Archives of Gynecology and Obstetrics

, Volume 282, Issue 6, pp 659–664 | Cite as

The role of lymphadenectomy in uterine carcinosarcomas (malignant mixed mullerian tumours): a critical literature review

Gynecologic Oncology

Abstract

Background

Uterine carcinosarcomas are rare and highly aggressive tumours. Although surgery is the cornerstone of treatment, the extent of the procedure remains controversial. We sought to evaluate the available literature data regarding the rationale of lymphadenectomy and its possible impact on survival.

Methods

A systematic Medline, PubMed and Scopus search with special focus on the publications of the last decade.

Results

Carcinosarcomas have similar clinical characteristics and behaviour with grade 3 endometrioid or aggressive variants of uterine adenocarcinoma. All studies have demonstrated that the FIGO stage of disease is the most important prognostic factor, followed by the depth of myometrial invasion, extra-uterine spread and positive peritoneal cytology. Moreover, lymph node involvement will be found in 14–38% of patients undergoing lymphadenectomy. This figure is similar to the one reported for endometrial carcinoma. Therefore, lymphadenectomy is mandatory for staging purposes. Regarding its impact on survival, the majority of studies confirm a significant survival benefit. The possible mechanisms for the improvement of survival from lymphadenectomy include removal of micro-metastatic foci, reduction of recurrence risk (removal of “target tissue”) and mechanical circumvallate of the disease. Given that 5–38% of the patients will experience local recurrence and 30–83% distant metastases, lymphadenectomy reduces the risk of the first and identifies patients in advanced stage that may benefit from adjuvant chemotherapy, aiming to reduce the second and ultimately improve overall survival.

Conclusions

Our review data fully justifies the rationale of lymphadenectomy, which beyond staging information seems to offer a measurable survival benefit.

Keywords

Carcinosarcoma Mixed mullerian tumour Lymphadenectomy Survival 

Notes

Conflict of interest

The authors declare that no conflict of interest exists.

