Adjuvant Therapy In Uterine Sarcomas

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Adjuvant Therapy In Uterine Sarcomas

  1. 1. ADJUVANT THERAPY IN UTERINE SARCOMAS Dr. T. Sujit A M O ( Radiation Oncology ) Valavadi Narayanaswami Cancer Centre, G.Kuppuswamy Naidu MemorialHospital, Coimbatore - 641037, Tamilnadu, India May 2007
  2. 2. PROGNOSTIC FACTORS <ul><li>LEIOMYOSARCOMAS </li></ul><ul><ul><li>Mitotic index : 10 -20 / ten HPF  61 % failure rate </li></ul></ul><ul><ul><ul><ul><ul><li>> 20 / ten HPF  79 % failure rate </li></ul></ul></ul></ul></ul><ul><li>MALIGNANT MIXED MULLERIAN TUMORS </li></ul><ul><ul><li>Adnexal spread , Lymph node mets </li></ul></ul><ul><ul><li>Histologic cell type ( Homologous Vs Heterologous ) </li></ul></ul><ul><ul><li>Grade </li></ul></ul>
  3. 3. PATTERNS OF FAILURE <ul><li>LMS : Majority of the recurrence is as distant metastasis </li></ul><ul><ul><li>28% - abdomino-pelvic recurrence </li></ul></ul><ul><ul><li>49% distant mets. </li></ul></ul><ul><ul><ul><li>Pelvic RT offers very little potential gain </li></ul></ul></ul><ul><li>MMMT : Pelvic recurrence rates are higher compared to distant mets </li></ul><ul><ul><li>56% pelvic recurrence </li></ul></ul><ul><ul><li>45% distant mets </li></ul></ul><ul><ul><ul><li>Implies surgery alone is not enough to achieve local control. </li></ul></ul></ul>
  4. 4. ADJUVANT MANAGEMENT <ul><li>Stage I & II – HGUD, LMS, Carcinosarcoma </li></ul><ul><ul><li>Pelvic RT ± Brachytherapy ± Chemotherapy </li></ul></ul><ul><li>Stage III A, III B - HGUD, LMS, Carcinosarcoma </li></ul><ul><ul><li>Pelvic RT ± Brachytherapy ± Chemotherapy </li></ul></ul><ul><ul><li>Abdomino-pelvic RT ( except LMS ) </li></ul></ul><ul><li>Stage III A & III B – ESS </li></ul><ul><ul><li>Hormone therapy ± Pelvic RT </li></ul></ul>
  5. 5. ADJUVANT MANAGEMENT <ul><li>Stage III C - HGUD, LMS, Carcinosarcoma </li></ul>PALN + ve PALN - ve Consider Pelvic RT and/or Vaginal brachytherapy and/or Chemotherapy Consider whole abdominopelvic RT ( except LMS ) Chemo Chest CT ± biopsy scalene nodes Whole abdominopelvic RT or Pelvic and para-aortic RT or Chemotherapy or - VE + VE
  6. 6. ADJUVANT MANAGEMENT <ul><li>Stage IV A – ESS, HGUD, LMS, Carcinosarcoma </li></ul><ul><ul><li>RT </li></ul></ul><ul><ul><li>and/or </li></ul></ul><ul><ul><li>Chemotherapy </li></ul></ul><ul><ul><li>or </li></ul></ul><ul><ul><li>Hormone therapy </li></ul></ul><ul><li>Stage IV B – ESS </li></ul><ul><ul><li>Hormone Therapy </li></ul></ul><ul><li>Stage IV B - HGUD, LMS, Carcinosarcoma </li></ul><ul><ul><li>Chemotherapy </li></ul></ul>
  7. 7. RADIOTHERAPY <ul><li>ADJUVANT RT : </li></ul><ul><li>~ NO RANDOMISED STUDIES </li></ul><ul><li>~ Some studies quote an improvement in pelvic control, especially for carcinosarcomas . * </li></ul><ul><li>~ Recent trials –  OS in stage I C.  </li></ul><ul><li>~ EBRT – 50 Gy / 5 weeks. </li></ul><ul><li>RADICAL RT : </li></ul><ul><li>~ Medically inoperable patients </li></ul><ul><li>~ EBRT 50 Gy + Brachytherapy </li></ul><ul><li>Gerszten K, Faul C, Kounelis S, et al. The impact of adjuvant radiotherapy on carcinosarcoma of the uterus . Gynecol Oncol 1998 </li></ul><ul><li>Tinkler SD, Cowie VJ. Uterine sarcomas: a review of the Edinburgh experience from 1974 to 1992. Br J Radiol 1993 </li></ul><ul><li>Lee CM, Szabo A, Shrieve DC, et al. Frequency and effect of adjuvant radiation therapy among women with stage I endometrial </li></ul><ul><li>adenocarcinoma. JAMA 2006;295:389-397. </li></ul>
  8. 8. E B R T <ul><li>PELVIC RT </li></ul>
  9. 9. BRACHYTHERAPY NORMAN SIMON APPLICATORS
  10. 10. BRACHYTHERAPY <ul><li>ROTTE TWO CHANNEL APPLICATOR ( NUCLETRON ) </li></ul>
  11. 11. POST – OP BRACHYTHERAPY <ul><li>VAGINAL CYLINDERS </li></ul>AFTER 45 – 50 Gy EBRT: 5 -6 Gy x 3 fractions for HDR or 15 Gy in a single fraction for LDR
  12. 12. CHEMOTHERAPY <ul><li>Single agent chemotherapy: </li></ul><ul><ul><li>MMMT: </li></ul></ul><ul><ul><ul><li>Ifosfamide - 1.5 g/m2/d for 5 days </li></ul></ul></ul><ul><ul><ul><li>Cisplatin - cisplatin, 50 mg/m2 </li></ul></ul></ul><ul><ul><li>LMS: </li></ul></ul><ul><ul><ul><li>Doxorubicin ( Adriamycin ) - 50–90 mg/m2 q3wk </li></ul></ul></ul><ul><li>Combination therapy : </li></ul><ul><ul><li>MMMT: </li></ul></ul><ul><ul><ul><li>MAID – Mesna , Adriamycin, Ifosfamide, Dacarbazine </li></ul></ul></ul><ul><ul><ul><li>Doxorubicin + DTIC </li></ul></ul></ul><ul><ul><ul><li>Ifosfamide + Cisplatin </li></ul></ul></ul><ul><ul><li>LMS </li></ul></ul><ul><ul><ul><li>Gemcitabine + Taxanes ( Paclitaxel , Docetaxel ) </li></ul></ul></ul>
  13. 13. HORMONE THERAPY <ul><li>Response to hormonal manipulation is seen in low grade ESS </li></ul><ul><ul><ul><ul><li>Megestrol acetate </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Medroxyprogesterone acetate </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Tamoxifen </li></ul></ul></ul></ul><ul><ul><ul><ul><li>GnRH analogs </li></ul></ul></ul></ul>
  14. 14. T h a n k y o u

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