Abstract
Objective
To investigate the incidence and survival rates of primary uterine carcinosarcoma (UCS) in Korea.
Methods
From the Korea Central Cancer Registry, we identified patients diagnosed with primary UCS between 1999 and 2018 and collected their information, including age at diagnosis, Surveillance, Epidemiology, and End Results (SEER) summary stage, and treatment. Age-standardized incidence rates (ASRs) and annual percent changes (APCs) were calculated. Baseline characteristics and overall survival (OS) were compared by study periods, ages, and stages at initial diagnosis.
Results
Overall, the incidence rate of primary UCS increased markedly during the time period: ASRs, 0.02 per 100,000 in 1999 and 0.25 per 100,000 in 2018 (APC, 13.9%; p<0.001). No difference in OS was observed between patients diagnosed in 1999–2008 and those diagnosed in 2009–2018 (5-year survival rate, 46.0% vs. 48.6%; p=0.871). Considering the mean patient age at diagnosis of UCS, we divided the study population into 2 groups. Patients aged ≥60 years had a more frequent prior radiation history, received less multi-modality treatment, and showed worse OS than those aged <60 years (5-year survival rate, 42.7% vs. 53.6%; p=0.001). In multivariate analysis, both old age at diagnosis (≥60 years) and the SEER summary stage were identified as independent poor prognostic factors for OS, whereas radiation history before the diagnosis of UCS was not.
Conclusion
The incidence rate of UCS in Korea increased significantly from 1999 to 2018. Advanced stage and old age (≥60 years) at diagnosis might be poor prognostic factors for survival, but not prior radiation history.
Keywords: Carcinosarcoma, Incidence, Registry, Survival, Uterine Cancer
Synopsis
We investigated the trends in the incidence and survival rates of uterine carcinosarcoma (UCS) between 1999 and 2018. According to the Korea Central Cancer Registry, the incidence rate of primary UCS has increased significantly. Advanced stage and old age might be poor prognostic factors for survival, but not prior radiation history.
INTRODUCTION
Uterine corpus cancer is a global burden as it ranks as the sixth most commonly diagnosed cancer in women, with an estimated 417,000 new cases and 97,000 deaths annually [1]. The incidence rate of uterine corpus cancer varies across regions, with higher rates in developed countries. In 2022, 65,950 new uterine corpus cancer cases are expected to occur, making it the fourth most common cancer in women (7.1%) in the United States [2]. In Korea, uterine corpus cancer is expected to account for 2.8% of new female cancers by 2022 [3], but there has been a gradual increase in the incidence rate of uterine corpus cancer [4]. Surgery is the primary treatment option for uterine corpus cancer. Depending on the risk of persistent or recurrent disease after surgery, radiation and/or systemic therapy may be administered. Uterine corpus cancer is not a single disease entity but encompasses various histologic types with distinct clinical features [5].
Uterine carcinosarcomas (UCSs), also known as malignant mixed Müllerian tumors, are rare, accounting for only 5% of uterine corpus cancers. Presented as biphasic tumors composed of epithelial and mesenchymal tissues, UCSs had been classified as uterine sarcomas. Currently, the pathogenesis of UCSs is recognized as sarcoma differentiation of epithelial elements through epithelial-to-mesenchymal transition, based on various molecular genomic analyses [6,7,8]. Compared to uterine endometrial carcinoma, which is the major histologic type of uterine corpus cancers, UCSs are more aggressive and commonly diagnosed at an advanced stage and have worse survival [5]. Nevertheless, the current practice guidelines recommend that UCS be considered and managed as a high-risk endometrial carcinoma; UCS-specific treatment has not been established [9,10].
In the literature, UCS and endometrial carcinoma share common risk factors, such as nulliparity, obesity, excessive estrogen exposure, and tamoxifen use [11]. Distinctively, patients with UCS are older and more commonly African-American than those with endometrial carcinoma [12]. Prior pelvic radiation has also been a unique risk factor for UCS [13]. In Korea, the prevalence of female obesity is rapidly increasing owing to changes in lifestyle, such as a westernized diet and physical inactivity [14]. The relationship between obesity and the risk of developing uterine corpus cancer among Korean women has also been ascertained [15]. However, to the best of our knowledge, no study has reported UCS-specific nationwide epidemiological data in Korea.
Therefore, we aimed to investigate baseline characteristics and trends in the incidence and survival rates of UCS among Korean women using the Korea Central Cancer Registry (KCCR) database.