References

  1. 1.
    Yamada SD, Burger RA, Brewster WR, Anton D, Kohler MF, Monk BJ (2000) Pathologic variables and adjuvant therapy as predictors of recurrence and survival for patients with surgically evaluated carcinosarcoma of the uterus. Cancer 88(12):2782–2786CrossRefPubMedGoogle Scholar
  2. 2.
    Arrastia CD, Fruchter RG, Clark M, Maiman M, Remy JC, Macasaet M, Gates EJ, Di Maio T, Marzec T (1997) Uterine carcinosarcomas: incidence and trends in management and survival. Gynecol Oncol 65(1):158–163CrossRefPubMedGoogle Scholar
  3. 3.
    Nordal RR, Thoresen SO (1997) Uterine sarcomas in Norway 1956–1992: incidence, survival and mortality. Eur J Cancer 33(6):907–911CrossRefPubMedGoogle Scholar
  4. 4.
    Dinh TV, Slavin RE, Bhagavan BS, Hannigan EV, Tiamson EM, Yandell RB (1989) Mixed müllerian tumors of the uterus: a clinicopathologic study. Obstet Gynecol 74(3 Pt 1):388–392PubMedGoogle Scholar
  5. 5.
    Kahanpää KV, Wahlström T, Gröhn P, Heinonen E, Nieminen U, Widholm O (1986) Sarcomas of the uterus: a clinicopathologic study of 119 patients. Obstet Gynecol 67(3):417–424PubMedGoogle Scholar
  6. 6.
    Schweizer W, Demopoulos R, Beller U, Dubin N (1990) Prognostic factors for malignant mixed müllerian tumors of the uterus. Int J Gynecol Pathol 9(2):129–136CrossRefPubMedGoogle Scholar
  7. 7.
    Callister M, Ramondetta LM, Jhingran A, Burke TW, Eifel PJ (2004) Malignant mixed Müllerian tumors of the uterus: analysis of patterns of failure, prognostic factors, and treatment outcome. Int J Radiat Oncol Biol Phys 58(3):786–796PubMedGoogle Scholar
  8. 8.
    Galaal K, Kew FM, Tam KF, Lopes A, Meirovitz M, Naik R, Godfrey KA, Hatem MH, Edmondson RJ (2009) Evaluation of prognostic factors and treatment outcomes in uterine carcinosarcoma. Eur J Obstet Gynecol Reprod Biol 143(2):88–92 Epub 2009 Feb 7CrossRefPubMedGoogle Scholar
  9. 9.
    Nemani D, Mitra N, Guo M, Lin L (2008) Assessing the effects of lymphadenectomy and radiation therapy in patients with uterine carcinosarcoma: a SEER analysis. Gynecol Oncol 111(1):82–88CrossRefPubMedGoogle Scholar
  10. 10.
    Morice P, Rodrigues A, Pautier P, Rey A, Camatte S, Atallah D, Pomel C, Lhommé C, Haie-Meder C, Duvillard P, Castaigne D (2003) Surgery for uterine sarcoma: review of the literature and recommendations for the standard surgical procedure. Gynecol Obstet Fertil 31(2):147–150CrossRefPubMedGoogle Scholar
  11. 11.
    Wright JD, Seshan VE, Shah M, Schiff PB, Burke WM, Cohen CJ, Herzog TJ (2008) The role of radiation in improving survival for early-stage carcinosarcoma and leiomyosarcoma. Am J Obstet Gynecol 199(5):536.e1–536.e8 (Epub 3 June 2008) CrossRefGoogle Scholar
  12. 12.
    Park JY, Kim DY, Kim JH, kim YT, Nam JH (2010) The role of pelvic and/or para-aortic lymphadenectomy in surgical management of apparently early stage carcinosarcoma of uterus. Ann Surg Oncol 17(3):861–868CrossRefPubMedGoogle Scholar
  13. 13.
    Winter R, Ostor A, Kapp K, Petru E (2004) Primary treatment of uterine sarcomas. In: Gershenson DM, McGuire WP, Gore M, Quinn MA, Thomas G (eds) Gynecologic cancer. Controversies in management. Elsevier, New York, pp 301–316CrossRefGoogle Scholar
  14. 14.
    Sutton G, Kavanagh J, Wolfson A, Tornos C (2005) Corpus: mesenchymal tumors. In: Hoskins WJ, Perez CA, Young RC, Barakat RR, Markman M, Randall ME (eds) Principles and practice of gynecologic oncology, 4th edn. Lippincott, Philadelphia, pp 873–894Google Scholar
  15. 15.
    Hacker NF (2005) Uterine cancer. In: Berek JS, Hacker NF (eds) Practical gynecologic oncology, 4th edn. Lippincott, Philadelphia, pp 397–442Google Scholar
  16. 16.
    Hacker NF, Marsden DE (2006) Surgery for uterine cancer. In: Luesley DM, Lawton FG, Berchuck A (eds) Uterine cancer. Taylor & Francis, London, pp 142–144Google Scholar
  17. 17.
    Kitchener HC, Trimble EL (2009) Endometrial cancer state of the art meeting. Int J Gynecol Cancer 19(1):134–140PubMedGoogle Scholar
  18. 18.
