adjuvant therapy in uterine sarcomas
TRANSCRIPT
ADJUVANT THERAPY IN
UTERINE SARCOMAS
Dr. T. SujitA M O ( Radiation Oncology )Valavadi Narayanaswami Cancer Centre,G.Kuppuswamy Naidu MemorialHospital,Coimbatore - 641037, Tamilnadu, India
May 2007
PROGNOSTIC FACTORS
• LEIOMYOSARCOMAS
– Mitotic index : 10 -20 / ten HPF 61 % failure rate
> 20 / ten HPF 79 % failure rate
• MALIGNANT MIXED MULLERIAN TUMORS
– Adnexal spread , Lymph node mets
– Histologic cell type ( Homologous Vs Heterologous )
– Grade
PATTERNS OF FAILURE
• LMS : Majority of the recurrence is as distant metastasis
– 28% - abdomino-pelvic recurrence
– 49% distant mets.
• Pelvic RT offers very little potential gain
• MMMT : Pelvic recurrence rates are higher compared to distant mets
– 56% pelvic recurrence
– 45% distant mets
• Implies surgery alone is not enough to achieve local control.
ADJUVANT MANAGEMENT
• Stage I & II – HGUD, LMS, Carcinosarcoma
– Pelvic RT ± Brachytherapy ± Chemotherapy
• Stage III A, III B - HGUD, LMS, Carcinosarcoma
– Pelvic RT ± Brachytherapy ± Chemotherapy
– Abdomino-pelvic RT ( except LMS )
• Stage III A & III B – ESS
– Hormone therapy ± Pelvic RT
ADJUVANT MANAGEMENT
Stage III C - HGUD, LMS, Carcinosarcoma
PALN + ve PALN - ve
Consider Pelvic RTand/or
Vaginal brachytherapyand/or
Chemotherapy
Consider whole abdominopelvic RT
( except LMS )
ChemoChest CT ± biopsy
scalene nodes
Whole abdominopelvic RT
orPelvic and para-
aortic RTor
Chemotherapy
or
- VE
+ VE
ADJUVANT MANAGEMENT
• Stage IV A – ESS, HGUD, LMS, Carcinosarcoma
– RT
and/or
– Chemotherapy
or
– Hormone therapy
• Stage IV B – ESS
– Hormone Therapy
• Stage IV B - HGUD, LMS, Carcinosarcoma
– Chemotherapy
RADIOTHERAPY
ADJUVANT RT :
~ NO RANDOMISED STUDIES
~ Some studies quote an improvement in pelvic control,
especially for carcinosarcomas .*
~ Recent trials – OS in stage I C.
~ EBRT – 50 Gy / 5 weeks.
RADICAL RT :
~ Medically inoperable patients
~ EBRT 50 Gy + Brachytherapy
Gerszten K, Faul C, Kounelis S, et al. The impact of adjuvant radiotherapy on carcinosarcoma of the uterus . Gynecol Oncol 1998 Tinkler SD, Cowie VJ. Uterine sarcomas: a review of the Edinburgh experience from 1974 to 1992. Br J Radiol 1993 Lee CM, Szabo A, Shrieve DC, et al. Frequency and effect of adjuvant radiation therapy among women with stage I endometrialadenocarcinoma. JAMA 2006;295:389-397.
E B R T
PELVIC RT
BRACHYTHERAPY
NORMAN SIMON APPLICATORS
BRACHYTHERAPY
ROTTE TWO CHANNEL APPLICATOR ( NUCLETRON )
POST – OP BRACHYTHERAPY
• VAGINAL CYLINDERS
AFTER 45 – 50 Gy EBRT:
5 -6 Gy x 3 fractions for HDR
or
15 Gy in a single fraction for LDR
CHEMOTHERAPY
• Single agent chemotherapy:– MMMT:
• Ifosfamide - 1.5 g/m2/d for 5 days• Cisplatin - cisplatin, 50 mg/m2
– LMS:• Doxorubicin ( Adriamycin ) - 50–90 mg/m2 q3wk
• Combination therapy :– MMMT:
• MAID – Mesna , Adriamycin, Ifosfamide, Dacarbazine
• Doxorubicin + DTIC• Ifosfamide + Cisplatin
– LMS• Gemcitabine + Taxanes ( Paclitaxel , Docetaxel )
HORMONE THERAPY
Response to hormonal manipulation is seen in low grade ESS
– Megestrol acetate
– Medroxyprogesterone acetate
– Tamoxifen
– GnRH analogs