Geburtshilfe Frauenheilkd 2015; 75(10): 1028-1042
DOI: 10.1055/s-0035-1558120
Guideline
GebFra Science
Georg Thieme Verlag KG Stuttgart · New York

Sarcoma of the Uterus. Guideline of the DGGG (S2k-Level, AWMF Registry No. 015/074, August 2015)

Uterine Sarkome. Leitlinie der DGGG (S2k-Level, AWMF-Registernummer 015/074, August 2015)
D. Denschlag
1   Frauenklinik, Hochtaunuskliniken Bad Homburg, Bad Homburg
,
F. C. Thiel
2   Frauenklinik, Alb Fils Kliniken, Göppingen
,
S. Ackermann
3   Frauenklinik, Klinikum Darmstadt, Darmstadt
,
P. Harter
4   Klinik für Gynäkologie und Gynäkologische Onkologie, Klinikum Essen Mitte, Essen
,
I. Juhasz-Boess
5   Klinik für Gynäkologie, Geburtshilfe und Reproduktionsmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar
,
P. Mallmann
6   Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Köln, Cologne
,
H.-G. Strauss
7   Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Halle, Halle/Saale
,
U. Ulrich
8   Klinik für Gynäkologie und Geburtshilfe, Martin-Luther-Krankenhaus Berlin, Paul Gerhardt Diakonie, Berlin
,
L.-C. Horn
9   Abteilung für Mamma-, Urogenital, und Perinatalpathologie, Institut für Pathologie, Universitätsklinikum Leipzig, Leipzig
,
D. Schmidt
10   Institut für Pathologie Mannheim, Mannheim
,
D. Vordermark
11   Universitätsklinik und Poliklinik für Strahlentherapie, Universitätsklinikum Halle, Halle/Saale
,
T. Vogl
12   Institut für diagnostische und interventionelle Radiologie, Universitätsklinikum Frankfurt, Frankfurt/Main
,
P. Reichardt
13   Klinik für interdisziplinäre Onkologie, Helios Kliniken Berlin-Buch, Berlin
,
P. Gaß
14   Frauenklinik, Universitätsklinikum Erlangen, Erlangen
,
M. Gebhardt
15   Frauenselbsthilfe nach Krebs e. V., Erlangen
,
M. W. Beckmann
14   Frauenklinik, Universitätsklinikum Erlangen, Erlangen
› Author Affiliations
Further Information

Publication History

Publication Date:
02 November 2015 (online)

Abstract

Purpose: Official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). Due to their rarity and their heterogeneous histopathology uterine sarcomas remain challenging tumors to manage and need a multidisciplinary approach. To our knowledge so far there is no evidence-based guideline on the appropiate management of these heterogeneous tumors. Methods: This S2k-guideline is the work of an representative committee of experts from a variety of different professions who were commissioned by the DGGG to carry out a systematic literature review of uterine sarcoma. Members of the participating scientific societies developed a structured consensus in a formal procedure. Recommendations: 1. The incidence and histopathologic classification of uterine sarcoma. 2. The clinical manifestations, diagnosis and staging of uterine sarcoma. 3. The management of leiomyosarcoma. 4. The management of endometrial stromal sarcoma and undifferentiated uterine sarcoma. 5. The management of adenosarcoma as well as carcinosarcomas. 6. The management of morcellated uterine sarcoma

Zusammenfassung