MATERIALS AND METHODS
This nationwide registry-based cohort study was approved by the Institutional Review Board of the National Cancer Center in Korea (No. NCC2022-0146). The requirement for informed consent was waived because the current study was a secondary analysis of de-identified data.
1. Patient selection and data collection
The KCCR, established in 1980 by the Korean government, became a nationwide, population-based cancer registry in 1999. Since then, the KCCR database has covered 98% of the cancer cases in Korea [16]. In this study, we extracted UCS-specific data from the KCCR database and identified all patients diagnosed with UCS between 1999 and 2018 using the topography codes C53-55 and morphological code M89803, according to the International Classification of Diseases for Oncology, 3rd edition [17] and Cancer Incidence in Five Continents histologic groups [18], respectively. The following patient information were collected: age at diagnosis of UCS, National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) summary stage (available since 2005), prior radiation history, and treatment modality within 4 months after the first diagnosis.
2. Statistical analyses
First, age-standardized incidence rates (ASRs) were calculated using Segi’s standard population. To estimate trends in the incidence rates of UCS, we calculated the annual percent changes (APCs) of UCS. Descriptive statistics were used to summarize the baseline characteristics, and Kaplan-Meier analysis was used in the survival analysis. In 2 group comparisons, Student’s t-test and Pearson’s χ2 test were used for continuous and categorical variables, respectively. We compared the overall survival (OS) between the 2 groups using Kaplan-Meier analysis with the log-rank test. Subgroup survival analyses were performed based on the year of diagnosis (1999–2008 and 2009–2018), age at diagnosis (<60 and ≥60 years), and SEER summary stage (localized, regional, and distant stages). In the multivariate analyses, we constructed Cox proportional hazards regression models to calculate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).
All statistical analyses were performed using the SAS 9.3 statistical software (SAS Institute Inc., Cary, NC, USA), Stata version 16.1 (StataCorp LP, College Station, TX, USA), and Joinpoint software 4.8.0.1 (National Cancer Institute, Bethesda, MD, USA). Statistical significance was defined as a 2-tailed p-value <0.05.
RESULTS
We identified 796 women diagnosed with UCS between 1999 and 2018. Although only 6 women were diagnosed with UCS in 1999, 115 women were diagnosed with UCS in 2018. During the 20-year period, the ASR of the UCS was 0.11 per 100,000 women. Overall, the incidence rate of UCS increased markedly, with an APC of 13.9% (p<0.001) (Table 1, Fig. S1).
Table 1. The incidence rates of primary uterine carcinosarcoma in Korea, 1999−2018.
| Year | Cases | Per 100,000 women | ||
|---|---|---|---|---|
| ASR | Age-specific incidence rate | |||
| <60 years | ≥60 years | |||
| 1999 | 6 | 0.02 | 0.01 | 0.10 |
| 2000 | 7 | 0.02 | 0.01 | 0.13 |
| 2001 | 7 | 0.03 | 0.02 | 0.10 |
| 2002 | 13 | 0.05 | 0.04 | 0.15 |
| 2003 | 10 | 0.03 | 0.01 | 0.20 |
| 2004 | 17 | 0.06 | 0.04 | 0.26 |
| 2005 | 15 | 0.05 | 0.04 | 0.19 |
| 2006 | 13 | 0.04 | 0.03 | 0.16 |
| 2007 | 33 | 0.10 | 0.08 | 0.42 |
| 2008 | 18 | 0.05 | 0.05 | 0.20 |
| 2009 | 23 | 0.06 | 0.05 | 0.31 |
| 2010 | 30 | 0.08 | 0.06 | 0.42 |
| 2011 | 39 | 0.10 | 0.09 | 0.47 |
| 2012 | 38 | 0.10 | 0.11 | 0.35 |
| 2013 | 42 | 0.10 | 0.09 | 0.48 |
| 2014 | 68 | 0.16 | 0.16 | 0.71 |
| 2015 | 80 | 0.18 | 0.15 | 0.96 |
| 2016 | 108 | 0.24 | 0.23 | 1.12 |
| 2017 | 114 | 0.25 | 0.26 | 1.11 |
| 2018 | 115 | 0.25 | 0.25 | 1.11 |
| 1999–2018 | 796 | 0.11 | 0.09 | 0.52 |
| APC (%) | 13.9 | 16.3 | 14.3 | |
| p | <0.001 | <0.001 | <0.001 | |
APC, annual percent change; ASR, age-standardized incidence rate.
