Diapositiva 1

1
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Sarcomi Uterini Chirurgia
M Franchi G Roviglione, Silvia Giudici
2
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Introduction
Personal experience
Technical Aspects
Conclusions
3
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Gynecological sarcomas should be treated as
sarcomas and not as Carcinomas
Sleijfer et al 2007492-6
4
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Primary treatment of uterine mesenchymal tumors
consists of surgical excision. Total abdominal
hysterectomy and bilateral salpingo-oophorectomy
represent the standard surgical procedure. In
premenopausal patients with low grade of LMS the
ovaries can be preserved.
Donadello N, Bergamini V, Franchi M. 2004
The only treatment of any proven curative value
for the frankly malignant uterine sarcomas is
surgical excision. Although in young patients
it may be resonable to preserve the ovaries.
Berek JS, Hacker NF. 2005
5
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
105 cases with uterine sarcomas 1995-2003
tahbso vs subopt Median Os 73.2vs15.5mths p.015
Yoney et al Bull Cancer 2008
6
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Endometrial stromal sarcoma
7
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Endometrial stromal sarcoma
Primary surgery Total Hysterectomy Bilateral
salpingo-oophorectomy Lymphadenectomy
Restaging
Surgery of recurrences
Fertility-sparing surgery
8
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
ESS (Low grade) confined to the uterus I-II
stage BSO
Progestins (GnRH analogs, aromatase inhibitors)
not defined value in adjuvant setting in LGESS
(Li et al OG 2005)
Progestins (GnRH analogs, aromatase inhibitors)
cause regression/stabilization of
recurrent LGESS (Gadducci et al CROH 2008)
Wide variation of recurrences if retained ovaries
(0-100) only 3-7 pts, inclusion of HG, age,
stg (Young et al Cancer 1984, Chang et al AJSP
1990, Mansiet al GO 1990, Li et al GO 2008)
Expression of ER/PR in LGESS suggests hormonal
responsiveness (Chu et al Go 2003)
Raccomandations to perform BSO (Berchuck et al
GO 1990, Li et al GO 2008)
Data in other hormonally responsive gyn cancers
(Morice et al Hum Rep 2005)
No in vitro studies have confirmed the hormonal
induced proliferation in LG (Li et al OG 2005)
BSO do not affect Survival
BSO improve Survival
9
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
ESS (Low grade) confined to the uterus I-II
stage BSO
Multicenter case control study (1976-2002)
Case control study
No differences in pattern of recurrence in pts
with no BSO no disease recurred in the ovaries
Li et al Obstet Gynecol 2005
10
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
ESS (Low grade) confined to the uterus I-II
stage BSO
The study has 13 power to detect the observed
difference in median DFS
Li et al Obstet Gynecol 2005
11
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
ESS (Low grade) confined to the uterus I-II
stage BSO
12 pts Ist Stage LGESS younger than 50 years
with TAH
Recurrent disease
33.3 with BSO
16.7 without BSO
12
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
ESS (Low grade) confined to the uterus I-II
stage BSO
18 pts I-IIst Stage LGESS Premenopausal with TAH
Recurrent disease
25 with BSO
17 without BSO
Results do not differ when postmenopausal
pts were included
13
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - PoliclinicoGB Rossi ,Verona
ESS Bilateral Salpingo-oophorectomy
Removal of the ovaries should be systematically
included in primary surgery of HGESS
Young women may be canditate to ovarian
preservation after an incidental finding of LGSS
at hysterectomy for benign indications
Decision to perform BSO should be discussed with
the patient and taken on an individual basis
14
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Early ESS and nodal metastases
LGESS Strong tendency for lymphatic invasion
(designation as endolymphatic stromal myosis)
ESS tendency to recur at different site Chang et
al AJSP 1990, Gadducci et al GO 1996, Amant et al
BJC 2007
33 (5/15) nodal metastases at some point in
their evolution (Riopel et al GO 2005)
Raccomandation to perform lymphadenectomy Reich
et al GO 2005
Only 3 (1/31) of retroperitoneal
recurrences Amant et al BJC 2007
Benefit of more accurate staging
2/3 ESS with node negative after RH had distant
mts at 12/36 mths (Li et al GO 2008)
No Benefit of lymphadenectomy
Benefit of lymphadenectomy
15
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - PoliclinicoGB Rossi ,Verona
ESS and nodal metastases
1972-2004 LG/HGESS 72/31 pts (36 pts had
lymphadenectomy all stages)
Positive pelvic nodes LGESS 9 Positive pelvic
nodes HGESS18
Positive aortic nodes LGESS 0 Positive aortic
nodes HGESS15
p.044
p.012
16
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
ESS and nodal metastases
17
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
ESS and nodal metastases