Ziel: Offizielle Leitlinie, publiziert und koordiniert von der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe (DGGG). Aufgrund ihrer Seltenheit und heterogenen Histopathologie stellen uterine Sarkome eine Herausforderung bzgl. des klinischen Managements dar und bedürfen von daher einem multidisziplinären Ansatz. Nach unserem Kenntnisstand existieren bis dato keine verbindlichen, evidenzbasierten Empfehlungen bzgl. des angemessenen Managements dieser heterogenen Tumore. Methoden: Die vorliegende S2k-Leitlinie ist das Ergebnis der Arbeit eines repräsentativen interdisziplinären Experten-Komitees, welches im Auftrag der Leitlinienkommission der DGGG eine systematische Literaturrecherche zum Thema Uterine Sarkome durchgeführt hat. Mitglieder der beteiligten Fachgesellschaften entwickelten in einem strukturierten Prozess einen formalen Konsensus. Empfehlungen: 1. Die Inzidenz und histopathologische Klassifikationen von uterinen Sarkomen. 2. Die klinische Symptomatik, Diagnostik und Stadieneinteilung von uterinen Sarkomen. 3. Das Management von Leiomyosarkome. 4. Das Management von endometrialen Stromasarkomen und undifferenzierten uterinen Sarkomen. 5. Das Management von Adenosarkomen als auch Karzinosarkomen. 6. Das Management von morcellierten uterinen Sarkomen

Supporting Information

 
  • References

  • 1 Brooks SE, Zhan M, Cote T et al. Surveillance, epidemiology, and end results analysis of 2677 cases of uterine sarcoma 1989–1999. Gynecol Oncol 2004; 93: 204-208
  • 2 Wittekind C, Meyer HJ. TNM-Klassifikation maligner Tumoren. Weinheim: Wiley-VHC Verlag; 2010: 184-187
  • 3 Oliva E, Carcangiu ML, Carinelli SG, Ip P, Loening T, Longacre TA, Nucci MR, Prat J, Zaloudek CJ. Mesenchymal Tumors of the Uterus. In: Kurman RJ, Carcangiu ML, Herrington CS, Young RH, eds. WHO Classification of Tumours of female reproductive Tract. Lyon: IARC Press; 2014: 135-147
  • 4 Conklin CM, Longacre TA. Endometrial stromal tumors: the new WHO classification. Adv Anat Pathol 2014; 21: 383-393
  • 5 Fletcher CDM, Bridge JA, Hogendoorn PCW, Mertens F. WHO Classification of soft Tissue and Bone. Lyon: IARC Press; 2013
  • 6 DʼAngelo E, Prat J. Uterine sarcomas: a review. Gynecol Oncol 2010; 116: 131-139
  • 7 McCluggage WG. Malignant biphasic uterine tumours: carcinosarcomas or metaplastic carcinomas?. J Clin Pathol 2002; 55: 321-325
  • 8 Lopez-Garcia MA, Palacios J. Pathologic and molecular features of uterine carcinosarcomas. Semin Diagn Pathol 2010; 27: 274-286
  • 9 Bansal N, Herzog TJ, Seshan VE et al. Uterine carcinosarcomas and grade 3 endometrioid cancers: evidence for distinct tumor behavior. Obstet Gynecol 2008; 112: 64-70
  • 10 Callister M, Ramondetta LM, Jhingran A et al. Malignant mixed Müllerian tumors of the uterus: analysis of patterns of failure, prognostic factors, and treatment outcome. Int J Radiat Oncol Biol Phys 2004; 58: 786-796
  • 11 Garg G, Shah JP, Kumar S et al. Ovarian and uterine carcinosarcomas: a comparative analysis of prognostic variables and survival outcomes. Int J Gynecol Cancer 2010; 20: 888-894
  • 12 Nemani D, Mitra N, Guo M et al. Assessing the effects of lymphadenectomy and radiation therapy in patients with uterine carcinosarcoma: a SEER analysis. Gynecol Oncol 2008; 111: 82-88
  • 13 Buttram jr. VC, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 1981; 36: 433-445
  • 14 Parker WH, Fu YS, Berek JS. Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma. Obstet Gynecol 1994; 83: 414-418
