Relapsing uterine carcino-sarcoma

[Kroll2013]

Dear colleagues,
I need your opinion concerning this patient:
-63 yo fit lady
-june 2016: TAH-BSO + abdominal exploration: carcino sarcoma taking the right adnexa, uterine posterior serosal wall, bladder peritoneum, jejunal-ile0-cecal meso as well as the jejunal serosa. cervix neg.
she received adjuvant chemotherapy: taxol-carboplatin
- f/up every 3 mo with IV-CT: NED
- Dec 2017: large bilobar mass in the posterior aspect of the midline pelvis, 7*7 cm , with central necrosis, adherent to the intestinal loops. biopsy shows a local recurrence
- 4 cycles chemotherapy: Holoxan/CDDP/uromitexan
- 60% size reduction and 45% reduction of FDG avidity
- surgical resection (posterior exenteration): parietal lesion of the resected segment of the colon, 4 cm, extending from submucosa to subserosa
negative but close margin (<2mm) at the colic serosal surface
IHC profil: anti-MCK +++. Chromogranine neg, Synaptophysine - CD56 neg, Vimentine neg, Ki67 5%
she received adjuvant chemotherapy .

- DO YOU GIVE ADJUVANT RADIATION ? WHERE and TO WHAT DOSE?
ty

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[Radiator20]

parietal lesion of the resected segment of the colon, 4 cm, extending from submucosa to subserosa
negative but close margin (<2mm) at the colic serosal surface

So at surgery, she had a 4 cm recurrence implanted on the colonic serosa and invading into the colon? And the close margin was longitudinal on the colon, ie, just proximal to the resection? Or am I misinterpreting?

Have you restaged after adjuvant chemo? She is surely at high risk of distant failure.

That said, if no distant mets yet, seems like she has already proven that local failure is her most pressing issue...

 

[Palex80]

I agree with Radiator20. There is no definitive proof of an advantage when doing adjuvant RT, but it seems worth it (there are few studies in all entities on the role of adjuvant RT after resection of reccurent tumors anyhow). I’’d also treat.

 

[Kroll2013]

So at surgery, she had a 4 cm recurrence implanted on the colonic serosa and invading into the colon? And the close margin was longitudinal on the colon, ie, just proximal to the resection? Or am I misinterpreting?

Have you restaged after adjuvant chemo? She is surely at high risk of distant failure.

That said, if no distant mets yet, seems like she has already proven that local failure is her most pressing issue...

no she took chemotherapy for reduction, so she responded partially 60% reduction in size.
and yes invading into the colon , infiltrating into the submucosa.
she still M0.

 

[seper]

I'd treat the whole pelvis to 45 Gy. Although prognosis is poor, your surgical colleagues are being aggressive.

 

[evilbooyaa]

I'd treat the whole pelvis to 45 Gy. Although prognosis is poor, your surgical colleagues are being aggressive.

Agreed. I'd do it using 4 field or draw out most of the intestine co-planar to the lower pelvic nodes as a target since you're not really going to know where to 'focus' your radiation with IMRT.

Tough case, bad tumor. Given the extensiveness of her disease at the beginning (IVA Carcinosarc?) her likelihood of doing well was not good to begin with.

As an aside - would anybody have treated at initial resection/chemo?

 

[Radiator20]

I'd do it using 4 field

Seems to me very reasonable to start with this--but probably worth taking some extra care given the exenteration and fact that her pelvis just not a normal place.

would anybody have treated at initial resection/chemo?

I'm not sure I'm clear on full details of the original surgery but, given the LR, hard to argue that adjuvant RT would have been wrong. Intuitively it seems like it would have been right.

Currently, I'm also not certain whether she still has a vaginal cuff but if she did, wonder if any role for VC brachy after beam. Also not certain about her nodal sampling/status, but if N+, also wonder about covering PA. Sounds like her current closest margin was at the distal end of her residual colon, which is presumably now forming her colostomy--so that site at least should be easy to surveil.

 

[Palex80]

The EORTC trial did notice an improvement in PFS when treating carcinosarcoma, albeit in earlier stages. No OS benefit though.