Diagnostik und Therapie der Uterussarkome

Zusammenfassung

In den frühen Stadien (I und II) des Uterussarkoms ist die Radikaloperation mit kompletter Tumorentfernung die einzige kurative Behandlungsoption. Eine adjuvante Strahlen- und oder Chemotherapie kommt gegebenenfalls nach Entfernung größerer Tumore (z. B. > 4 cm) und Lymphknotenmetastasen mit hohem Lokalrezidivrisiko in Betracht. Dies gilt vorzugsweise für endometriale Stromasarkome und mesodermale Mischtumore (Karzinosarkome). Leiomyosarkome sind weitestgehend resistent gegenüber einer Strahlen- und Chemotherapie, ihre Anwendung dürfte hier mehr Toxizität als Nutzen bringen.

In höheren Stadien und in der Rezidivsituation ist das Behandlungskonzept palliativ. Dabei muss der mögliche - meist sehr begrenzte - Behandlungserfolg und die oft beträchtlichen Nebenwirkungen mit Einschränkung der Lebensqualität abgewogen werden

Abstract

Radical surgery in stage I and II uterine sarcoma removing all tumor manifestations is the only curative therapy option for early stage disease. Larger tumors (> 4 cm) and the presence of lymph node metastasis correlate with a high local recurrence rate. For these tumors adjuvant radiation and/or adjuvant chemotherapy may be recommended after surgical therapy. Adjuvant therapy however, should preferably be considered for uterine stromal sarcomas and mixed mesodermal tumors. The toxicity of radiation and/or chemotherapy is greater than any possible benefit for patients with leiomysarcomas as these tumors rarely respond to radiation or chemotherapy. For advanced (> stage I and II) and recurrent disease, curative therapy options are not available and palliative therapy for these patients has to take into consideration the negative side effects and weigh up quality of life against an often very limited possible benefit of such therapy.

Sarkome des Uterus - Diagnostik - Klassifikation - Stadieneinteilung - Therapie - Rezidiv - Prognose

Uterine sarcoma - classification - diagnosis - staging - therapy - recurrence - prognosis