  • 15 Liao Q, Wang J, Han J. [Clinical and pathological analysis on 106 cases with uterine sarcoma]. Zhonghua Fu Chan Ke Za Zhi 2001; 36: 104-107
  • 16 Sreenan JJ, Hart WR. Carcinosarcomas of the female genital tract. A pathologic study of 29 metastatic tumors: further evidence for the dominant role of the epithelial component and the conversion theory of histogenesis. Am J Surg Pathol 1995; 19: 666-674
  • 17 Zaloudek CJ, Hendrickson MR, Soslow RA. Mesenchymal Tumors of the Uterus. In: Kurman RJ, Hedrick Ellenson L, Ronnett BM, eds. Blausteinʼs Pathology of the female genital Tract. New York, Dodrecht, Heidelberg, London: Springer; 2011
  • 18 Park JY, Park SK, Kim DY et al. The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma. Gynecol Oncol 2011; 122: 255-259
  • 19 Santos P, Cunha TM. Uterine sarcomas: clinical presentation and MRI features. Diagn Interv Radiol 2015; 21: 4-9
  • 20 Sadeghi R, Zakavi SR, Hasanzadeh M et al. Diagnostic performance of fluorine-18-fluorodeoxyglucose positron emission tomography imaging in uterine sarcomas: systematic review and meta-analysis of the literature. Int J Gynecol Cancer 2013; 23: 1349-1356
  • 21 Sharma P, Kumar R, Singh H et al. Role of FDG PET-CT in detecting recurrence in patients with uterine sarcoma: comparison with conventional imaging. Nucl Med Commun 2012; 33: 185-190
  • 22 Coffey D, Kaplan AL, Ramzy I. Intraoperative consultation in gynecologic pathology. Arch Pathol Lab Med 2005; 129: 1544-1557
  • 23 Otis CN et al. Protocol for the examination of specimens from patients with sarcoma. 2013.. Online: http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2013/UterineSarcomaProtocol_3000.pdf last access: 19.06.2015
  • 24 McCluggage WG, Fisher C, Hirschowitz L. Dataset for histological reporting of uterine sarcomas. 2014.. Online: https://www.rcpath.org/Resources/RCPath/Migrated%2520Resources/Documents/G/G106_UterineSarcomaDataset_Dec14.pdf last access: 19.06.2015
  • 25 Ehdaivand S, Simon RA, Sung CJ et al. Incidental gynecologic neoplasms in morcellated uterine specimens: a case series with follow-up. Hum Pathol 2014; 45: 2311-2317
  • 26 Horn LC, Schierle K, Schmidt D et al. [Current TNM/FIGO classification for cervical and endometrial cancer as well as malignant mixed müllerian tumors. Facts and background]. Pathologe 2011; 32: 239-243
  • 27 Hedrick Ellenson L, Ronnett BM, Soslow RA, Zaino RJ. Endometrial Carcinoma. In: Kurman RJ, Hedrick Ellenson L, Ronnett BM, eds. Blausteinʼs Pathology of the female genital Tract. New York, Dodrecht, Heidelberg, London: Springer; 2011
  • 28 Amant F, de la Rey M, Dorfling CM et al. PTEN mutations in uterine sarcomas. Gynecol Oncol 2002; 85: 165-169
  • 29 McCluggage WG, Haller U, Kurman RJ, Kubik-Huch RA. Mixed epithelial and mesenchymal Tumours. In: Tavassoli FA, Devilee P, eds. Pathology and Genetics of Tumours of the Breast and female genital Organs. World Health Organization Classification of Tumours. Lyon: IARC Press; 2003: 245-249
  • 30 Horn LC, Dallacker M, Bilek K. [Carcinosarcomas (malignant mixed Mullerian tumors) of the uterus. Morphology, pathogenetic aspects and prognostic factors]. Pathologe 2009; 30: 292-301
  • 31 Amant F, Moerman P, Davel GH et al. Uterine carcinosarcoma with melanocytic differentiation. Int J Gynecol Pathol 2001; 20: 186-190