The baseline characteristics and treatment details are presented in Table 2. The mean patient age at the initial diagnosis of UCS was 61.7 years. A prior radiation history was observed in 3.6% of the patients. UCS was most frequently diagnosed at the localized stage (45.2%), followed by the regional (26.8%), and distant (21.6%) stages. Although 5.3% of the patients did not receive any treatment, 38.1% and 56.6% received single- and multi-modality treatments, respectively. Surgery, chemotherapy, and radiation were provided to 89.8%, 51.7%, and 18.3% of the patients, respectively.
Table 2. Characteristics of patients with uterine carcinosarcoma in Korea.
| Characteristics | All (n=796) | Age at diagnosis (yr) | p | ||
|---|---|---|---|---|---|
| <60 (n=362) | ≥60 (n=434) | ||||
| Follow-up from registration (mo) | 42.7±1.6 | 49.9±2.8 | 36.6±1.9 | <0.001 | |
| Age at diagnosis (yr) | 61.7±0.4 | 52.7±0.3 | 69.1±0.3 | <0.001 | |
| Prior radiation history | 0.019 | ||||
| Yes | 29 (3.6) | 7 (1.9) | 22 (5.1) | ||
| No | 767 (96.4) | 355 (98.1) | 412 (94.9) | ||
| Stage at diagnosis (since 2005) | 0.404 | ||||
| Local | 333 (45.2) | 142 (42.6) | 191 (47.4) | ||
| Regional | 197 (26.8) | 93 (27.9) | 104 (25.8) | ||
| Distant | 159 (21.6) | 79 (23.7) | 80 (19.9) | ||
| Unknown | 47 (6.4) | 19 (5.7) | 28 (6.9) | ||
| Treatment modality* | 0.020 | ||||
| No treatment | 42 (5.3) | 15 (4.1) | 27 (6.3) | ||
| Single | 302 (38.1) | 123 (34.0) | 179 (41.5) | ||
| Multiple | 449 (56.6) | 224 (61.9) | 225 (52.2) | ||
| Treatment details* | 0.040 | ||||
| No treatment | 42 (5.3) | 15 (4.1) | 27 (6.3) | ||
| Surgery only | 268 (33.8) | 110 (30.4) | 158 (36.7) | ||
| Chemo only | 23 (2.9) | 12 (3.3) | 11 (2.6) | ||
| RT only | 11 (1.4) | 1 (0.3) | 10 (2.3) | ||
| Surgery + Chemo | 315 (39.7) | 157 (43.4) | 158 (36.7) | ||
| Surgery + RT | 62 (7.8) | 28 (7.7) | 34 (7.9) | ||
| Chemo + RT | 5 (0.6) | 3 (0.8) | 2 (0.5) | ||
| Surgery + Chemo + RT | 67 (8.4) | 36 (9.9) | 31 (7.2) | ||
Values are presented as number (%) or mean ± SD.
Chemo, chemotherapy; RT, radiation; SD, standard deviation.
*Missing data: 3.
The mean follow-up period was 42.7 months from the UCS diagnosis. During which, 399 patients died of the disease, corresponding to 4.2 years of a median OS (5-year survival rate, 47.8%) (Fig. 1). Between patients diagnosed in 1999–2008 and 2009–2018, no difference in OS was observed (median, 4.0 vs. 4.5 years; 5-year survival rate, 46.0% vs. 48.6%; p=0.871) (Fig. S2). The survival rates of patients with UCS significantly differed according to the SEER summary stage; the 5-year survival rates were 64.1%, 48.3%, and 15.0% for the localized, regional, and distant stages, respectively (p<0.001) (Fig. 2A).
Fig. 1. Survival curve of all primary UCS.
CI, confidence interval; OS, overall survival; UCS, uterine carcinosarcoma.
Fig. 2. Comparisons of OS. (A) Survival curve by the Surveillance, Epidemiology, and End Results summary stage; (B) Survival curve by the age at diagnosis.
CI, confidence interval; NA, not available; OS, overall survival.
Considering the mean patient age at the initial diagnosis of UCS, we divided the study population into 2 groups: <60 and ≥60 years. As shown in Table 1 and Fig. S1, the incidence rate of UCS was significantly higher in patients aged ≥60 years than in those aged <60 years. Between 1999 and 2018, the incidence rates of UCS significantly increased in patients aged <60 and ≥60 years, with APCs rates of 16.3% and 14.3%, respectively (both p-values <0.001).