1972-2003 LG/HGESS 19/9 pts (13 pts had complete
lymphadenectomy all stages)
Geller et al Gynecol Oncol 2004
18
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Early ESS lymphadenectomy
Decision to perform lymphadenectomy should be
discussed with the patient and taken on an
individual basis
19
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
ESS and restaging
For pts with LGESS approaching menopause BSO is
of less concern
These pts may not need additional BSO if was not
performed during primary hysterectomy
Lymph node sampling is rarely performed,
because ESS is often diagnosed as benign
condiction
The prognostic significance of nodal mts in LGESS
is still unknow Gadducci et al Cr Rew Oncol
Hematol 2008
Li et al ObsGyn 2005 Gadducci et al Cr Rew
Oncol Hematol 2008 Li et al Gynecol Oncol 2008
20
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
ESS advanced/recurrent
Surgery was the most common option for salvage
therapy Li et al Gynecol Oncol 2008
Rationale of secondary and tertiary debulking
surgery Amant et al BJC 2007
Rationale of performing secondary debulking
surgery if primary surgery was suboptimal Yoney
et al Bull Cancer 2008
21
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
48 pts 1976-1985 71 Ist stage 46 pts TAH and BSO
22
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
ESS outside the uterus (HGESS stage III-IV)
Five Institutions 1972-2004 HGESS 31 pts (Opt
did not correlate with 82.1 of 72 pts alive at
78 mths)
p.007 (HR4.1, 95 CI 2.1-117)
Optimal Cytoreduction (Opt) Residual tumor no
greater than 2 cm in greatest diameter
25 Omentectomy, 13 Peritenectomy, 6.4
Bowel resection
Leath III CA et al Gynecol Oncol 2007
23
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
6 nulliparous pts Median age 27 (18-36
yrs) Median f-up 51 (12-84 mths) 1982-1996
Laparotomic myomectomy
3 pregnancies (37) with 2 spont deliveries
2 pts second surgical procedure Resection of
peduncolated lesion seen at Ist surg
(ESS) Resection of myoma 31 mts after Ist surgery
All alive and well, no recurrences
24
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Clinical case
27 yr nulliparous woman with 2 years history of
AUB Operative hysteroscopy for submucosal myoma
of 5 cm with diagnosis of LGESS
Myomectomy with opening of uterine cavity LGESS
5-7 mitosis x10HPF 3 mm free margins
CS after 24 months neg washing and uterine
biopsies Repeated CS after 27 mts, post partum
haemorrhage TAH, surgical specimen negative for
ESS
Alive and well 13 yrs after diagnosis
25
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
4 patients with pregnancy (4 term deliveveries
2CS, 1miscarriage) after myomectomy for
ESS (1973 - 1997)
24 yo HGESS rec 66 mts TAH, died dd 10yrs after
diagnosis 27 yo LGESS Chemo, rec 29 mts TAH, AWD
32 mts after diagnosis
HGESS Possible residual ESS in hysterectomy
specimen
ESS Possible conservative surg
Tumor completely resected free margins gt2mm
Strongly desires fertility Accepts risk of
recurrence-related mortality Attends close f-up
procedures Accepts radical surgery after
reproduction
Additional Surgery recommended
Mansi et al Gyn Onc 1990 Lissoni et al IJGC
1997 Franchi et al 2008 unpublished
26
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Leiomyosarcoma LMS
27
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Leiomyosarcoma LMS
Surgery after Primary operation for Myoma/AUB
Lymphadenectomy Early/advanced cases
BSO More/less 50 yr
Hysterectomy Fertility-sparing surgery
Surgery of Advanced Cases/Recurrences
28
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
LMS stage I-II
Postmenopausal women or Age gt 50
TAH (stage I) / RadHyst (stage II) Bilateral
Salpingo-oophoporectomy
More radical initial surgery is controversial
Peters et al Obstet Gynecol 1984 Benoit et al
EJSO 2005 Gadducci et al Crit Rev in Onc/Hem 2008
29
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Early LMS less than 50yo BSO
Preservation of ovaries does not apper to affect
outcome Gadducci ed al Cr Rew Onc/Hem 2008
Case reports of regression of LMS after
oophorectomy, Abu-Rustum et al OG 1997
No apparent difference in recurrence in pts with
retained ovaries Leitao et al GO 2003
Risk of about 3 of microscopic metastasis Major
et al Cancer 1993, Leitao et al GO 2003
No Benefit of BSO
Benefit with BSO
30
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e GeneticaUniversità degli
Studi - Policlinico GB Rossi ,Verona
Two cases with complete regression after
oophorectomy and no further therapy
Oophorectomy in pts with retained ovarian
function may play a role in primary therapy after
confirmation of diagnosis with the least invasive
technique
Abu-Rustum et al Obstet Gynecol 1997
31
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Early LMS ovarian metastases
Early LMS Peritoneal positive cytology
32
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
(1976-1999)
77 power to detect a 50 difference in outcome
