Adjuvant Therapy In Uterine Sarcomas

ADJUVANT THERAPY IN

UTERINE SARCOMAS

Dr. T. SujitA M O ( Radiation Oncology )Valavadi Narayanaswami Cancer Centre,G.Kuppuswamy Naidu MemorialHospital,Coimbatore - 641037, Tamilnadu, India

May 2007

PROGNOSTIC FACTORS

• LEIOMYOSARCOMAS

– Mitotic index : 10 -20 / ten HPF 61 % failure rate

> 20 / ten HPF 79 % failure rate

• MALIGNANT MIXED MULLERIAN TUMORS

– Adnexal spread , Lymph node mets

– Histologic cell type ( Homologous Vs Heterologous )

– Grade

PATTERNS OF FAILURE

• LMS : Majority of the recurrence is as distant metastasis

– 28% - abdomino-pelvic recurrence

– 49% distant mets.

• Pelvic RT offers very little potential gain

• MMMT : Pelvic recurrence rates are higher compared to distant mets

– 56% pelvic recurrence

– 45% distant mets

• Implies surgery alone is not enough to achieve local control.

ADJUVANT MANAGEMENT

• Stage I & II – HGUD, LMS, Carcinosarcoma

– Pelvic RT ± Brachytherapy ± Chemotherapy

• Stage III A, III B - HGUD, LMS, Carcinosarcoma

– Pelvic RT ± Brachytherapy ± Chemotherapy

– Abdomino-pelvic RT ( except LMS )

• Stage III A & III B – ESS

– Hormone therapy ± Pelvic RT

ADJUVANT MANAGEMENT

Stage III C - HGUD, LMS, Carcinosarcoma

PALN + ve PALN - ve

Consider Pelvic RTand/or

Vaginal brachytherapyand/or

Chemotherapy

Consider whole abdominopelvic RT

( except LMS )

ChemoChest CT ± biopsy

scalene nodes

Whole abdominopelvic RT

orPelvic and para-

aortic RTor

Chemotherapy

or

- VE

+ VE

ADJUVANT MANAGEMENT

• Stage IV A – ESS, HGUD, LMS, Carcinosarcoma

– RT

and/or

– Chemotherapy

or

– Hormone therapy

• Stage IV B – ESS

– Hormone Therapy

• Stage IV B - HGUD, LMS, Carcinosarcoma

– Chemotherapy

RADIOTHERAPY

ADJUVANT RT :

~ NO RANDOMISED STUDIES

~ Some studies quote an improvement in pelvic control,

especially for carcinosarcomas .*

~ Recent trials – OS in stage I C.

~ EBRT – 50 Gy / 5 weeks.

RADICAL RT :

~ Medically inoperable patients

~ EBRT 50 Gy + Brachytherapy

Gerszten K, Faul C, Kounelis S, et al. The impact of adjuvant radiotherapy on carcinosarcoma of the uterus . Gynecol Oncol 1998 Tinkler SD, Cowie VJ. Uterine sarcomas: a review of the Edinburgh experience from 1974 to 1992. Br J Radiol 1993 Lee CM, Szabo A, Shrieve DC, et al. Frequency and effect of adjuvant radiation therapy among women with stage I endometrialadenocarcinoma. JAMA 2006;295:389-397.

E B R T

PELVIC RT

BRACHYTHERAPY

NORMAN SIMON APPLICATORS

BRACHYTHERAPY

ROTTE TWO CHANNEL APPLICATOR ( NUCLETRON )

POST – OP BRACHYTHERAPY

• VAGINAL CYLINDERS

AFTER 45 – 50 Gy EBRT:

5 -6 Gy x 3 fractions for HDR

or

15 Gy in a single fraction for LDR

CHEMOTHERAPY

• Single agent chemotherapy:– MMMT:

• Ifosfamide - 1.5 g/m2/d for 5 days• Cisplatin - cisplatin, 50 mg/m2

– LMS:• Doxorubicin ( Adriamycin ) - 50–90 mg/m2 q3wk

• Combination therapy :– MMMT:

• MAID – Mesna , Adriamycin, Ifosfamide, Dacarbazine

• Doxorubicin + DTIC• Ifosfamide + Cisplatin

– LMS• Gemcitabine + Taxanes ( Paclitaxel , Docetaxel )

HORMONE THERAPY

Response to hormonal manipulation is seen in low grade ESS

– Megestrol acetate

– Medroxyprogesterone acetate

– Tamoxifen

– GnRH analogs