UTERINE SARCOMA ESMO Summit Africa 2018 Dr Thobile Goba-Mjwara - - PowerPoint PPT Presentation

UTERINE SARCOMA

ESMO Summit Africa 2018 Dr Thobile Goba-Mjwara Prof Hannah Simonds

I have nothing to declare.

Introduction

• Uterine sarcomas are malignant mesenchymal

tumours that include leiomyosarcoma (LMS), endometrial stromal sarcomas (ESS)and undifferentiated uterine sarcomas (UUS).

• Accounts for 3-9% of all uterine malignant

neoplasms.

• Compared to the more common endometrial

carcinomas, uterine sarcomas, particularly LMS, behave aggressively and are associated with a poorer prognosis.

Classification of uterine sarcomas

• 1. Stromal:
• ESS
• LMS
• UUS
• 2. Mixed epithelial-stromal neoplasms:
• Adenosarcomas are considered as sarcomas.
• Uterine Carcinosarcoma is now classified as a

carcinoma rather than a sarcomas though they have stromal differentiation.

Case presentation

• Mrs AB, 57yrs
• Symptoms:

Post menopausal bleeding refractory to cyclokapron with associated lower abdominal pain for 4/12. Past medical history: HIV -ve, Asthmatic on treatment.

• Gynae history: P3G3,

menarche 16yrs, menopause 46yrs, no previous pap smears.

• Family history: nil
• Past surgical history:

BTL 40yrs

• Social history: smokes

4 cigarettes per day, no alcohol history, good family support.

Clinical examination

Pre-op examination: ECOG PS1

Unremarkable general examination Thyroid and breast examination normal Chest: clear breath sounds Abdomen: soft, 14/40 weeks size uterus, no adnexal masses. Vulva and perineum normal Cervix normal with PVB PR: normal rectal mucosa, no masses palpated.

Investigations

Pipelle biopsy 30/10/17: IHC profile compatible with part of a

• carcinosarcoma. Positive p16 & p57 favours a serous epithelial

component while the focal myogenin positivity confirms heterologous rhabdomyoplastic differentiation in the sarcomatous component. Labs 21/11/17: Normal FBC,U&E and LFT LDH 259, AFP 2.9, BHCG 2 , CEA 5.3 CXR 20/11/17: Normal, no metastasis noted. Abdominal U/S 21/11/17: Normal liver and kidneys, no metastasis noted. Pelvic U/S 15/11/17- Enlarged uterus with a heterogeneous compressible structure of 64x51x69mm in size. Ovaries not visualized.

Histology

TAH, BSO, PLND+Omentectomy 22/12/2017: Carcinosarcoma with heterologous differentiation (Rhabdoid), High grade. 80% sarcoma: 20% carcinoma >50% myometrium involved LVI present Cervix, adnexa, omentum not involved No nodes involved- 0/31

Questions

• 1. Does the percentage of sarcomatous elements

influence treatment?

• 2. Is there a role for chemotherapy in view of the

histology of the “Rhabdoid” heterologous differentiation , 80% sarcoma: 20% carcinoma ?

• 3. If the histology showed 100% rhabdomyosarcoma

would the patient be treated as a sarcoma?

• 4. Does the panel agree that the best adjuvant

treatment for this patient – Stage Ib G3 – is pelvic radiotherapy alone?

Planned Management

In keeping with Stage pIbG3 pn0 Carcinosarcoma. Discussed at the MDT – treat as an epithelial endometrial carcinoma. For adjuvant whole pelvic radiotherapy as per preliminary results of PORTEC 3.

THANK YOU!

Radiotherapy planning

• Technique: 3D CRT
• Data acquisition: CT scan 3mm

slices L1-5cm below the vaginal introitus with IV contrast.

• Modality: 10MV
• Position: supine, arms on the side
• Immobilization: neck rest, knee

and ankle stocks.

• Anterior and lateral tattoos marked

with radio-opaque material aligned with lasers to prevent lateral rotation.

• Bladder protocol used to maintain

a constant bladder filling.

• Prescription: 40Gy/20#, 5 days a

week.

Plan evaluation

References

• 1. NCCN Guideline Uterine neoplasms -

http://www.nccn.org/professionals/physician_gls/f_guidelines.

• 2. Uptodate
• 3. Practical Radiotherapy Planning (4th edition) – Barrett, Dobbs, Morris &

Roques