  • 32 Baschinsky DY, Niemann TH, Eaton LA et al. Malignant mixed Müllerian tumor with rhabdoid features: a report of two cases and a review of the literature. Gynecol Oncol 1999; 73: 145-150
  • 33 Fukunaga M, Nomura K, Endo Y et al. Carcinosarcoma of the uterus with extensive neuroectodermal differentiation. Histopathology 1996; 29: 565-570
  • 34 Shokeir MO, Noel SM, Clement PB. Malignant mullerian mixed tumor of the uterus with a prominent alpha-fetoprotein-producing component of yolk sac tumor. Mod Pathol 1996; 9: 647-651
  • 35 Takano M, Shibasaki T, Sato K et al. Malignant mixed Mullerian tumor of the uterine corpus with alpha-fetoprotein-producing hepatoid adenocarcinoma component. Gynecol Oncol 2003; 91: 444-448
  • 36 Park JY, Kim DY, Kim JH et al. The role of pelvic and/or para-aortic lymphadenectomy in surgical management of apparently early carcinosarcoma of uterus. Ann Surg Oncol 2010; 17: 861-868
  • 37 Gadducci A, Cosio S, Romanini A et al. The management of patients with uterine sarcoma: a debated clinical challenge. Crit Rev Oncol Hematol 2008; 65: 129-142
  • 38 Tanner EJ, Leitao jr. MM, Garg K et al. The role of cytoreductive surgery for newly diagnosed advanced-stage uterine carcinosarcoma. Gynecol Oncol 2011; 123: 548-552
  • 39 Wolfson AH, Brady MF, Rocereto T et al. A gynecologic oncology group randomized phase III trial of whole abdominal irradiation (WAI) vs. cisplatin-ifosfamide and mesna (CIM) as post-surgical therapy in stage I–IV carcinosarcoma (CS) of the uterus. Gynecol Oncol 2007; 107: 177-185
  • 40 Cantrell LA, Havrilesky L, Moore DT et al. A multi-institutional cohort study of adjuvant therapy in stage I–II uterine carcinosarcoma. Gynecol Oncol 2012; 127: 22-26
  • 41 Powell MA, Filiaci VL, Rose PG et al. Phase II evaluation of paclitaxel and carboplatin in the treatment of carcinosarcoma of the uterus: a Gynecologic Oncology Group study. J Clin Oncol 2010; 28: 2727-2731
  • 42 Reed NS, Mangioni C, Malmström H et al. European Organisation for Research and Treatment of Cancer Gynaecological Cancer Group. Phase III randomised study to evaluate the role of adjuvant pelvic radiotherapy in the treatment of uterine sarcomas stages I and II: an European Organisation for Research and Treatment of Cancer Gynaecological Cancer Group Study (protocol 55874). Eur J Cancer 2008; 44: 808-818
  • 43 Nam JH. Surgical treatment of uterine sarcoma. Best Pract Res Clin Obstet Gynaecol 2011; 25: 751-760
  • 44 Sutton G, Brunetto VL, Kilgore L et al. 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
  • 45 Galaal K, van der Heijden E, Godfrey K et al. Adjuvant radiotherapy and/or chemotherapy after surgery for uterine carcinosarcoma. Cochrane Database Syst Rev 2013; (2) CD006812
  • 46 Homesley HD, Filiaci V, Markman M et al. Gynecologic Oncology Group. Phase III trial of ifosfamide with or without paclitaxel in advanced uterine carcinosarcoma: a Gynecologic Oncology Group Study. J Clin Oncol 2007; 25: 526-531
  • 47 du Bois A, Burges A, Meier W et al. Arbeitsgemeinschaft Gynaekologische Onkologie Studiengruppe Ovarialkarzinom. Pegylated liposomal doxorubicin and carboplatin in advanced gynecologic tumors: a prospective phase I/II study of the Arbeitsgemeinschaft Gynaekologische Onkologie Studiengruppe Ovarialkarzinom (AGO-OVAR). Ann Oncol 2006; 17: 93-96