Literatur

• 1 Aaro L A, Symmonds R E, Dockerty M B. Sarcoma of the uterus. A clinical and pathologic study of 177 cases.  Am J Obstet Gynecol. 1966;  94 101-109
• 2 Atzinger A, Ries G, Hotzinger H, Hermans M, Pfandner K. Clinical presentation, therapy and prognosis of the sarcoma of the uterus.  Strahlentherapie. 1982;  158 210-216
• 3 Chi D S, Mychalczak B, Saigo P E, Rescigno J, Brown C L. The role of whole-pelvic irradiation in the treatment of early-stage uterine carcinosarcoma.  Gynecol Oncol. 1997;  65 493-498
• 4 Cohen I, Beyth Y, Altaras M M, Shapira J, Tepper R, Cardoba M, Yigael D, Figer A, Fishman A, Berenhein J. Estrogen and progesterone receptor expression in postmenopausal tamoxifen-exposed endometrial pathologies.  Gynecol Oncol. 1997;  67 8-15
• 5 DiSaia P J, Morrow C P, Boronow R, Creasman W, Mittelstaedt L. Endometrial sarcoma: lymphatic spread pattern.  Am J Obstet Gynecol. 1978;  130 104-105
• 6 Duk J M, Bouma J, Burger G T, Nap M, De Bruijn H W. CA 125 in serum and tumor from patients with uterine sarcoma.  Int J Gynecol Cancer. 1994;  4 156-160
• 7 Echt G, Jepson J, Steel J, Langholz B, Luxton G, Hernandez W, Astrahan M, Petrovich Z. Treatment of uterine sarcomas.  Cancer. 1990;  66 35-39
• 8 Evans H L, Chawla S P, Simpson C, Finn K P. Smooth muscle neoplasms of the uterus other than ordinary leiomyoma: a study of 46 cases, with emphasis on diagnostic criteria and prognostic factors.  Cancer. 1988;  62 2239-2247
• 9 Gynecological G roup, Clinical Oncological Society of Australia and the Cancer I nstitute, Melbourne, Australia. Tamoxifen in advanced and recurrent uterine sarcomas: a phase II study.  Cancer Treat Rep. 1986;  70 811-812
• 10 Hornback N B, Omura G, Major F J. Observations on the use of adjuvant radiation therapy in patients with stage I and II uterine sarcoma.  Int J Radiat Oncol Biol. Phys1986;  12 2127-2130
• 11 Katz L, Merino M J, Sakamoto H, Schwartz P E. Endometrial stromal sarcoma: a clinicopathologic study of 11 cases with determination of estrogen and progestin receptor levels in three tumors.  Gynecol Oncol. 1987;  26 87-97
• 12 Kawamura N, Ichimura T, Ito F, Shibata S, Takahashi K, Tsujimura A, Ishiko O, Haba T, Wakasa K, Ogita S. Transcerivical needle biopsy for the differential diagnosis between uterine sarcoma and leiomyoma.  Cancer. 2002;  94 1713-1720
• 13 Kohorn E I, Schwartz P E, Chambers J T, Peschel R E, Kapp D S, Merino M. Adjuvant therapy in mixed mullerian tumors of the uterus.  Gynecol Oncol. 1986;  23 212-221
• 14 Kurjak A, Kupesic S, Shalan H, Jukic S, Kosuta D, Ilijas M. Uterine sarcoma: a report of 10 cases studied by transvaginal color and pulsed Doppler sonography.  Gynecol Oncol. 1995;  59 342-346
• 15 Larson B, Silfversward C, Nilsson B, Pettersson F. Mixed Mullerian tumours of the uterus - prognostic factors: a clinical and histopathologic study of 147 cases.  Radiotherapy and Oncology. 1990;  17 123-132
• 16 Liao J B, Lin J Y. Estrogen receptor expression in an endometrial stromal sarcoma after tamoxifen therapy.  Eur J Gynaecol Oncol. 2001;  22 417-419
• 17 Major F J, Blessing J A, Silverberg S G, Morrow C P, Creasman W T, Currie J L, Yordan E, Brady M F. Prognostic factors in early-stage uterine sarcoma: a Gynecologic Oncology Group study.  Cancer. 1993;  71 1702-1709
• 18 Matsumoto Y, Ishiko O, Sumi T, Yoshida H, Deguchi M, Nakagawa E, Haba T, Wakasa K, Ogita S, Ando Y. Cyclooxygenase-2 expression in malignant mesenchymal tumors and related uterine lesions.  Oncol Rep. 2001;  8 1225-1227
• 19 Miller D S, Blessing J A, Kilgore L C, Mannel R, Van Le L. Phase II trial of topotecan in patients with advanced, persistent, or recurrent uterine leiomyosarcomas: a Gynecologic Oncology Group Study.  Am J Clin Oncol. 2000;  23 355-357
• 20 Muss H B, Bundy B, DiSaia P J, Homesley H D, Fowler WC J r, Creasman W, Yordan E. Treatment of recurrent or advanced uterine sarcoma. A randomized trial of doxorubicin versus doxorubicin and cyclophosphamide (a phase III trial of the Gynecologic Oncology Group).  Cancer. 1985;  55 1648-1653
• 21 Olah K S, Dunn J A, Gee H. Leiomyosarcomas have a poorer prognosis than mixed mesodermal tumours when adjusting for known prognostic factors: the result of a retrospective study of 423 cases of uterine sarcoma.  Br J Obstet Gynaecol. 1992;  99 590-594
• 22 Omura G A, Blessing J A, Major F, Lifshitz S, Ehrlich C E, Mangan C, Beecham J, Park R, Silverberg S. A randomized clinical trial of adjuvant adriamycin in uterine sarcomas: a Gynecologic Oncology Group study.  J Clin Oncol. 1985;  3 1240-1245
• 23 Omura G A, Major F J, Blessing J A, Sedlacek T V, Thigpen J T, Creasman W T, Zaino R J. A randomized study of adriamycin with and without dimethyl triazenoimidazole carboxamide in advanced uterine sarcomas.  Cancer. 1983;  52 626-632
