2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

Fig. 1. PET CT of synchronous lung and acetabular metastatic
lesions, managed surgically after an initial 7.5-year disease-free
interval.
Abbreviation: PET CT, positron emission tomography/computerized
tomography.
sectomy, listed earlier, should be expanded to encourage
consideration of pulmonary metastasectomy for patients
who have either synchronous or prior resectable metastases
outside of the chest. 16 This point is illustrated by our case
history. Figure 1 is a positron emission tomography/computerized
tomography (CT) demonstrating the two sites of
recurrent disease at the time of the initial metastasectomy.
Liver Metastasectomy
Resection is frequently performed for liver metastases
resulting from colorectal cancer. However, the role of surgery
is less clear in the case of sarcomatous liver metastases.
Due to the paucity of cases, few studies specifically address
liver metastasectomy in uterine sarcoma. However, several
small studies of heterogeneous patient populations with
metastatic leiomyosarcoma have demonstrated that in appropriately
chosen patients, liver resection for metastatic
disease can prolong survival. 18,19 In one small series of 66
patients who underwent resection, resection with radiofrequency
ablation, or radiofrequency ablation alone, the median
overall survival after the procedure was 47 months.
Longer survival was associated with metastases 3 cm or
smaller and with resection alone compared with radiofrequency
ablation with or without surgical resection. 19 A
study of 11 patients demonstrated a median survival of 39
months after resection and improved survival associated
with complete resection of metastatic disease. 18
Inferior Vena Cava Resection or Intracardiac
Metastasectomy for Recurrent ESS
Vascular extension is a common characteristic of ESS.
Inferior vena cava tumor thrombus likely begins as tumor
growth within the uterine or ovarian veins. 20 Multiple case
364
reports and small series have documented extensive resections
for recurrent ESS with inferior vena cava and intracardiac
extension. 21,22 Preoperatively, imaging studies such
as CT, magnetic resonance imaging, and transesophageal
ultrasound or echocardiography can delineate the extent of
disease. Depending on the findings of these studies, the
surgery may be done by laparotomy, thoracotomy, or combined
sternolaparotomy. In one series of 19 patients, cardiopulmonary
bypass was required during seven procedures.
When reconstruction of major vascular structures such as
the inferior vena cava was necessary, xenopericardium and
graft replacements were used. In this series, a radical
resection resulting in complete tumor removal was possible
in 10 patients, some of whom required concurrent surgical
procedures for synchronous metastases, including pulmonary
metastasectomy or pelvic extenteration. The median
survival was 2 years, with a range of 0.3 to 4.5 years. 21
Because of the overall excellent prognosis in completely
resected ESS and the likelihood of imminent heart failure or
pulmonary tumor embolism in women with intracaval or
intracardiac extension, surgical excision is considered appropriate
for well-selected patients. 22,23
Resection of Recurrent Adenosarcoma
Few data are available on resection for the treatment of
recurrent adenosarcoma. In one small study of 23 women, 24
17 had resection of recurrence in the vagina, pelvis, or
abdomen. Of these women, eight had a durable and possibly
curative response, with disease-free intervals of 5 to 12
years.
Survival after Surgery for Recurrent Disease
Survival after resection for recurrence of uterine sarcoma
varies among studies. In studies that include patients with
all types of soft tissue sarcoma, 15,25 the median overall
survival as well as disease-specific survival after metastasectomy
is poorer than in studies of more homogenous
populations of patients with gynecologic sarcomas. 14,17,26
This finding may reflect more aggressive tumor biology in
patients with nongynecologic sarcomatous metastases.
In studies of patients with metastatic gynecologic sarcoma,
the median survival after resection of metastatic
disease ranges from 24 to 31 months, similar to the survival
for the patient described in our case history. 9,10 In one study,
disease-free survival after surgical resection of first recurrence
was nearly 4 years. 17 Five and 10-year survival ranges
from 38% to 47% and 34% to 35%, respectively. 12,14,26
Studies addressing outcomes after surgical resection of recurrent
uterine sarcoma are summarized in Table 1. Given
these favorable survival data, it is clear that in the appropriately
selected patient, surgical resection of metastatic
disease may prolong disease-free and overall survival.
Characteristics Correlating with Improved Outcome
after Metastasectomy
Characteristics associated with improved survival after
resection of recurrent disease have been retrospectively
assessed in multiple studies. Factors that have been assessed
for correlation with improved outcome after metastasectomy
include complete response after upfront
treatment, disease-free interval between primary diagnosis
and surgery for first recurrence, presence of residual disease