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How to Tell a Sarcoma from a Myoma? Gynecologist ’ s Point of View

How to Tell a Sarcoma from a Myoma? Gynecologist ’ s Point of View. Ginger J. Gardner, MD Associate Professor, Weill Cornell Medical College Associate Member, Gynecology Service Director, Survivorship Program Department of Surgery Memorial Sloan-Kettering Cancer Center. Case.

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How to Tell a Sarcoma from a Myoma? Gynecologist ’ s Point of View

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  1. How to Tell a Sarcoma from a Myoma?Gynecologist’s Point of View Ginger J. Gardner, MD Associate Professor, Weill Cornell Medical College Associate Member, Gynecology Service Director, Survivorship Program Department of Surgery Memorial Sloan-Kettering Cancer Center

  2. Case 50yo undergoing work-up for newly diagnosed breast cancer, presents with increasing vaginal bleeding and associated dysmenorrhea. Pelvic exam consistent with an enlarged fibroid uterus. Endometrial biopsy benign. Pelvic imaging reveals…

  3. Peri or Post-Menopausal Bleeding&Enlarging / Necrotic Uterine Mass…Think SARCOMA!

  4. Uterine Leiomyosarcoma Histologic Features high mitotic rate atypia and necrosis SMA positive, h-caldesmon positive ER/PR positive 7-71% Multiple, complex chromosomal abnormalities No single specific translocation Clinical Features Median age 56 years 40-70% risk for recurrence in 2-5 years for uterus-limited disease Lung, liver, rarely bone Median survival after dx of metastatic disease is 1 year

  5. Uterine LeiomyosarcomaDiagnosis Soslow RA. Diagn Histopathol 2008;14:175-188.

  6. Uterine SarcomasDiagnosis • The vast majority are diagnosed incidentally after a procedure for presumed benign indications • No reliable method to detect these preoperatively • Myomectomy, SCH, morcellations for specimen removal are commonly performed • Patient counseling • What is the risk of malignancy? • What are the implications in patients ultimately diagnosed with sarcomas?

  7. Uterine SarcomasIncidence SEER data

  8. Surgery for Presumed LeiomyomaRisk of Malignancy *371 with “rapidly” enlarging – 1 (0.27%) LMS found ** 2 (0.2%) endometrial carcinomas also found “New” or enlarging symptomatic fibroids in postmenopausal women should raise some concerns?

  9. Uterine morcellationResidual disease *1 LMS upstaged on imaging (lung nodules); 2/4 (50%) with residual at reoperation Eisenhauer MH, et al. Int J Gynecol Cancer 2008;18:1065-1070.

  10. Uterine morcellationImpact on LMS outcome Perri T, et al. Int J Gynecol Cancer 2009;19:257-260.

  11. Uterine morcellationRecommendations • Avoid in women with highly concerning pelvic imaging • Avoid in postmenopausal women with a newly diagnosed pelvic mass or an enlarging pelvic mass • If sarcoma encountered post morcellation, consider MIS re-evaluation to remove cervix if retained and careful peritoneal inspection

  12. Post-Menopausal Bleeding&Enlarging / Necrotic Uterine Mass…Think SARCOMA!

  13. Uterine Sarcomas: histologic types • 2000 cases/yr • 0.5-3.3 cases/100,000 women • Heterogenous group of tumors • Natural history, prognosis, treatment vary by histology and grade ESS 15% AS 5% CS 45% LMS 35%

  14. International Society of Gynecologic Pathologists’ Classification of Uterine Sarcomas • Pure non-epithelial sarcomas • Leiomyosarcoma (LMS) • Endometrial stromal sarcoma (ESS) • Mixed ESS/LMS • Other homologous/heterologous tumors • Mixed epithelial and non-epithelial sarcomas • Carcinosarcoma (mixed malignant Mullerian tumor) • Adenofibroma • Carcinofibroma • Undifferentiated sarcomas

  15. Uterine SarcomasGOG classification • Leiomyosarcoma • Smooth muscle tumor of uncertain malignant potential (STUMP) • Endometrial stromal sarcoma (low grade) • Undifferentiated sarcoma • Others: adenosarcoma, carcinofibroma • Carcinosarcoma (MMMT, metaplastic carcinoma) GOG Pathology Manual. Revised 2009

  16. Adjuvant Treatment for our Patient?Status post resection for Stage I LMS

  17. EORTC Radiation TrialAdjuvant Therapy for LMS • Uterine Sarcoma Stage I/II • Randomized to Pelvic RT vs Observation • Total patients 223 -Leiomyosarcoma 103 -Carcinosarcoma 91 -Endometrial Stromal Sarcoma 28

  18. EORTC Radiation TrialAdjuvant Therapy for LMS In subset analysis, adjuvant RT did not improve local control or distant recurrence for LMS patients Reed, et al. Eur J Cancer 2008.

  19. GOG 277Adjuvant Therapy for LMS Eligibility • High grade uterine LMS • Uterine limited disease (FIGO stage I) • >5 mitoses/hpf • <12 weeks since surgery • Negative preoperative imaging

  20. Uterine SarcomasSummary • Uterine sarcomas can masquerade as benign uterine fibroids • Incidence is <0.5% among pts undergoing fibroid surgery • Peri- or Post-menopausal bleeding and an enlarging necrotic uterine mass are red flags for possible sarcoma • Avoid Morcellation for patients with these clinical characteristics • For early stage LMS, GOG277 is evaluating appropriate adjuvant management

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