|Uterine LMS and Adjuvant Treatment
written and compiled by doctordee
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|What is Adjuvant Treatment?|
with special reference to Uterine LMS
Adjuvant treatment is treatment when there is no evidence of disease, after surgical removal with wide clear margins.
It is best to review all the medical articles relevant to your primary site when you make a decision about adjuvant treatment.
It is NOT adjuvant treatment if radiotherapy or chemotherapy is given because there are surgical margins that are either too narrow, or contaminated with tumor. In these situations, treatment is NOT adjuvant treatment and usually does extend survival time. Sometimes when an LMS tumor bursts [another reason to read your operation report], adjuvant treatment is also considered.
For Uterine LMS, the decision to have adjuvant treatment is usually made in the flurry of desperation that accompanies the diagnosis. Usually it is adjuvant radiotherapy that is offered to decrease possible local recurrences. Since the repercussions of having adjuvant pelvic radiation are permanent and serious, we urge that considerable thought and discussion go into the decision.
The challenge of surviving with LMS involves using appropriate treatments that are proven to have benefit, and avoiding treatments in situations where they will have less or no proven benefit. The number and type of treatments are limited, and take their toll on the patients. Choose what will be most effective. Try to avoid any unnecessary treatment or a damaging treatment with no proven benefit.
The clinical trials that have been done on whether or not pelvic irradiation is effective, either show decreased recurrence, or no effect upon recurrence. They do not show increased survival time. You can print out the studies, and discuss them with your doctor. You can also visit the Radiation Damage page, and print out those articles for discussion, as well.
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For UTERINE LMS resected with CLEAR MARGINS and NO EVIDENCE OF DISEASE:
pro and cons of adjuvant pelvic irradiation
Benefits of Adjuvant Pelvic Irradiation:
Might reduce local recurrence rates.
Disadvantages of Adjuvant Pelvic Irradiation:
1. It gives NO increase in survival time.
2. Does not prevent the occurrence of of metastases.
3. Might reduce, but does not eliminate, recurrence in the irradiated field.
4. Because of the possibility of the radiation causing dedifferentiation in any surviving tumor cells, a recurrence after irradiation might be exceedingly aggressive.
5. Recurrence can occur outside the irradiated field.
6. Major PERMANENT organ Damage from toxic effects of radiation on normal tissue. Permanent damage starts showing after 3 months, and continues to develop as time goes on.
[Local tissue that can get damaged includes bladder, ureters, bowel, major blood vessels, major blood forming areas and nerve plexuses in the area.
There are two 20 year survivors of LMS that had pelvic radiation. Both have had such serious damage to their intestines that they require Total Parenteral Nutrition. One has difficulty walking because of severe neuropathy in her legs from the irradiation of her spinal cord and nerves.
See the Radiation Damage page on this website.
7. Adjuvant pelvic irradiation may close some future surgical options.
Surgery is much more difficult in the area afterwards, because radiation seriously impairs the blood supply to irradiated tissues. Tissues that have been irradiated do not usually heal so well because of the blood vessel damage.
The heavy impenetrable scarring that can occur after radiation can make surgery difficult to impossible. And LMS is a disease best handled with surgery.
8. Adjuvant pelvic irradiation may close some future radiation options.
It may prevent the use of radiation later on, if there is an inoperable tumor.
9. Adjuvant pelvic irradiation may close some future chemotherapy options. Radiation and chemotherapy both hit the bone marrow with cumulative effects. [See discussion about myelodysplasia on this website's chemotherapy page.] It may decrease the amount of chemotherapy allowable in the future.
10. Adjuvant pelvic irradiation may close some clinical trial options. It may prevent admission to some clinical trials.
11. There is an increased risk of a new, different, primary cancer in the area irradiated.
12. We are not counting the time and effort and symptoms endured over the 6 weeks, nor the financial cost.
I have been told that this listing is "one sided".
It is not meant to be a "side", but a listing of the advantages and disadvantages of adjuvant pelvic irradiation in uterine LMS where there are CLEAR MARGINS and all disease was resected.
One is trading a possibly decreased chance of local recurrence against certain damage, and probable decreased future options, and there is no increase in survival time.
This is a complex decision, and should be discussed with a sarcoma oncologist.
Information from the Medical Literature
These will give you the articles, and then the abstracts of the articles [click on the title], on the subjects listed. These are not difficult to read. It is worth the search. You can copy the abstracts and bring them in to discuss with your doctor/s.
Search Pubmed for uterine LMS and adjuvant radiation
Search Pubmed for uterine LMS recurrence and adjuvant radiation
Search Pubmed for uterine LMS and adjuvant radiation and survival
From the LMS List at ACOR:
Subject: Response to radiation appointment
I'm writing to you because your tumor was similar in origin to mine. My
tumor arose from the perineal body, was recto-vaginal but not adherent to
either. My surgery removed the tumor only...nothing else...and my margins
were clear but quite, quite close.
Radiation was discussed but not recommended!
Pelvic radiation can cause serious marrow suppression and the pelvis is where most of the cells of the blood are made. Also, it would have meant damage to the vulva, vagina, and bowels. This came from both Dr. Demetri of Dana-Farber and my local gyn-onc.
Dr. Demetri also told me that radiation might help prevent a recurrence IN THE RADIATED FIELD but that just centimeters away from that one could have a recurrence.
[Pelvic radiation might also limit future choices in surgery, chemotherapy, clinical trials, and radiotherapy. doctordee]
It has been 19 months since my diagnosis and surgery and there has been no
recurrence for me.
I am not recommending that you NOT do radiation, simply letting you know the scenario that I went through.
The studies show no consistent advantage for adjuvant chemotherapy in Uterine LMS.
There is no increase in survival time.
Part of the problem is that most of the agents tried have low rates of response from LMS tumors. It will be interesting to see if a Gemcitabine clinical trial for grade I/II ULMS has better results.
Women whose tumors show invasion of blood vessels or lymphatic vessels are at greater risk of developing metastases. At some centers, these women are offered AIM or other chemotherapy. Again, the past clinical trials should be looked at, and the subject discussed carefully with the oncologists.
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