How to deal with prognostic factors and radiotherapy results in uterine neoplasms with a sarcomatous component?

Abstract

Uterine tumours with a sarcomatous component are rare neoplasms with a wide pathologic heterogeneity in which the stage is the main prognostic factor. These aspects and their aggressiveness make the analysis of prognostic factors and radiotherapy difficult. The aim of this study was to evaluate the prognostic factors by stages and to assess the impact of prognostic factors and the effect of radiotherapy on the outcome of the disease. Eighty-one patients diagnosed and treated for uterine tumours with a sarcomatous component at the Hospital Clinic in Barcelona between 1975 and 2003 were retrospectively studied; 76/81 patients underwent surgery (total hysterectomy plus bilateral salpingo-oophorectomy, and in 13/76 of these patients an additional pelvic lymphadenectomy was performed). All 76 patients were staged after pathological evaluation of the surgical specimen by FIGO classification with 54 patients being stages I-II and 27 patients stages III-IVA. Only 5 patients were clinically staged as III-IVA. Radiotherapy was administered in 21 women with early-stage tumours and in 16 with advanced neoplasms. 5/81 patients received complementary chemotherapy to the surgery and 5 patients received chemotherapy as treatment of local and distant relapse (All the patients were treated with a different chemotherapy schedule). The impact of pathologic prognostic factors and radiotherapy on specific overall survival (OS), disease-free survival (DFS), local relapse-free survival (LRFS) and distant metastasis-free survival (DMFS) were analysed by Log Rank test and Cox proportional risk models. The effect of each risk factor was studied by the hazard ratio and 95% confidence interval. An increased frequency of several adverse prognostic factors was observed in tumours with advanced stages compared to early neoplasms in deep myometrial invasion (83% vs. 27%), VLSI (75% vs. 29%), tumour size >8 cm (50% vs. 30%) and multicentricity (36% vs. 10%), and similar values were found for necrosis (79% vs. 78%) and high mitotic index (78% vs. 80%). For pathological type the frequency by advanced vs. early stages was 54% vs. 52% for carcinosarcomas, 33.5% vs. 17.5% for leiomyosarcoma, and 30.5% and 12.5% for adenosarcoma and endometrial stromal sarcoma, respectively. Univariate analysis showed that the stage was the only independent prognostic factor. Stratification by early (I-II) and advanced stages (III, IV) revealed tumour size >8 cm was the only prognostic factor significantly associated with OS, DFS, LRFS and DMFS on univariate analysis for early stages (HR: OS 2.52, DFS 3.10, LRFS 3.10 and DMFS 2.63). For advanced stages, radiotherapy was the only prognostic factor associated with OS, DFS, LRFS and DMFS on multivariate analysis (HR: OS 4.26, DFS 3.14, LRFS 3.25 and DMFS 3.66). Uterine tumours with a sarcomatous component have a poor outcome in spite of treatment in comparison to endometrial carcinoma, probably due to the higher frequency of adverse prognostic factors. In early stages tumour size was the most determining factor for OS, DFS, LRFS and DMFS. Radiotherapy significantly improved these survivals in advanced cases.