Serous carcinomas, also referred to as uterine papillary serous carcinomas, are considered high-risk lesions. The first description in 1982, noted that this entity usually occurred in elderly, hypoestrogenic women who presented with advanced-stage disease and accounted for up to one-half of deaths from endometrial carcinoma (101). Since then, several reports documented the aggressive nature and poor prognosis of serous carcinomas.
They are commonly admixed with other histologic patterns, but mixed tumors behave as aggressively as pure serous carcinomas. Even patients with a very small proportion of serous features (5%) remain at high risk of recurrence (105). Serous carcinomas are often associated with lymph– vascular space and deep myometrial invasion. The presence of lymph node metastases, positive
Figure 35.4 Serous carcinoma of endometrium. Branching papillae are supported by delicate fibrovascular cores and lined with columnar cells with moderate nuclear atypism, multiple nucleoli, and mitotic figures. (Provided by Gordana Stevanovic, MD, and Jianyu Rao, MD, Department of Pathology, UCLA.) peritoneal cytology, and intraperitoneal tumor does not necessarily correlate with increasing myometrial invasion (104). Even when these tumors appear to be confined to the endometrium or endometrial polyps without myometrial or vascular invasion, they behave more aggressively than endometrioid carcinomas and have a propensity to spread intra-abdominally, simulating the behavior of ovarian carcinoma. In one series, 37% of patients with serous carcinomas of the endometrium confined to a polyp demonstrated extrauterine disease when subjected to exploration and surgical staging (106).
A multi-institutional review of 206 patients with surgical stage I and II serous carcinomas demonstrated recurrence in 21% (105). Substage and treatment with platinum-based chemotherapy were associated with improved overall survival. Survival of surgically staged patients without myometrial invasion or extrauterine disease is between 89% and 100%, suggesting that observation may be appropriate in select patients, particularly in elderly patients with comorbidities (107). However, stage I patients, particularly those with myometrial invasion, remain at high risk of both peritoneal and vaginal recurrence. Therefore, platinum-based chemotherapy and vaginal brachytherapy should be considered in these patients (107–109).
Surgical treatment of advanced disease is no different fromthe endometrioid subtype, consisting of complete extirpation of visible disease (108). In one investigation from the Mayo Clinic, cytoreduction to microscopic residual was associated with a median overall survival of 51 versus 12 months for those patients with any residual (110). Postoperative treatment of advanced disease in the United States consists of chemotherapy and pelvicradiation, with or withoutpara-aortic radiation. The Gynecologic Oncology Group study GOG184 included serous carcinomas and randomized patients to carboplatin and paclitaxel versus cisplatin, doxorubicin (Adriamycin), and paclitaxel together with tumor volume–directed radiation (111). The former regimen demonstrated similar outcomes with less toxicity. Limited data suggest that delivering radiation “sandwiched” with chemotherapy improves progression-free and overall 3-year survival rates (112). Ongoing studies are evaluating the role of chemotherapy alone for these tumors, especially because of the high rate of peritoneal dissemination and recurrences. It remains unknown whether radiation improves survival in addition to chemotherapy alone. For elderly patients with multiple comorbidities who cannot tolerate multimodal therapy, chemotherapy alone.