    Iwasa Y, Haga H, Konishi I, Kobashi Y, Higuchi K, Katsuyama E, Minamiguchi S, Yamabe H (1998) Prognostic factors in uterine carcinosarcoma: a clinicopathologic study of 25 patients. Cancer 82(3):512–519CrossRefPubMedGoogle Scholar
  19. 19.
    McCluggage WG (2002) Uterine carcinosarcomas (malignant mixed Mullerian tumors) are metaplastic carcinomas. Int J Gynecol Cancer 12(6):687–690CrossRefPubMedGoogle Scholar
  20. 20.
    McCluggage WG (2002) Recent advances in immunohistochemistry in gynaecological pathology. Histopathology 40(4):309–326CrossRefPubMedGoogle Scholar
  21. 21.
    Brown L (2008) Pathology of uterine malignancies. Clin Oncol (R Coll Radiol) 20(6):433–447 Epub 2008 May 21Google Scholar
  22. 22.
    Kernochan LE, Garcia RL (2009) Carcinosarcomas (malignant mixed Müllerian tumor) of the uterus: advances in elucidation of biologic and clinical characteristics. J Natl Compr Canc Netw 7(5):550–556PubMedGoogle Scholar
  23. 23.
    Nola M, Babić D, Ilić J, Marusić M, Uzarević B, Petrovecki M, Sabioncello A, Kovac D, Jukić S (1996) Prognostic parameters for survival of patients with malignant mesenchymal tumors of the uterus. Cancer 78(12):2543–2550CrossRefPubMedGoogle Scholar
  24. 24.
    Amant F, Cadron I, Fuso L, Berteloot P, de Jonge E, Jacomen G, Van Robaeys J, Neven P, Moerman P, Vergote I (2005) Endometrial carcinosarcomas have a different prognosis and pattern of spread compared to high-risk epithelial endometrial cancer. Gynecol Oncol 98(2):274–280CrossRefPubMedGoogle Scholar
  25. 25.
    Rovirosa A, Ascaso C, Ordi J, Abellana R, Arenas M, Lejarcegui JA, Pahisa J, Puig-Tintoré LM, Mellado B, Armenteros B, Iglesias X, Biete A (2002) Is vascular and lymphatic space invasion a main prognostic factor in uterine neoplasms with a sarcomatous component? A retrospective study of prognostic factors of 60 patients stratified by stages. Int J Radiat Oncol Biol Phys 52(5):1320–1329CrossRefPubMedGoogle Scholar
  26. 26.
    Benito V, Lubrano A, Arencibia O, Andújar M, Alvarez E, Medina N, Falcón JM, Falcón O (2009) Clinicopathologic analysis of uterine sarcomas from a single institution in the Canary Islands. Int J Gynaecol Obstet (Epub ahead of print)Google Scholar
  27. 27.
    Park JY, Kim DY, Suh DS, Kim JH, Kim YM, Kim YT, Nam JH (2008) Prognostic factors and treatment outcomes of patients with uterine sarcoma: analysis of 127 patients at a single institution, 1989–2007. J Cancer Res Clin Oncol 134(12):1277–1287 Epub 2008 May 28CrossRefPubMedGoogle Scholar
  28. 28.
    Kokawa K, Nishiyama K, Ikeuchi M, Ihara Y, Akamatsu N, Enomoto T, Ishiko O, Motoyama S, Fujii S, Umesaki N (2006) Clinical outcomes of uterine sarcomas: results from 14 years worth of experience in the Kinki district in Japan (1990–2003). Int J Gynecol Cancer 16(3):1358–1363CrossRefPubMedGoogle Scholar
  29. 29.
    Wu TI, Hsu KH, Huang HJ, Hsueh S, Chou HH, Tsai CS, Ho KC, Chao A, Chang TC, Lai CH (2008) Prognostic factors and adjuvant therapy in uterine carcinosarcoma. Eur J Gynaecol Oncol 29(5):483–488PubMedGoogle Scholar
  30. 30.
    Nordal RR, Kristensen GB, Stenwig AE, Nesland JM, Pettersen EO, Trope CG (1997) An evaluation of prognostic factors in uterine carcinosarcoma. Gynecol Oncol 67(3):316–321CrossRefPubMedGoogle Scholar
  31. 31.
    Yalman D, Ozsaran Z, Baltalarli B, Demir O, Ozdemir N, Aras A (2008) Results of postoperative radiotherapy in the treatment of uterine sarcomas: a retrospective analysis of 46 patients. Eur J Gynaecol Oncol 29(1):46–51PubMedGoogle Scholar
  32. 32.
    El Husseiny G, Al Bareedy N, Mourad WA, Mohamed G, Shoukri M, Subhi J, Ezzat A (2002) Prognostic factors and treatment modalities in uterine sarcoma. Am J Clin Oncol 25(3):256–260CrossRefPubMedGoogle Scholar
  33. 33.
    Inthasorn P, Carter J, Valmadre S, Beale P, Russell P, Dalrymple C (2002) Analysis of clinicopathologic factors in malignant mixed Müllerian tumors of the uterine corpus. Int J Gynecol Cancer 12(4):348–353CrossRefPubMedGoogle Scholar
  34. 34.
