Trial of Radiation Therapy "Sandwiched" Between Chemotherapy to Treat Uterine Carcinosarcoma (MMMT)

The purpose of this study is to determine whether radiation therapy "sandwiched" between paclitaxel/carboplatin chemotherapy is effective in the treatment of uterine carcinosarcoma,and particularly whether this treatment will lessen the chance of the cancer returning in the pelvis or elsewhere in the body.

Uterine carcinosarcomas represent approximately 4% of primary uterine malignancies. However, our rates in the Bronx are about double the national rate likely due to a number of factors including the referral patterns and the ethnic and racial diversity of the community the investigator serve at Montefiore Medical Center. Carcinosarcoma is an aggressive uterine tumor with a poor prognosis and a recurrence rate of 53%. Sites of failure include pelvic and extrapelvic with most patients developing extrapelvic disease. Pelvic radiation decreases the risk of pelvic recurrence, but has not been shown to improve overall survival secondary to extrapelvic recurrences and the hematogenous route of metastasis. Use of radiotherapy alone does not control extrapelvic recurrences. Combination chemotherapy has been shown to provide an improvement in response rate but with increased toxicity. The investigators have had considerable experience here at Montefiore combining sequenced radiation therapy sandwiched with chemotherapy before and after radiation therapy for both carcinosarcoma and uterine papillary serous carcinoma. In our most recent carcinosarcoma trial, 27 patients with surgical stage 1-4 uterine carcinosarcoma, without evidence of gross disease, were treated with adjuvant ifosfamide/cisplatin or ifosfamide for three cycles, then received pelvic external beam radiotherapy and brachytherapy followed by three more cycles of ifosfamide/cisplatin or ifosfamide. The two year disease free survival for stage I patients was 18.75 months and for stages II-IV was 15.81 months. Similar to a GOG trial in the recurrent setting, in our adjuvant trial, toxicity was increased in patients who received ifosfamide with cisplatin without added efficacy. Thus, in the last cohort of this trial, the investigators dropped the cisplatin from the regimen because it was adding toxicity without benefit. In our uterine papillary serous carcinoma "sandwich" trial, 30 patients with surgical stages I-IV, without evidence of gross residual disease received adjuvant paclitaxel/platinum for three cycles, followed by external beam pelvic radiotherapy and brachytherapy, and then three more cycles of paclitaxel/platinum. The three year disease free survival for stage I/II patients was 69% and for stage III/IV patients was 54%. 29 out of the 30 patients completed the protocol with grade 3/4 neutropenia occurring in 42% of cycles. 6 out of 177 cycles were delayed 1 week for neutropenia. Both in-house trials of sequenced chemotherapy and radiation therapy resulted in higher than expected survival in the adjuvant setting. Multiple studies have demonstrated a response of carcinosarcoma to carboplatin and paclitaxel as well as the role of adjuvant radiotherapy in improvement in local control. Due to the recent reports of efficacy of paclitaxel and carboplatin in recurrent carcinosarcoma, this pilot protocol is designed to determine the toxicity and clinical benefit of radiation therapy "sandwiched" between three cycles of paclitaxel and carboplatin before and after radiation therapy.

Inclusion Criteria:

• Histologically documented uterine carcinosarcoma with no visible residual disease.
• Surgical staging to include total abdominal hysterectomy, bilateral salpingo- oophorectomy, peritoneal washings, and lymph node samplings.
• Patients must be entered no more than 12 weeks post operatively.
• Age > 18 years.
• ECOG performance status of < 2.
• Written voluntary informed consent.

Exclusion Criteria:

• Patient has impairment of hepatic, renal or hematologic function as defined by the following baseline laboratory values:
• Serum SGOT and /or SGPT > 2.5 times the institutional upper limit of normal
• Total serum bilirubin > 1.5 mg/dl
• History of chronic or active hepatitis
• Serum creatinine > 2.0 mg/dl
• Platelets < 100,000/mm3
• Absolute neutrophil count (ANC) < 1500/mm3
• Hemoglobin < 8.0 g/dl (the patient may be transfused prior to study entry)
• Patient has severe or uncontrolled concurrent medical disease (eg. uncontrolled diabetes, unstable angina, myocardial infarction within 6 months, congestive heart failure, etc.)
• Patient with any prior chemotherapy or radiotherapy for pelvic malignancy.
• Patients with dementia or altered mental status that would prohibit the giving and understanding of informed consent at the time of study entry.