13.4%) FGTCSs (55% carcinomatous component [CC] only, 18% sarcomatous component [SC] only, and 27% in both). EGFR was associated with adenosquamous histology of the CC (P < 0.05) and heterologous rhabdomyosarcomatous differentiation in the SC (P < 0.05); no other histopathologic features were correlated. p185erbB-2 reactivity was present in 79 (87.8% strong [S], 78% membrane [M], and 8.5% weak) FGTCSs (1% CC only, 0% SC only, and 99% in both). p185erbB-2 did not correlate with histopathologic features or EGFR. Seventy-seven patients had clinical follow-up for longer than 12 months. Approximately 49.3% and 72.3% of patients had recurrent disease by 12 and 80 months, respectively; all but 1 were dead from disease. 27% of patients were disease free after 15 to 307 months (median, 77 months; mean, 92 months). EGFR, but not p185erbB-2 expression predicted disease recurrence (P < 0.05). Recurrent disease was associated with Stage greater than I (P < 0.0001), vascular space invasion in resection specimens (P < 0.01), and deep myometrial invasion in hysterectomies (P < 0.05). EGFR was associated with Stage greater than I and did not help predict recurrence in good prognosis groups.

CONCLUSIONS

p185erbB-2 overexpression in both CC and SC of FGTCS suggests a common carcinogenic mechanism for both components and supports the conversion-histogenesis hypothesis implicating a dominant role for the CC with the SC arising as a metaplastic change from the CC. EGFR may be expressed in either component and indicates aggressive biologic behavior; however, its prognostic utility is limited by its low predictive value for recurrence (40.3%), inability to foretell recurrence in good prognosis groups, and dependence on stage. High frequency of overexpression and dismal prognosis make FGTCS patients good candidates for trials of therapeutic strategies involving the p185erbB-2 receptor manipulations.

Malignant mixed müllerian tumors of the ovary: experience with surgical cytoreduction and combination chemotherapy

BACKGROUND

The role of surgical cytoreduction and combination chemotherapy for malignant mixed müllerian tumors (MMMT) of the ovary was evaluated.

METHODS

A retrospective review of 27 women with ovarian MMMT treated from 1980 to 1990 was performed.

RESULTS

The International Federation of Gynecology and Obstetrics stages for the 27 women were 1 Stage I, 3 Stage II, 17 Stage III, and 6 Stage IV. Only 10 of the 23 patients with Stage III or IV disease were cytoreduced optimally. With respect to postoperative therapy, 3 women received no treatment, 6 were treated with whole abdomen radiotherapy, 1 received melphalan, and 17 received chemotherapy incorporating a platinum agent (3), doxorubicin (4), or both (10). The significant prognostic factors were stage (P < 0.001) and, for women with Stage III or IV disease, the feasibility of cytoreductive surgery (P = 0.03). The four patients in Stages I or II remained disease free after an interval of at least 5 years. The median and 5-year survival rates for patients with Stages III or IV disease was 18 months and 8%, respectively. Patients in Stage III or IV for whom optimal cytoreduction was not possible had a 2-year survival of 14%, whereas optimal cytoreduction was associated with a 52% 2-year survival. Median survival for the 14 women with Stage III or IV ovarian MMMT treated with combination chemotherapy was 25 months and nine women achieved progression free intervals of greater than 18 months.

CONCLUSIONS

Aggressive surgical cytoreduction followed by combination chemotherapy may result in improved progression free intervals for women with advanced ovarian MMMT. However, a major improvement in prognosis for this rare malignancy has not yet been achieved.

Ovarian mucinous tumors of low malignant potential: a clinicopathologic study of 54 tumors of intestinal and müllerian type

We have reviewed 44 mucinous intestinal (MI) and 10 mucinous mullerian (MM) tumors of low malignant potential (LMP) seen at The George Washington University Medical Center. As previously reported by Rutgers and Scully, MMLMP tumors occurred in younger women, were generally smaller and more frequently bilateral, had a papillary rather than multicystic appearance, and lacked goblet cells. All patients with MMLMP tumors were recurrence-free at last follow-up, including three whose tumors were microinvasive. Patients with MILMP tumors also all did well regardless of tumor grade, with the exception of a single patient with bilateral grade 1 ovarian tumors, an appendiceal villous adenoma, and pseudomyxoma peritonei. Microinvasion was also seen in four of these tumors, none of which recurred. Review of the literature suggests that MILMP tumors without stromal invasion but with either prominent cell stratification or marked nuclear atypia may have a worse prognosis than those lacking these features, but probably largely because of a correlation with higher stage disease. We believe that tumors of this sort should not be diagnosed as "noninvasive carcinomas," but should be sectioned more extensively for evidence of stromal invasion and subjected to careful staging. If the tumor is still noninvasive and in stage I after these procedures, the likelihood of treatment failure appears to be in the range of 1-3%.

