uterine sarcoma epidemiology, staging, Leiomyosacoma, carcinosarcoma, ESS Treatment of uterine sarcoma modality Early stage and advanced stage Cancer of Uterus surgery: TAH, Radical Hysterectomy, BSO, Lymphadenectomy, Cytoreductive surgery, Radiotherapy, chemotherapy, Hormonal therapy: Progestin, Aromatase inhibitors, GnRH analogue

1. TREATMENT OF UTERINE
SARCOMA
By wondu Belayneh, final year OBGYN resident
October 2,2021

2. TREATMENT OF UTERINE SARCOMA
.
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3. REATMENT OF EARLY—STAGE DISEASE
• Surgery
• The highest chance of cure is achieved by complete surgical resection of a
sarcoma that is confined to the uterus
• The staging laparotomy—Exploration laparotomy
• Leiomyosarcoma:
TAH or for parametrial infiltration modified radical or radical procedure.
In the absence of gross disease, <5 % ovarian or nodal metastases.
Ovarian preservation for premenopausal women
lymph node dissection is reserved only for clinically suspicious nodes.
• For STUMP, STUMP, Endometrial stromal tumors and adenosarcomas
hysterectomy alone is sufficient.
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4. Mgt of uterine sarcoma
• In the absence of extrauterine disease (for leiomyosarcoma, STUMP, Endometrial
stromal tumors and adenosarcomas)
Hysterectomy alone is sufficient, in the absence of parametrical infiltration
A modified radical or radical procedure—if there is parametrical infiltration
Ovarian preservation for premenopausal women, is generally accepted
Lymph node dissection is reserved for clinically suspicious nodes
• For high-grade undifferentiated sarcomas:
Hysterectomy, BSO and lymph node dissection
• Uterine carcinosarcoma,
Hysterectomy, BSO and comprehensive lymphadenectomy
Plus, infracolic omentectomy and peritoneal biopsies for serous/clear cell
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5. Mgt of uterine sarcoma
Surveillance—Most recurrences will be distant
postoperative radiation with or without chemotherapy
Estrogen replacement therapy
Ok! for leiomyosarcomas, high grade undifferentiated sarcomas, and
adenosarcomas.
Associated with disease progression in endometrial stromal sarcoma
Physical examination every 3 months or the first 2 years and then at 6- to 12-
month intervals thereafter
CXR or CT is performed every 6 to 12 months or 2 years, then annually
Postoperative pelvic radiation for surgical stage I or II uterine sarcomas
Reduced pelvic relapse for carcinosarcomas
No benefit for leiomyosarcomas
No significant increase in survival rates for either group.
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6. Mgt of uterine sarcoma
Radiotherapy options: Pelvic radiation, vaginal brachytherapy and Whole
abdominal radiotherapy (WAR)
WAR Vs Ifosfamide and cisplatin chemotherapy: combination chemotherapy
preferred
Adjuvant Chemotherapy
No survival benefit for stage I uterine sarcoma and stage I and II
leiomyosarcomas
Considered for advanced high-grade undifferentiated sarcomas and
carcinosarcomas
Fertility sparing Management
Myomectomy and hysterectomy after pregnancy delivered
Egg retrieval, assisted reproductive technologies, and pregnancy surrogacy
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7. TREATMENT OF ADVANCED (STAGES III AND IV)
OR RECURRENT DISEASE
• Advanced or recurrent uterine sarcoma carries poor prognosis.
• For advanced-stage disease,
• Neoadjuvant chemotherapy for unresectable tumor
• Surgery with maximal debulking
• Adjuvant chemotherapy.
• For recurrent disease,
• Secondary cytoreductive surgery
• Palliative radiation depending on the site and distribution
• Relapse at distant sites so chemotherapy is more useful
• Encouraged to enroll in experimental clinical trials
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8. TREATMENT OF ADVANCED (STAGES III AND IV) OR RECURRENT DISEASE
• Leiomyosarcoma
Doxorubicin is considered the most active single agent
The combination of gemcitabine and docetaxel currently has the highest
proven response rate (36 percent)
Addition of bevacizumab to this regimen has not benefit
For late recurrences of leiomyosarcoma, surgery must be individualized.
Five-year survival rates of 30 to 50% reported following pulmonary resection
for lung metastases.
Local and regional recurrences may also be amenable to surgical resection.
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9. TREATMENT OF ADVANCED (STAGES III AND IV) OR RECURRENT
• Endometrial Stromal Tumors: has ER/PR positive
• Surgical resection with recurrent endometrial stromal sarcoma,
• But hormonal therapy is particularly useful.
Progestins, Aromatase inhibitors and GnRH agonists
Used for: postoperatively or advanced-stage or for relapses
Complete responses are often possible.
 High-grade undifferentiated sarcomas
Are ER/PR negative
Advanced disease or recurrences not amenable to surgical resection,
Palliative radiation have some utility.
Systemic chemotherapy is Ifosfamide is the only option
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10. TREATMENT OF ADVANCED (STAGES III AND IV) OR RECURRENT
Carcinosarcoma
• Ifosfamide is the most active single agent for carcinosarcoma.
• Combination of Ifosfamide and paclitaxel is preferred treatment for advanced or
recurrent uterine carcinosarcoma
• Carboplatin and paclitaxel Vs Ifosfamide and paclitaxel
• The most active single agent for
LD-for Leiomyosarcoma—Doxorubicin
CI—for Carcinosarcoma—Ifosfamide
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11. SURVIVAL AND PROGNOSTIC FACTORS
• In general, women with uterine sarcoma have a poor prognosis
• FIGO stage is the most important independent variable of prognosis
• Other poor prognostic factors: older age, black race, and lack of primary surgery
• Tumor histology: Leiomyosarcomas have the worst prognosis and are followed by
carcinosarcoma and the group of endometrial stromal tumors.
• Endometrial stromal sarcomas and uterine adenosarcomas without sarcomatous
overgrowth are the two notable exceptions.
* Patients with these tumors tend to have a good prognosis due to their indolent
growth
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12. Reference
1. William Gynecology 4th edition,2020: CHAPTER 34, Uterine Sarcoma; page 722-to-732
2. Berek and Novak's Gynecology, 16 Edition,2020: Chapter 37: Uterine Cancer; Uterine Sarcoma
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