33
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
LMS Salpingo-oophorectomy
Stage I-II (lt50 yrs) Surveillance, Epidemiology,
and End Results data base 1988-2003
5-year DSS 83.2 vs 83.2 p0.445
Kapp et al Cancer 2008
34
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
LMS Salpingo-oophorectomy
Removal of the ovaries should be systematically
included in primary surgery of LMS more than 50
years
Pts less than 50years may be canditate to ovarian
preservation (macroscopically uninvolved) after
an incidental finding of LMS at
myomectomy/hysterectomy for benign indications
35
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e GeneticaUniversità degli
Studi - Policlinico GB Rossi ,Verona
Early LMS less than 50yo BSO
Decision to perform BSO should be discussed with
the patient
36
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Early LMS lymphadenectomy
Less 1 of pos nodes from larger studies (gt20
pts) Major et al Cancer 1993, Leitao et al GO
2003, Kapp et al Cancer 2008
Better OS for negative node pts (not corrected
for stage) Kapp et al Cancer 2008
Very rare retroperitoneal recurrences Gadducci ed
al Cr Rew Onc/Hem 2008
Recomandation to perform lymphadenectomy not
specific for LMS (Abd-Alla H et al JENCI 2000)
About 40 early LMS with node negative had
distant failure (Goff et al GO 1996)
Benefit of more accurate staging
No Benefit of lymphadenectomy
Benefit of lymphadenectomy
37
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Early LMS Incidence of lymph-nodal metastases
38
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
N

39
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e GeneticaUniversità degli
Studi - Policlinico GB Rossi ,Verona
Early LMS lymphadenectomy
Discussion with the patient. No Benefits of
lymphadenectomy
40
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Advanced LMS lymphadenectomy
High incidence of pos nodes Leitao et al GO
2003, Kapp et al Cancer 2008
Very rare retroperitoneal recurrences Gadducci ed
al Cr Rew Onc/Hem 2008
Better OS for negative node pts (not corrected
for stage) Kapp et al Cancer 2008
About 40 early LMS with node negative had
distant failure (Goff et al GO 1996)
Benefit of more accurate staging
No Benefit of lymphadenectomy
Benefit of lymphadenectomy
41
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Advanced LMS Incidence of lymph-nodal metastases
42
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Advanced LMS Lymphadenectomy
1988-2003 Data abstracted from the Surveillance
, Epidemiology and End Results database


Neg nodes more OS vs pos nodes (plt.001) 2 pos
nodes less OS vs 1 pos node (p.001)
70 of pts with nodal mts had IV stage
43
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Advanced LMS lymphadenectomy
Decision to perform lymphadenectomy should be
discussed only in selected cases with the
patient and taken on an individual basis
44
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
27 pts
Optimal surgical cytoreduction (16 pts) (no
visible disease)
plt0.003
Subptimal surgical cytoreduction (9 pts)
TAH BSO 27 (100) Bowel resection 7
(26) Omentectomy 3 (11) Pelvic node
dissection 8 (30)
Dinh et al Gyn Onc 2004
45
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
1991-2001 (median f-up 25 mts 2-110) 41pts LMS
submitted to Secondary Cytoreduction
Optimal largest residual tumor 1cm

P.005
P.002
OS after SCS comparing time from PCS to first
recurrence (more or less than 12 mts)
OS after SCS comparing the extent of surgical
resection

OS similar to pts not submitted to surgery
46
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
1976-1999 120 pts with recurrent uterine LMS
(median f-up 3.2 yr 0.3-33.9 yrs) 80 pts LMS
submitted to Secondary Cytoreduction
64 pts (80) No residual disease
Residual Disease (site of resection) 6
Residual Not stated 3
Local no Residual Disease (tumor in another site)
11
No data reported on complications
47
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
1976-1999 120 pts with recurrent uterine LMS
(median f-up 0.3-33.9 yrs) 80 pts LMS submitted
to Secondary Cytoreduction
48
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
26 pts 1982-1996 34 hepatic resections for
metastatic LMS (23 first, 9 second, 2 third)
Surgery gives better survival than
chemoembolization or chemotherapy
First Resections (23 pts)
R0 vs R1/2 NS
Only an R0 resection offers the chance of long
term OS
Median survival 32mts 5yr OS 20 for R0
Extrahepatic tumor has no influence on OS (5yr OS
33 )
Careful preop diagnostic workup can improve
curative resection rate (65)
Surgical complication rate 29 Surgical death
rate 6
49
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
8 nulliparous pts Median age 29 (19-32
yrs) Median f-up 42 (11-92 mths) 1982-1996
Laparotomic myomectomy
3 pregnancies (37) with 2 deliveries
21yo, 8cm fundic LMS (10 mitosis x10HPF) local
recurrence at 14 mts during CS TAHBSOChemo
Death after 26 mts, dd.