• 24 Pecorelli S L.. EORTC Gynecological Cancer Group: .Phase III Randomized Study of Adjuvant Pelvic Radiotherapy Versus Observation Alone in Patients With Completely Resected, Stage I or II, High-Grade Uterine. Sarcoma (Summary Last Modified 12/2001), EORTC-55874, Clinical trial, Closed
• 25 Peters WA 3 rd, Rivkin S E, Smith M R, Tesh D E. Cisplatin and adriamycin combination chemotherapy for uterine stromal sarcomas and mixed mesodermal tumors.  Gynecol Oncol. 1989;  34 323-327
• 26 Piver M S, Lele S B, Marchetti D L, Emrich L J. Effect of adjuvant chemotherapy on time to recurrence and survival of stage I uterine sarcomas.  Journal of Surgical Oncology. 1988;  38 233-239
• 27 Shepherd J H. Revised FIGO staging for gynaecological cancer.  Br J Obstet Gynaecol. 1989;  96 889-892
• 28 Silverberg S G, Major F J, Blessing J A, Fetter B, Askin F B, Liao S Y, Miller A. Carcinosarcoma (malignant mixed mesodermal tumor) of the uterus: a Gynecologic Oncology Group pathologic study of 203 cases.  International Journal of Gynecological Pathology. 1990;  9 1-19
• 29 Sutton G, Blessing J A, Ball H. Phase II trial of paclitaxel in leiomyosarcoma of the uterus: a gynecologic oncology group study.  Gynecol Oncol. 1999;  74 346-349
• 30 Sutton G, Blessing J A, Malfetano J H. Ifosfamide and doxorubicin in the treatment of advanced leiomyosarcomas of the uterus: a Gynecologic Oncology Group study.  Gynecol Oncol. 1996;  62 226-229
• 31 Sutton G, Blessing J A, Park R, DiSaia P J, Rosenshein N. Ifosfamide treatment of recurrent or metastatic endometrial stromal sarcomas previously unexposed to chemotherapy: a study of the Gynecologic Oncology Group.  Obstet Gynecol. 1996;  87 747-750
• 32 Sutton G, Brunetto V L, Kilgore L, Soper J T, McGehee R, Olt G, Lentz S S, Sorosky J, Hsiu J G. A phase III trial of ifosfamide with or without cisplatin in carcinosarcoma of the uterus: A gynecologic oncology group study.  Gynecol Oncol. 2000;  79 147-153
• 33 Sutton G P, Blessing J A, Barrett R J, McGehee R. Phase II trial of ifosfamide and mesna in leiomyosarcoma of the uterus: a Gynecologic Oncology Group study.  Am J Obstet Gynecol. 1992;  166 556-559
• 34 Sutton G P, Blessing J A, Rosenshein N, Photopulos G, DiSaia P J. Phase II trial of ifosfamide and mesna in mixed mesodermal tumors of the uterus (a Gynecologic Oncology Group Study).  Am J Obstet Gynecol. 1989;  161 309-312
• 35 Sutton G P, Stehman F B, Michael H, Young P C, Ehrlich C E. Estrogen and progesterone receptors in uterine sarcomas.  Obstet Gynecol. 1986;  68 709-714
• 36 Szabo I, Szantho A, Csabay L, Csapo Z, Szirmai K, Papp Z. Color Doppler ultrasonography in differentiation of uterine sarcoma from uterine leiomyomas.  Eur J Gynaecol Oncol. 2002;  23 29-34
• 37 Thigpen J T, Blessing J A, Beecham J, Homesley H, Yordan E. Phase II trial of cisplatin as first- line chemotherapy in patients with advanced or recurrent uterine sarcomas: a Gynecology Oncology Group Study.  J Clin Oncol. 1991;  9 1962-1966
• 38 Thigpen J T, Blessing J A, Wilbanks G D. Cisplatin as second-line chemotherapy in the treatment of advanced or recurrent leiomyosarcoma of the uterus. A phase II trial of the Gynecologic Oncology Group.  Am J Clin Oncol. 1986;  9 18-20
• 39 Tsujimura A, Kawamura N, Ichimura T, Honda K, Ishiko O, Ogita S. Telomerase activity in needle biopsied uterine myoma-like tumors: differential diagnosis between uterine sarcomas and leiomyomas.  Int J Oncol. 2002;  20 361-365
• 40 Umesaki N, Tanaka T, Miyama M, Kawamura N, Ogita S, Kawabe J, Okamura T, Koyama K, Ochi H. Positron emission tomography with (18)F-fluorodeoxyglucose of uterine sarcoma: a comparison with magnetic resonance imaging and power Doppler imaging.  Gynecol Oncol. 2001;  80 372-377
• 41 van Nagell JR J r, Hanson M B, Donaldson E S, Gallion H H. Adjuvant vincristine, dactinomycin, and cyclophosphamide therapy in stage I uterine sarcomas. A pilot study.  Cancer. 1986;  57 1451-1454
• 42 Wade K, Quinn M A, Hammond I, Williams K, Cauchi M. Uterine sarcoma: steroid receptors and response to hormonal therapy.  Gynecol Oncol. 1990;  39 364-367
• 43 Wang X, Khoo U S, Xue W C, Cheung A N. Cervical and peritoneal fluid cytology of uterine sarcomas.  Acta Cytol. 2002;  46 465-469
• 44 Wickerham D L, Fisher B, Wolmark N, Bryant J, Costantino J, Bernstein L, Runowicz C D. Association of tamoxifen and uterine sarcoma.  J Clin Oncol. 2002;  20 2758-2760
• 45 Wysowski D K, Honig S F, Beitz J. Uterine sarcoma associated with tamoxifen use.  N Engl J Med. 2002;  346 1832-1833
• 46 Liao J B, Lin J Y. Estrogen receptor expression in an endometrial stromal sarcoma after tamoxifen therapy.  Eur J Gynaecol Oncol. 2001;  22 417-419