    Ozguroglu M, Bilici A, Ilvan S, Turna H, Atalay B, Mandel N, Sahinler I (2008) Determining predominating histologic component in malignant mixed Müllerian tumors: is it worth it? Int J Gynecol Cancer 18(4):809–812 Epub 2007 Sep 24CrossRefPubMedGoogle Scholar
  35. 35.
    Leath CA 3rd, Numnum TM, Kendrick JE 4th, Frederick PJ, Rocconi RP, Conner MG, Straughn JM Jr (2009) Patterns of failure for conservatively managed surgical stage I uterine carcinosarcoma: implications for adjuvant therapy. Int J Gynecol Cancer 19(5):888–891Google Scholar
  36. 36.
    Gadducci A, Cosio S, Romanini A, Genazzani AR (2008) The management of patients with uterine sarcoma: a debated clinical challenge. Crit Rev Oncol Hematol 65(2):129–142 Epub 2007 Aug 13. ReviewCrossRefPubMedGoogle Scholar
  37. 37.
    Major FJ, Blessing JA, Silverberg SG, Morrow CP, Creasman WT, Currie JL, Yordan E, Brady MF (1993) Prognostic factors in early-stage uterine sarcoma. A Gynecologic Oncology Group study. Cancer 71(4 Suppl):1702–1709PubMedGoogle Scholar
  38. 38.
    Creasman WT, Odicino F, Maisonneuve P, Quinn MA, Beller U, Benedet JL, Heintz AP, Ngan HY, Pecorelli S (2006) Carcinoma of the corpus uteri. FIGO 6th annual report on the results of treatment in gynecological cancer. Int J Gynaecol Obstet 95(Suppl 1):S105–S143CrossRefPubMedGoogle Scholar
  39. 39.
    Ayhan A, Tuncer ZS, Tanir M, Yüce K, Ayhan A (1997) Uterine sarcoma: the Hacettepe hospital experience of 88 consecutive patients. Eur J Gynaecol Oncol 18(2):146–148PubMedGoogle Scholar
  40. 40.
    Temkin SM, Hellmann M, Lee YC, Abulafia O (2007) Early-stage carcinosarcoma of the uterus: the significance of lymph node count. Int J Gynecol Cancer 17(1):215–219CrossRefPubMedGoogle Scholar
  41. 41.
    Akahira J, Tokunaga H, Toyoshima M, Takano T, Nagase S, Yoshinaga K, Tase T, Wada Y, Ito K, Niikura H, Yamada H, Sato A, Sasano H, Yaegashi N (2006) Prognoses and prognostic factors of carcinosarcoma, endometrial stromal sarcoma and uterine leiomyosarcoma: a comparison with uterine endometrial adenocarcinoma. Oncology 71(5–6):333–340 Epub 2007 Aug 9CrossRefPubMedGoogle Scholar
  42. 42.
    Sagae S, Yamashita K, Ishioka S, Nishioka Y, Terasawa K, Mori M, Yamashiro K, Kanemoto T, Kudo R (2004) Preoperative diagnosis and treatment results in 106 patients with uterine sarcoma in Hokkaido, Japan. Oncology 67(1):33–39CrossRefPubMedGoogle Scholar
  43. 43.
    Manolitsas TP, Wain GV, Williams KE, Freidlander M, Hacker NF (2001) Multimodality therapy for patients with clinical Stage I and II malignant mixed Müllerian tumors of the uterus. Cancer 91(8):1437–1443CrossRefPubMedGoogle Scholar
  44. 44.
    Reed NS, Mangioni C, Malmström H, Scarfone G, Poveda A, Pecorelli S, Tateo S, Franchi M, Jobsen JJ, Coens C, Teodorovic I, Vergote I, Vermorken JB (2008) European Organisation for Research and Treatment of Cancer Gynaecological Cancer Group. Phase III randomised study to evaluate the role of adjuvant pelvic radiotherapy in the treatment of uterine sarcomas stages I and II: an European Organisation for Research and Treatment of Cancer Gynaecological Cancer Group Study (protocol 55874). Eur J Cancer 44(6):808–18 (Epub 2008 Apr 2). Erratum in: Eur J Cancer. 2008 Jul; 44(11):1612Google Scholar
  45. 45.
    Gerszten K, Faul C, Kounelis S, Huang Q, Kelley J, Jones MW (1998) The impact of adjuvant radiotherapy on carcinosarcoma of the uterus. Gynecol Oncol 68(1):8–13CrossRefPubMedGoogle Scholar
  46. 46.
    Shimizu S, Yajima M, Yoshii A, Nishikawa T, Ohta H (2009) Malignant pericardial effusion and cardiac tamponade originating from uterine carcinosarcoma. Arch Gynecol Obstet 279(3):373–375 Epub 2008 Jun 12CrossRefPubMedGoogle Scholar
  47. 47.
    Yoney A, Eren B, Eskici S, Salman A, Unsal M (2008) Retrospective analysis of 105 cases with uterine sarcoma. Bull Cancer 95(3):E10–17Google Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  1. 1.Department of GynaecologyMetaxa Memorial Cancer HospitalPiraeusGreece
  2. 2.Department of Obstetrics and GynaecologyUniversity of Athens School of Medicine, Aretaieion HospitalAthensGreece

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