50
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
13 patients with pregnancy after myomectomy for
LMS (1950 and 2007)
32 yo (4 mitosis x10HPF) recurrence 24 mts 21yo
(10 mitosis x10HPF) recurrence at 14 mts
High-grade LMS Possible residual LMS in
hysterectomy specimen
LMS Possible conservative surg
Strongly desires fertility Accepts risk of
recurrence-related mortality Attends close f-up
procedures Accepts radical surgery after
reproduction
Additional Surgery recommended
Davis AM AJOG 1952 Aaro et al AJOG 1966 Van
DinhWoodruff AJOG 1982 Berchuck et al Obs Gyn
1988
Hannigan, Gyn Onc 1992 Bell, Am Surg Pathol
1994 Lissoni et al Gyn Onc 1998 Salman et al IJOG
2007
51
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Carcinosarcoma
52
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Carcinosarcoma
Exploratory laparotomy TAHBSO Peritoneal
surgical staging Peritoneal cytology Omentectomy B
iopsies of any suspicious lesion Tumour
debulking Pelvic Para-aortic Lymphadenectomy
Surgery of advanced cases
Restaging
53
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Cancer 2000882782-86
62 consecutive pts 1974-1995 Primary Surgeon
Gynecologic Oncologist 81
Cases with tumor clinically I/II stage
Pelvic lymphadenectomy 89 Aortic lymphadenectomy
42
61 Disease outside the uterus after surgical
staging
54
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Early carcinosarcoma lymphadenectomy
Prognostic significance at mv analysis Major et
al (GOG) Cancer 1993
Morbidity related to age overweight hypertension
(Franchi et al AJS 2001, Inthasorn et al IJGC
2002)
About 15-20 of pts have nodal Metastasis
(Sartori et al GO 1997)
About 6 of pts had first failure in the
paraortic nodes Callister et al IJROBP 2004
No Benefit of lymphadenectomy
Benefit of lymphadenectomy
55
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e GeneticaUniversità degli
Studi - Policlinico GB Rossi ,Verona
1991-2000 206 consecutive pts 133 had
lymphadenectomy median nodes removed 19 (9-74)
A higher rate of complications was observed when
14 nodes were removed
56
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
236 MMT Submitted to lymphadenectomy 1979-1988
Two deaths due to surgical complications
pulmonary emboli Two related surgical deaths
(post op RT) pulmonary embolus, sepsis from
necrotic bowel
Cancer 1993711702-9
57
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
47 pts 1980-2005 mean f-up 41 mts
TAH BSO, pelvic washing pelvic and paraortic
lymph node sampling /- omental biopsy
Mean Pelvic/Aortic nodes removed 11.5 9.7
(1-34)
DFS p0.044
OS p0.024
DFS p0.044
OS p0.024
Kaplan-Meyer Analisys gt 11 nodes only factor
related DFS/OS P.001
Including a visual inspection of the nodes
removal of any and suspicious node Performed
at the discretion of the surgeon
58
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
301 MMT 1979-1988
Lymph node involvement 51/287 (17.7) Adnexal
involvement 36/300 (12.0) Positive peritoneal
cytology 63/284 (22.2)
Positive nodes Pelvic 15 Aortic 7.8
Pts with PPC had 44 pos nodes
Cancer 1993711702-9
59
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
301 MMT 1979-1988
PFI by adnxal and node metastases
Cancer 1993711702-9
60
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Lymphadenectomy
1980-1994 118 pts
Lymphadenectomy 46 pts Total Positive nodes 15.2
(PN 10.9 AoN 4.3)
Lymphadenectomy I-II Total Positive nodes 13.2
61
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
1953-1998 300 pts 273 pts submitted to Primary
Surgery
Recurrences among 300 pts
62
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Early carcinosarcoma lymphadenectomy
Selective aortic and pelvic lymphadenectomy may
be useful in determining the need of post
op-therapy. It is a procedure that can be done
without significant morbidity by trained
surgeons on propely selected pts
63