  • 48 Lacour RA, Euscher E, Atkinson EN et al. A phase II trial of paclitaxel and carboplatin in women with advanced or recurrent uterine carcinosarcoma. Int J Gynecol Cancer 2011; 21: 517-522
  • 49 Dusenbery KE, Potish RA, Judson P. Limitations of adjuvant radiotherapy for uterine sarcomas spread beyond the uterus. Gynecol Oncol 2004; 94: 191-196
  • 50 Amant F, Coosemans A, Debiec-Rychter M et al. Clinical management of uterine sarcomas. Lancet Oncol 2009; 10: 1188-1198
  • 51 Abeler VM, Røyne O, Thoresen S et al. Uterine sarcomas in Norway. A histopathological and prognostic survey of a total population from 1970 to 2000 including 419 patients. Histopathology 2009; 54: 355-364
  • 52 Pelmus M, Penault-Llorca F, Guillou L et al. Prognostic factors in early-stage leiomyosarcoma of the uterus. Int J Gynecol Cancer 2009; 19: 385-390
  • 53 Iasonos A, Keung EZ, Zivanovic O et al. External validation of a prognostic nomogram for overall survival in women with uterine leiomyosarcoma. Cancer 2013; 119: 1816-1822
  • 54 King ME, Dickersin GR, Scully RE. Myxoid leiomyosarcoma of the uterus. A report of six cases. Am J Surg Pathol 1982; 6: 589-598
  • 55 Coindre JM. Grading and Staging of Sarcoma. In: Fletcher CDM, Bridge JA, Hogendoorn PCW, Mertens F, eds. WHO Classification of Tumours of soft Tissue and Bone. Lyon: IARC Press; 2013: 17-18
  • 56 Guillou L, Coindre JM, Bonichon F et al. Comparative study of the National Cancer Institute and French Federation of Cancer Centers Sarcoma Group grading systems in a population of 410 adult patients with soft tissue sarcoma. J Clin Oncol 1997; 15: 350-362
  • 57 Deyrup AT, Weiss SW. Grading of soft tissue sarcomas: the challenge of providing precise information in an imprecise world. Histopathology 2006; 48: 42-50
  • 58 Coindre JM. Grading of soft tissue sarcomas: review and update. Arch Pathol Lab Med 2006; 130: 1448-1453
  • 59 Kapp DS, Shin JY, Chan JK. Prognostic factors and survival in 1396 patients with uterine leiomyosarcomas: emphasis on impact of lymphadenectomy and oophorectomy. Cancer 2008; 112: 820-830
  • 60 Perri T, Korach J, Sadetzki S et al. Uterine leiomyosarcoma: does the primary surgical procedure matter?. Int J Gynecol Cancer 2009; 19: 257-260
  • 61 Leitao MM, Sonoda Y, Brennan MF et al. Incidence of lymph node and ovarian metastases in leiomyosarcoma of the uterus. Gynecol Oncol 2003; 91: 209-212
  • 62 Pautier P, Floquet A, Gladieff L et al. A randomized clinical trial of adjuvant chemotherapy with doxorubicin, ifosfamide, and cisplatin followed by radiotherapy versus radiotherapy alone in patients with localized uterine sarcomas (SARCGYN study). A study of the French Sarcoma Group. Ann Oncol 2013; 24: 1099-1104
  • 63 Hensley ML, Ishill N, Soslow R et al. Adjuvant gemcitabine plus docetaxel for completely resected stages I–IV high grade uterine leiomyosarcoma: results of a prospective study. Gynecol Oncol 2009; 112: 563-567
  • 64 Hensley ML, Wathen JK, Maki RG et al. Adjuvant therapy for high-grade, uterus-limited leiomyosarcoma: results of a phase 2 trial (SARC005). Cancer 2013; 119: 1555-1561
  • 65 Bernstein-Molho R, Grisaro D, Soyfer V et al. Metastatic uterine leiomyosarcomas: a single-institution experience. Int J Gynecol Cancer 2010; 20: 255-260
