Lymphadenectomy and Adjuvant Therapy Improve Survival with Uterine Carcinosarcoma: A Large Retrospective Cohort Study

Abstract

Objective: Uterine carcinosarcoma is a rare, aggressive subtype of endometrial cancer. Treatment consists of hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy (LND). The survival benefit of LND in relation to adjuvant radio- and/or chemotherapy is unclear. We evaluated the impact of LND on survival in relation to adjuvant therapy in uterine carcinosarcoma. Methods: Retrospective data on 1,140 cases were combined from the Netherlands Cancer Registry (NCR) and the nationwide network and registry of histo- and cytopathology in the Netherlands (PALGA). LND was defined as the removal of any nodes. Additionally, cases where 10 nodes or less (LND ≤10) or more than 10 nodes (LND > 10) were removed were analyzed separately. Adjuvant therapy was evaluated as radiotherapy, chemotherapy, or radiochemotherapy. Associations were analyzed by χ² test, log-rank test, and Cox regression analysis. Results: Overall survival (OS) had improved after total abdominal hysterectomy with bilateral salpingo-oophorectomy with LND > 10 (HR 0.62, 95% CI 0.47–0.83). Adjuvant therapy was related to OS with an HR of 0.64 (95% CI 0.54–0.75) for radiotherapy, an HR of 0.65 (95% CI 0.48–0.88) for chemotherapy, and an HR of 0.25 (95% CI 0.13–0.46) for radiochemotherapy. Additionally, adjuvant treatment was related to OS when lymph nodes were positive (HR 0.22, 95% CI 0.11–0.42), but not when they were negative. Conclusion: LND is related to improved survival when more than 10 nodes are removed. Adjuvant therapy improves survival when LND is omitted, or when nodes are positive.

Role of minimally invasive surgery versus open approach in patients with early-stage uterine carcinosarcomas: a retrospective multicentric study

“…Assessment of pelvic lymph node status was carried out in about 60% of overall patients; in this context, we have to acknowledge that > 75% of our patients had comorbidities, and around one-third were obese, and this could have led to spare patients pelvic lymphadenectomy to limit the operative time, and also reduce surgical morbidity since the high aggressiveness of this histological subtype strongly increases the probability that patients would require adjuvant treatment. Finally, it has been recognized that in the real-world practice, only 35–57% of patients in some gynecologic oncology centres in USA were triaged to lymphadenectomy, as summarized in the Vorgias review (Vorgias and Fotiou 2010 ); as a matter of fact, even considering the large series from the SEER database ( N = 1885 patients), and the Netherland Cancer registry ( N = 1140 patients), the “lymphadenectomy issue” still remains controversial (Nemani et al 2008 ; Versluis et al 2018 ); indeed, the SEER study concluded that lymphadenectomy is associated with improved overall survival with no benefit associated to adjuvant radiotherapy (Nemani et al 2008 ), while the Dutch study demonstrates that (1) lymphadenectomy is related to improved survival only if > 10 lymph nodes are removed, and (2) adjuvant therapy improves survival when lymphadenectomy is omitted, or when lymph nodes are positive (Versluis et al 2018 ). Probably, these conflicting findings could be related to the fact that the two studies included also stage III (Nemani et al 2008 ; Versluis et al 2018 ), and even stage IV disease (Versluis et al 2018 ).…”

“…Finally, it has been recognized that in the real-world practice, only 35-57% of patients in some gynecologic oncology centres in USA were triaged to lymphadenectomy, as summarized in the Vorgias review (Vorgias and Fotiou 2010); as a matter of fact, even considering the large series from the SEER database (N = 1885 patients), and the Netherland Cancer registry (N = 1140 patients), the "lymphadenectomy issue" still remains controversial (Nemani et al 2008;Versluis et al 2018); indeed, the SEER study concluded that lymphadenectomy is associated with improved overall survival with no benefit associated to adjuvant radiotherapy (Nemani et al 2008), while the Dutch study demonstrates that (1) lymphadenectomy is related to improved survival only if > 10 lymph nodes are removed, and (2) adjuvant therapy improves survival when lymphadenectomy is omitted, or when lymph nodes are positive (Versluis et al 2018). Probably, these conflicting findings could be related to the fact that the two studies included also stage III (Nemani (Versluis et al 2018). Indeed, in the large series including 5614 stage I UCS patients, lymphadenectomy ≥ 15-20 lymph nodes removed was associated with better survival (Seagle et al 2017).…”

Adjuvant vaginal interventional radiotherapy in early-stage non-endometrioid carcinoma of corpus uteri: a systematic review

“…Radical surgery with total hysterectomy and bilateral salpingo-oophorectomy is the current standard treatment for non-metastatic UCS, UCCC, and UPSC [ 5 , 23 , 24 ]. The role of complete staging with systemic lymphadenectomy and omentectomy should be considered in early-stage diseases due to its improvement in survival and a decrease of overall recurrence rate, especially in UPSC [ 25 - 28 ].…”

Uterine Carcinosarcomas versus Leiomyosarcomas: DuaL Institutional Experience from Mansoura and Zagazig Universities

“…Adjuvant chemotherapy (carboplatin/ifosfamide or carboplatin/paclitaxel) was received by 5 of our CS patients (42%). A recent retrospective study from the Netherlands [12], consisting of 1140 cases of CS, proved that adjuvant treatment, whether chemotherapy, radiotherapy or both, improved OS, especially if lymph node dissection was not performed or if the lymph nodes were infiltrated. Wong et al [13] analysed 4906 CS patients and found that the impact of both adjuvant chemotherapy and radiotherapy on OS was greater than the impact of each modality alone and better than no adjuvant at all.…”