Ovarian malignant mixed müllerian tumors treated with platinum-based chemotherapy

OBJECTIVE

To characterize the clinical course of patients diagnosed with ovarian malignant mixed müllerian tumors treated with platinum-based chemotherapy.

METHODS

Thirty-six patients received this treatment at The University of Texas M. D. Anderson Cancer Center in the period 1979-1993. The mean age was 59 years. Stage distribution was as follows: stage IA, one (3%) patient; stage IIIB, two (5.5%); stage IIIC, 21 (58%); and stage IV, two (5.5%). Ten (28%) patients were unstaged. Chemotherapy regimens included cisplatin, doxorubicin, and cyclophosphamide in 16 patients; cisplatin-ifosfamide in five; cisplatin-cyclophosphamide in four; carboplatinum in three; cisplatin-doxorubicin in three; and various other combinations in the remaining five.

RESULTS

Of 16 patients evaluated for clinical response, seven (44%) had a complete response and four (25%) had a partial response, for a total clinical response rate of 69%. Nine patients were evaluated for surgical response: five (56%) had a complete response and one (11%) had a partial response, for a total surgical response rate of 67%. The median survival for the cohort was 18 months. At the time of this analysis, five (14%) patients were alive and disease-free, 25 (69%) had died of disease, five (14%) were alive with disease, and one had been lost to follow-up.

CONCLUSION

This study suggests that the clinical course of patients with ovarian malignant mixed müllerian tumors treated with platinum-based chemotherapy is similar to the clinical course experienced by patients with high-grade epithelial carcinoma of the ovary.

A phase II study of etoposide, cisplatin, and doxorubicin chemotherapy in mixed müllerian tumors (MMT) of the uterus

Mixed Müllerian tumors (MMT) of the uterus are aggressive entities that result in a very poor prognosis even for patients in whom the disease is limited to the uterus. This phase II trial was undertaken in an attempt to improve overall survival as well as progression-free survival of these patients. Forty-two consecutive patients were treated with a combination chemotherapy containing etoposide 100 mg/m2 on Days 1 and 2, cisplatin 50 mg/m2 on Day 1, and doxorubicin 50 mg/m2 on Day 1, repeated every 28 days. There were 23 patients with early-stage disease (stages I and II) and 19 patients with advanced (stages III and IV) or recurrent disease. In the early-stage group, the number of cycles ranged from 2 to 9 (5.2 +/- 1.9). The median follow-up was 32 months (range 11-93). There were five recurrences: three patients died of disease at 11, 36, and 51 months, and two patients are still alive with disease at 12 and 19 months. Two-year overall survival was 92%. In the advanced disease group, the number of cycles ranged from 1 to 11 (5.9 +/- 2.4). The median follow-up for this group was 20 months (range 5-62). The median overall survival was 18 months. Two-year overall survival was 33%. Two-year progression-free survival was 20%. Four patients were evaluable for response. There were two complete responses (duration 15-33 months) and two partial responses (duration 6-10 months). The responders were patients whose adenocarcinoma component was of the papillary serous (UPSC) variety. The chemotherapy combination appears to be highly active in early-stage disease. In the advanced uterine MMT it has moderate activity, especially when associated with the UPSC component.

Malignant mixed müllerian tumor versus high-grade endometrial carcinoma and aggressive variants of endometrial carcinoma: a comparative analysis of survival

To ascertain whether uterine malignant mixed müllerian tumors are biologically distinct from high-grade endometrial carcinomas (FIGO grade 3), we compared patient survival in 32 and 39 cases, respectively. The Cox proportional hazard model was employed to determine whether tumor type was an independent predictor of survival. The survival of patients with MMMT was also compared to that of patients with serous adenocarcinoma and clear cell carcinoma. The 5-year overall and disease-free survival were significantly lower for malignant mixed müllerian tumors (25% and 11%) than for high-grade endometrial carcinomas (64% and 56%). Using the Cox proportional hazard model, tumor type (MMMT vs. high-grade endometrial carcinoma) was a statistically significant predictor of survival after other important prognostic variables such as pathologic stage, depth of myometrial invasion, and vascular invasion had been taken into account. The increased aggressiveness of MMMT appears most attributable to their tendency to reach a more advanced stage by the time of clinical presentation and to their greater propensity for upper abdominal dissemination. The survival of patients with MMMT was also lower than that of patients with the special histologic variants of endometrial carcinoma, serous adenocarcinoma and clear cell carcinoma, which are recognized for their unusually aggressive clinical behavior. These results indicate that uterine malignant mixed müllerian tumors are clinically more aggressive than high-grade endometrial carcinomas and should continue to be recognized as a distinct entity.