  • 66 Leitao MM, Brennan MF, Hensley M et al. Surgical resection of pulmonary and extrapulmonary recurrences of uterine leiomyosarcoma. Gynecol Oncol 2002; 87: 287-294
  • 67 Levenback C et al. Resection of pulmonary metastases from uterine sarcomas. Gynecol Oncol 1992; 45: 202-205
  • 68 Weiser MR, Downey RJ, Leung DH et al. Repeat resection of pulmonary metastases in patients with soft-tissue sarcoma. J Am Coll Surg 2000; 191: 184-190 discussion 190–191
  • 69 Giuntoli 2nd RL, Garrett-Mayer E, Bristow RE et al. Secondary cytoreduction in the management of recurrent uterine leiomyosarcoma. Gynecol Oncol 2007; 106: 82-88
  • 70 Anraku M, Yokoi K, Nakagawa K et al. Metastatic Lung Tumor Study Group of Japan. Pulmonary metastases from uterine malignancies: results of surgical resection in 133 patients. J Thorac Cardiovasc Surg 2004; 127: 1107-1112
  • 71 Chen H, Pruitt A, Nicol TL et al. Complete hepatic resection of metastases from leiomyosarcoma prolongs survival. J Gastrointest Surg 1998; 2: 151-155
  • 72 Maki RG, Wathen JK, Patel SR et al. Randomized phase II study of gemcitabine and docetaxel compared with gemcitabine alone in patients with metastatic soft tissue sarcomas: results of sarcoma alliance for research through collaboration study 002 [corrected]. J Clin Oncol 2007; 25: 2755-2763
  • 73 Sutton G, Blessing JA, Malfetano JH. Ifosfamide and doxorubicin in the treatment of advanced leiomyosarcomas of the uterus: a Gynecologic Oncology Group study. Gynecol Oncol 1996; 62: 226-229
  • 74 Hensley ML, Maki R, Venkatraman E et al. Gemcitabine and docetaxel in patients with unresectable leiomyosarcoma: results of a phase II trial. J Clin Oncol 2002; 20: 2824-2831
  • 75 Gupta AA, Yao X, Verma S et al. Sarcoma Disease Site Group and the Gynecology Cancer Disease Site Group. Systematic chemotherapy for inoperable, locally advanced, recurrent, or metastatic uterine leiomyosarcoma: a systematic review. Clin Oncol (R Coll Radiol) 2013; 25: 346-355
  • 76 Sutton GP, Blessing JA, Barrett RJ et al. 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
  • 77 Look KY, Sandler A, Blessing JA et al. Gynecologic Oncology Group (GOG) Study. Phase II trial of gemcitabine as second-line chemotherapy of uterine leiomyosarcoma: a Gynecologic Oncology Group (GOG) Study. Gynecol Oncol 2004; 92: 644-647
  • 78 Thigpen T, Blessing JA, Yordan E et al. Phase II trial of etoposide in leiomyosarcoma of the uterus: a Gynecologic Oncology Group study. Gynecol Oncol 1996; 63: 120-122
  • 79 Rose PG, Blessing JA, Soper JT et al. Prolonged oral etoposide in recurrent or advanced leiomyosarcoma of the uterus: a gynecologic oncology group study. Gynecol Oncol 1998; 70: 267-271
  • 80 Miller DS, Blessing JA, Kilgore LC et al. 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
  • 81 Gallup DG, Blessing JA, Andersen W et al. Evaluation of paclitaxel in previously treated leiomyosarcoma of the uterus: a gynecologic oncology group study. Gynecol Oncol 2003; 89: 48-51
  • 82 Demetri GD, Chawla SP, von Mehren M et al. Efficacy and safety of trabectedin in patients with advanced or metastatic liposarcoma or leiomyosarcoma after failure of prior anthracyclines and ifosfamide: results of a randomized phase II study of two different schedules. J Clin Oncol 2009; 27: 4188-4196