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Carcinosarcoma Surgery for advanced disease
1988-2000 37 pts stage III-IV 49
plt0.0000
Lymphadenectomy 20pts 35 positive Omentectomy
9pts 33 positive Cytology 16pts 19
positive Residual Tumor 75 NED
Multivariate analysis Only stage predictive of
Overall Survival P.034
Silasi et al IJGC 1993
64
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Carcinosarcoma Restaging
Hystérectomie sub-totale ou totale
Une chirurgie de complément doit theoriquement
être réalisé. Cette chirurgie doit comporter une
omentectomie et une lymphadénectomie.
65
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Overall surgical management 1. Techinical aspects
66
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Overall surgical management 1. Techinical aspects
Gynecologist must take caution when attempting to
sound the uterus
Useful the sonography to guide intraoperatively th
e surgeon into the uterine cavity
67
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
2. Techinical aspects
Uetrine sarcomas surgical aspects
Gynecologist must take caution when managing
intraoperatively the uterus
68
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
3. Techinical aspects
To consider the surgical challenge when sarcomas
are as plypoid masses that dilate and balloon out
the cervix and lower uterine segment
Dissection of the parametria must be performed in
a more radical manner if complete removal of the
uterus is to be accomplished
May mean tumor extruded into the peritoneal
cavity
Portion of the tumor-laden cervix left behiind
Failure to do so
Virtually assuring an abdominal or vaginal
recurrence
69
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Creasman T. Ch 47 p 1445-86 2003
70
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Creasman T. Ch 47 p 1445-86 2003
71
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Recurrence of Uterine Sarcomas
Cancer 2000881425-31
1976-1995 157 pts
72
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Sensitivity 92.9 Specificity 100 Accuracy
94.4 PPV100 NPV80
1976-1999 18 pts submitted to PET-PET/CT with
suspected recurrence at TC Median age 48 (30-61)
F
73
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
1985-2001 70 pts 31 (44) cases uterine
sarcomas Median mts resected 2 (1-19) median
f-up 36 mts (6-156)
Clavero et al 2006 812004-7
Initial Pulmonary Resection Wedge excision 44
pts Lobectomy14 pts Bilobectomy 2 pts Pneumectomy
1 Combination of resctions 9 pts Incomplete
resection 7 (16 pts had secondary Gyn procedure)
Mortality 1.4
74
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Conclusions 1
For early stages hysterectomy is the mainstay of
the tretment Resection of ovaries/l nodes
(ESSLMS) as standard procedures is not justified
For early stages of MMT an intraperitoneal
surgical staging with pelvic and aortic
lymphadenectomy can be done by trained surgeons
For adv/recurrent pts primary/secondary
cytoreduction/metastasectomy with no residual
tumor (or gt1-2 cm) )may be effective in selected
cases (interval from primary surgery more than 6
months)
Fertility-sparing surgery is feasible in selected
pts (ESSLMS) desiring pregnancy
75
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Conclusion 2
Sarcomas sholuld be surgically treated as
sarcoma and not carcinoma
Gruppo Italiano per lo Studio e Cura dei
Sarcomi Ginecologici
76
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Conclusions 3
The surgical treatment of these pts should be a
multidisciplinary approach Gynecological
Oncologist, General/Thoracic Surgeon, Urologist
with the Clinical Pathologist
In view of their rarity the management must be
undertaken by Physicians experienced in these
malignancies
77
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
Conclusions 4
78
Sez Ginecologia e Ostetricia Dip. Materno
Infantile Biologia e Genetica Università degli
Studi - Policlinico GB Rossi ,Verona
The end