Malignant mixed Müllerian tumors of the uterus

OBJECTIVE

To review the prognostic factors of Chinese women with mixed Müllerian tumors of the uterus.

METHOD

A retrospective review of 21 cases of malignant mixed Müllerian tumors of the uterus treated during the 10-year period from 1980 to 1990.

RESULTS

All patients except one were postmenopausal. The incidence of previous pelvic irradiation was 9.5%. The most common presenting symptom was abnormal vaginal bleeding. One-third of patients yielded an abnormal cervical smear. Treatment included surgery, chemotherapy and radiotherapy in the majority of patients. Prognosis was poor with only three long-term survivors, all with stage-I homologous tumors with superficial myometrial invasion. The survival rate for stage-I and -II disease at 2 years was 50% and for more advanced disease extending beyond the uterus was 0%. The survival rate for all stages at 5 years was 14.3%, and the cumulative probability of survival at 5 years was 0.165.

CONCLUSION

The most important prognostic factors appear to be the extent of tumor involvement at the time of diagnosis and the depth of myometrial invasion.

Primary malignant mixed Müllerian tumor (metaplastic carcinoma) of the female peritoneum. A clinical, pathologic, and immunohistochemical study of three cases and a review of the literature

BACKGROUND

Malignant mixed mesodermal tumors (malignant mixed Müllerian tumors [MMMT]) occur rarely in extragenital sites.

METHODS

The authors analyzed the clinical, pathologic, and immunohistochemical features of three cases of primary MMMT of the female peritoneum.

RESULTS

The neoplasms occurred in 60-, 64- and 84-year-old women and arose from pelvic peritoneum. Two patients died with disseminated disease 8 and 24 months postoperatively. The third died of cardiac failure 12 months postoperatively with questionable metastatic disease. Microscopically, two tumors were of the heterologous type, containing foci of rhabdomyosarcomatous (case 1) and chondrosarcomatous (case 3) differentiation. Immunohistochemically, coexpression of keratin and vimentin was observed focally in both carcinomatous and sarcomatous components in all three neoplasms, whereas coexpression of low molecular weight cytokeratin, vimentin and actin was observed focally in case 2. Rhabdomyosarcomatous areas were positive with desmin and actin, and chondrosarcomatous areas for S-100 protein. Both epithelial and mesenchymal components were positive for alpha-1 antichymotrypsin in all cases.

CONCLUSIONS

On the basis of the present cases and a review of 15 reports from the literature, primary MMMT of the female peritoneum proved to be a rare but highly malignant neoplasm occurring in elderly postmenopausal women. Of 15 patients with available follow-up, 12 died with disease, mostly within 1 year, regardless of the initial tumor stage, histology (homologous versus heterologous MMMT) or treatments attempted. The tumor developed within pelvic peritoneum in half the cases. Histogenetically, peritoneal MMMT are thought to represent "metaplastic" carcinomas originating from the secondary Müllerian system.

Morphologic prognostic factors of malignant mixed müllerian tumors of the ovary: a clinicopathologic study of 15 cases

Fifteen ovarian malignant mixed müllerian tumors (MMMT) of the ovary are reported in an attempt to identify morphologic factors of prognostic interest. Several features were correlated to survival: histologic subtype and nuclear and histologic grades of the epithelial component; histologic subtype, grade, and mitotic rate of the mesenchymal component; necrosis and epithelial-to-mesenchymal ratio. The epithelial component was mainly of endometrioid (four cases) and serous (four cases) types. The mesenchymal component was largely heterologous, of which five were of chondromatous and five of rhabdomyoblastic differentiation. This latter differentiation was further demonstrated by electron microscopy (two cases) and immunohistochemistry (four cases). Ten tumors showed hyaline droplets that stained for alpha 1-antitrypsin in two cases. Eight patients died of their disease, 13 days to 32 months after diagnosis (median, 5 months). Seven were alive 3 to 49 months (median, 10 months) after initial therapy. No morphologic factor was found to correlate with survival, but a tendency was observed for ovarian MMMTs with a high epithelial nuclear grade, a predominance of the mesenchymal component, or a rhabdomyoblastic mesenchymal component to be associated with more aggressive behavior. The histologic appearance of metastases did not correlate with prognosis.