  • 83 van der Graaf WT, Blay JY, Chawla SP et al. EORTC Soft Tissue and Bone Sarcoma Group; PALETTE study group. Pazopanib for metastatic soft-tissue sarcoma (PALETTE): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet 2012; 379: 1879-1886
  • 84 Chew I, Oliva E. Endometrial stromal sarcomas: a review of potential prognostic factors. Adv Anat Pathol 2010; 17: 113-121
  • 85 Chang KL, Crabtree GS, Lim-Tan SK et al. Primary uterine endometrial stromal neoplasms. A clinicopathologic study of 117 cases. Am J Surg Pathol 1990; 14: 415-438
  • 86 Barney B, Tward JD, Skidmore T et al. Does radiotherapy or lymphadenectomy improve survival in endometrial stromal sarcoma?. Int J Gynecol Cancer 2009; 19: 1232-1238
  • 87 Einstein MH, Barakat RR, Chi DS et al. Management of uterine malignancy found incidentally after supracervical hysterectomy or uterine morcellation for presumed benign disease. Int J Gynecol Cancer 2008; 18: 1065-1070
  • 88 Shah JP, Bryant CS, Kumar S et al. Lymphadenectomy and ovarian preservation in low-grade endometrial stromal sarcoma. Obstet Gynecol 2008; 112: 1102-1108
  • 89 Leath 3rd CA, Huh WK, Hyde jr. J et al. A multi-institutional review of outcomes of endometrial stromal sarcoma. Gynecol Oncol 2007; 105: 630-634
  • 90 Sampath S, Schultheiss TE, Ryu JK et al. The role of adjuvant radiation in uterine sarcomas. Int J Radiat Oncol Biol Phys 2010; 76: 728-734
  • 91 Piver MS, Rutledge FN, Copeland L et al. Uterine endolymphatic stromal myosis: a collaborative study. Obstet Gynecol 1984; 64: 173-178
  • 92 Weitmann HD, Knocke TH, Kucera H et al. Radiation therapy in the treatment of endometrial stromal sarcoma. Int J Radiat Oncol Biol Phys 2001; 49: 739-748
  • 93 Kortmann B, Reimer T, Gerber B et al. Concurrent radiochemotherapy of locally recurrent or advanced sarcomas of the uterus. Strahlenther Onkol 2006; 182: 318-324
  • 94 Cheng X, Yang G, Schmeler KM et al. Recurrence patterns and prognosis of endometrial stromal sarcoma and the potential of tyrosine kinase-inhibiting therapy. Gynecol Oncol 2011; 121: 323-327
  • 95 Dahhan T, Fons G, Buist MR et al. The efficacy of hormonal treatment for residual or recurrent low-grade endometrial stromal sarcoma. A retrospective study. Eur J Obstet Gynecol Reprod Biol 2009; 144: 80-84
  • 96 Maluf FC, Sabbatini P, Schwartz L et al. Endometrial stromal sarcoma: objective response to letrozole. Gynecol Oncol 2001; 82: 384-388
  • 97 Pink D, Lindner T, Mrozek A et al. Harm or benefit of hormonal treatment in metastatic low-grade endometrial stromal sarcoma: single center experience with 10 cases and review of the literature. Gynecol Oncol 2006; 101: 464-469
  • 98 Harter P, Canzler U, Lueck H et al. Pegylated liposomal doxorubicin and carboplatin in malignant mixed epithelial mesenchymal and mesenchymal gynecologic tumors: A phase II trial of the AGO study group. J Clin Oncol 2011; 29 (Suppl.) Abstr. 5093
  • 99 du Bois A, Pfisterer J, Burchardi N et al. Arbeitsgemeinschaft Gynäekologische Onkologie Studiengruppe Ovarialkarzinom; Kommission Uterus. Combination therapy with pegylated liposomal doxorubicin and carboplatin in gynecologic malignancies: a prospective phase II study of the Arbeitsgemeinschaft Gynäkologische Onkologie Studiengruppe Ovarialkarzinom (AGO-OVAR) and Kommission Uterus (AGO-K-Ut). Gynecol Oncol 2007; 107: 518-525
