Invasive breast carcinoma - IARC

Prognosis and predictive factors
The clinical course of uterine carcinosarcoma
is generally aggressive with a poor
overall prognosis, considerably worse
than that of a poorly diff e re n t i a t e d
endometrial carcinoma. The pattern of
spread is generally similar to that of high
grade endometrial carcinoma, and deep
myometrial invasion and extrauterine
spread are often observed at the time of
presentation. The clinical staging is the
same as that for endometrial carcinoma.
Some studies have found no independent
prognostic factors other than tumour
stage, whereas others have found that
the characteristics of the epithelial component
such as high grade carcinoma,
including serous or clear cell components,
are associated with a worse prognosis
{2692}. Previously, it was thought
that the presence of heterologous mesenchymal
components indicated a worse
outcome; however, recent larger studies
have suggested that the histological features
of the mesenchymal component
bear no relationship to the overall prognosis
{2692}.
The biological behaviour of uterine carcinosarcomas
is more akin to high grade
endometrial carcinomas than to uterine
sarcomas {282,2692}. Carcinosarcomas
primarily spread via lymphatics, whereas
pure uterine sarcomas commonly spread
h a e m a t o g e n o u s l y. Detailed studies of
uterine carcinosarcoma have shown that
metastatic foci and foci within lymphatic
or vascular spaces are commonly carcinomatous
with pure sarcomatous elements
being rare {282,2692,2767}.
Although the tumour stage is the most
important prognostic factor, recurrences
may be encountered even in those rare
cases lacking myometrial infiltration.
However, tumours confined to an otherwise
benign polyp appear to have a
somewhat better outcome {188,1382}.
Adenosarcoma
Definition
Adenosarcoma is a biphasic neoplasm
containing a benign epithelial component
and a sarcomatous mesenchymal
component.
Epidemiology
Adenosarcoma occurs in women of all
ages, ranging from 15-90 years with a
median age at diagnosis of 58.
Adenosarcomas have been reported in
women undergoing tamoxifen therapy for
breast cancer {509} and occasionally
after prior pelvic radiation {515}. There is
no association of adenosarcoma with
obesity or hypertension.
Clinical features
Typical symptoms of patients with
a d e n o s a rcoma are abnormal vaginal
bleeding, an enlarged uterus and tissue
p rotruding from the external os. The
tumour may not be correctly diagnosed
as adenosarcoma until re-excision of a
recurrent polypoid lesion {515}.
Macroscopy
Adenosarcomas typically grow as exophytic
polypoid masses that extend into
the uterine cavity. Rarely, they may arise
in the myometrium, presumably fro m
adenomyosis. Although the tumour is
usually a single polypoid mass, it sometimes
may present as multiple papillary
masses. On sectioning, the surface is tan
b rown with foci of haemorrhage and
necrosis. Small cysts are frequently present.
Most adenosarcomas do not invade
the myometrium.
Histopathology
Under low magnification a leaf-like pattern
closely resembling phyllodes tumour of
the breast is observed. Isolated glands,
often dilated and compressed into thin
slits, are dispersed throughout the mesenchymal
component. Characte- ristically,
t h e re is stromal condensation surro u n d i n g
the glands and clefts. It is in these are a s
w h e re the greatest degree of stro m a l
atypia and mitotic activity is present. By
definition the epithelium is benign and
may show focal metaplastic changes. The
mesenchymal component of an
a d e n o s a rcoma is generally a low grade
homologous stromal sarcoma containing
v a rying amounts of fibrous tissue and
smooth muscle. Mesenchymal mitotic figu
res, usually stated to be more than one
per 10 high power fields, are re q u i red in
the hypercellular cuffs. Cytological atypia
is typically only mild, but is occasionally
moderate. Sex cord-like components
resembling those in endometrial stro m a l
s a rcomas are found in less than 10% of
a d e n o s a rcomas. Heterologous components
consisting of striated muscle (most
commonly), cartilage, fat and other components
are present in approximately 10-
15% of tumours The diagnosis of sarc o-
matous overgrowth is made if the pure
A
Fig. 4.44 Adenosarcoma. A The tumour is composed of tubular and convoluted, cleft-like glands of endometrioid type surrounded by a cuff of cellular mesenchyme.
B A polypoid structure compresses a glandular lumen producing a leaf-like pattern similar to that of a mammary phyllodes tumour. The epithelial component is cytologically
bland, and the mesenchymal component is cellular and fibromatous without significant nuclear atypia but contained abundant mitoses.
B
Mixed epithelial and mesenchymal tumours 247