••• Chapter 45^ Uterine Sarcomas^455
❍ How does staging differ for a leiomyosarcoma versus a carcinosarcoma?
Early stage disease refers to stage 1 (tumor confined to the uterus) and stage 2 (tumor extends to the pelvis).
Surgery is the best treatment via staging laparotomy.
With uterine leiomyosarcoma, all patients should undergo a hysterectomy, if feasible. A modified radical or radical
procedure may be occasionally required if there is parametrial infiltration. In the absence of other gross
disease, fewer than 5% will have ovarian or nodal metastases. Ovarian preservation is therefore an option for
premenopausal women. In addition, lymph node dissection should be reserved for patients with clinically
suspicious nodes.
For uterine carcinosarcoma, hysterectomy and BSO are mandatory.
Lymph node metastases will be found in up to one-third of patients with clinical stage I disease, and thus,
comprehensive lymphadenectomy should be performed. Omentectomy is usually performed as part of surgical
staging for carcinosarcoma as well.
❍ How do you follow patients after surgical staging?
Physical examination every 3 months for the first 2 years and then at 6- to 12-month intervals thereafter. Most
recurrences will be distant, and thus Pap tests are not part of routine surveillance according to guidelines of the
Society of Gynecologic Oncology.
❍ What is the most independent variable associated with survival for sarcomas?
International Federation of Gynecologists and Obstetricians (FIGO) staging.
❍ Describe the differences in patterns of spread of leiomyosarcoma versus carcinosarcomas.
Leiomyosarcomas have a propensity for hematogenous dissemination. For example, lung metastases are particularly
common, and more than half of patients will have distant spread if diagnosed with recurrent disease. To a lesser
extent, leiomyosarcomas metastasize via lymphatic channels
The opposite is true for carcinosarcomas in which one-third of patients with clinically stage I tumors will have
nodal metastases. Thus, comprehensive pelvic and para-aortic lymphadenectomy is particularly important in
staging this disease.
❍ Based on the last FIGO staging recommendations for uterine sarcomas in 2009, how should
carcinosarcomas be staged?
As carcinomas of the endometrium.
❍ What criteria are used to define stage 1 (limited to uterus) leiomyosarcomas versus ESS and adenosarcomas?
For leiomyosarcomas → the definition is based on the tumor size. Stage 1 A is <5 cm and stage 1B is >5 cm.
For ESS and adenosarcomas → myometrial invasion. Therefore, stage 1 A implies no myometrial invasion, 1B
<half of myometrial invasion, and 1C >half myometrial invasion.