  • 100 Malouf GG, Lhommé C, Duvillard P et al. Prognostic factors and outcome of undifferentiated endometrial sarcoma treated by multimodal therapy. Int J Gynaecol Obstet 2013; 122: 57-61
  • 101 Tanner EJ, Garg K, Leitao jr. MM et al. High grade undifferentiated uterine sarcoma: surgery, treatment, and survival outcomes. Gynecol Oncol 2012; 127: 27-31
  • 102 Schick U, Bolukbasi Y, Thariat J et al. Outcome and prognostic factors in endometrial stromal tumors: a Rare Cancer Network study. Int J Radiat Oncol Biol Phys 2012; 82: e757-e763
  • 103 Oliva E. Cellular mesenchymal tumors of the uterus: a review emphasizing recent observations. Int J Gynecol Pathol 2014; 33: 374-384
  • 104 Hendrickson MA, Tavassoli FA, Kempson RL, McCluggage WG, Haller U, Kubik-Huch RA. Mesenchymal Tumors and related Lesions. In: Tavassoli FA, Devilee P, eds. Pathology and Genetics of Tumours of the Breast and female genital Organs. World Health Organization Classification of Tumours. Lyon: IARC Press; 2003: 233-249
  • 105 Fleming NA, Hopkins L, de Nanassy J et al. Mullerian adenosarcoma of the cervix in a 10-year-old girl: case report and review of the literature. J Pediatr Adolesc Gynecol 2009; 22: e45-e51
  • 106 Clement PB, Scully RE. Mullerian adenosarcoma of the uterus: a clinicopathologic analysis of 100 cases with a review of the literature. Hum Pathol 1990; 21: 363-381
  • 107 Arend R, Bagaria M, Lewin SN et al. Long-term outcome and natural history of uterine adenosarcomas. Gynecol Oncol 2010; 119: 305-308
  • 108 McCluggage WG. Mullerian adenosarcoma of the female genital tract. Adv Anat Pathol 2010; 17: 122-129
  • 109 Wells M, Oliva E, Palacios J, Prat J. Mixed epithelial and mesenchymal Tumors of the Uterus. In: Kurman RJ, Carcangiu ML, Herrington CS, Young RH, eds. WHO Classification of Tumours of female reproductive Tract. Lyon: IARC Press; 2014: 148-151
  • 110 Tanner EJ, Toussaint T, Leitao jr. MM et al. Management of uterine adenosarcomas with and without sarcomatous overgrowth. Gynecol Oncol 2013; 129: 140-144
  • 111 Beckmann MW, Juhasz-Böss I, Denschlag D et al. Surgical methods for the treatment of uterine fibroids – risk of uterine sarcoma and problems of morcellation: position paper of the DGGG. Geburtsh Frauenheilk 2015; 75: 148-164
  • 112 Chan JK, Kawar NM, Shin JY et al. Endometrial stromal sarcoma: a population-based analysis. Br J Cancer 2008; 99: 1210-1215
  • 113 Bai H, Yang J, Cao D et al. Ovary and uterus-sparing procedures for low-grade endometrial stromal sarcoma: a retrospective study of 153 cases. Gynecol Oncol 2014; 132: 654-660
  • 114 Amant F, De Knijf A, Van Calster B et al. Clinical study investigating the role of lymphadenectomy, surgical castration and adjuvant hormonal treatment in endometrial stromal sarcoma. Br J Cancer 2007; 97: 1194-1199
  • 115 Beck TL, Singhal PK, Ehrenberg HM et al. Endometrial stromal sarcoma: analysis of recurrence following adjuvant treatment. Gynecol Oncol 2012; 125: 141-144
  • 116 Chu MC, Mor G, Lim C et al. Low-grade endometrial stromal sarcoma: hormonal aspects. Gynecol Oncol 2003; 90: 170-176