Table 2 also presents comparisons of the baseline characteristics and treatment details between the 2 groups. Although the proportion of patients who had a history of prior radiation was significantly lower in patients aged <60 years than in those aged ≥60 years (1.9% vs. 5.1%; p=0.019), there were no differences in the SEER summary stage (p=0.404) or the proportion of patients who did not receive any treatment (4.1% vs. 6.3%; p=0.184) between the patients aged <60 and ≥60 years. Regarding treatment, the proportions of patients who underwent surgery (91.4% vs. 88.4%; p=0.159) and radiation (18.8% vs. 17.9%; p=0.739) were similar between the 2 groups. However, chemotherapy was more frequently administered in patients aged <60 years (57.5% vs. 46.9%; p=0.003). In patients aged <60 years, the most common treatment method was surgery plus chemotherapy (n=157, 43.4%), followed by surgery only (n=110, 30.4%). In patients aged ≥60 years, the same number of patients received surgery plus chemotherapy (n=158, 36.7%) and surgery only (n=158, 36.7%). Multi-modality treatment was more frequently administered in patients aged <60 years than in those aged ≥60 years (61.9% vs. 52.2%; p=0.014).
The mean follow-up period was significantly longer in patients aged <60 years than in those aged ≥60 years (49.9 vs. 36.6 months; p<0.001). Survival analysis revealed that patients aged <60 years had significantly better OS than those aged ≥60 years (median, 6.9 vs. 3.4 years; 5-year survival rate, 53.6% vs. 42.7%; p=0.001) (Fig. 2B). The survival rates of patients aged <60 years and ≥60 years differed significantly according to the SEER summary stage (both p-values <0.001) (Fig. 3). For the localized stage, patients aged <60 years had significantly better OS than those aged ≥60 years (5-year survival rate, 69.2% vs. 59.9%; p=0.038). However, no difference in OS was observed between patients aged <60 and ≥60 years for the regional (5-year survival rate, 55.4% vs. 41.7%; p=0.096) and distant (5-year survival rate, 17.1% vs. 13.1%; p=0.165) stages.
Fig. 3. Comparisons of OS rates according to the Surveillance, Epidemiology, and End Results summary stage and age at diagnosis.
CI, confidence interval; NA, not available; OS, overall survival.
In multivariate analysis, old age at diagnosis (≥60 years) (aHR=1.40; 95% CI=1.13−1.72; p=0.002) and advanced SEER summary stage (regional vs. local, aHR=1.85; 95% CI=1.40−2.44; p<0.001; and distant vs. local, aHR=4.96; 95% CI=3.83−6.43; p<0.001) were identified as independent poor prognostic factors for OS (Table 3). However, prior radiation history before diagnosis of UCS did not influence OS (aHR=1.24; 95% CI=0.76−2.03; p=0.385).
Table 3. Factors associated with overall survival.
| Characteristics | aHR | 95% CI | p | |
|---|---|---|---|---|
| Age group at diagnosis (yr) | ||||
| <60 | Reference | |||
| ≥60 | 1.40 | 1.13–1.72 | 0.002 | |
| Prior radiation history | ||||
| No | Reference | |||
| Yes | 1.24 | 0.76–2.03 | 0.385 | |
| Stage at diagnosis (since 2005) | ||||
| Local | Reference | |||
| Regional | 1.85 | 1.40–2.44 | <0.001 | |
| Distant | 4.96 | 3.83–6.43 | <0.001 | |
| Unknown | 2.31 | 1.53–3.49 | <0.001 | |
aHR, adjusted hazard ratio; CI, confidence interval.
DISCUSSION
In this nationwide registry-based cohort study, the ASR of UCS between 1999 and 2018 was observed as 0.11 per 100,000 women. Over the past 2 decades, the incidence rate of UCS has increased significantly (APC, 13.9%; p<0.001), which was the same in patients aged <60 and ≥60 years. Patients aged ≥60 years had prior radiation history more frequently, received multi-modality treatment less frequently, and had significantly worse OS than those aged <60 years. Advanced stage and old age (≥60 years) at diagnosis were associated with poor OS.
In Korea, there has been a significant increase in the incidence rate of uterine corpus cancer [4]. This increase originated from the westernization of diet and lifestyle, which led to increased obesity and excessive estrogen exposure [15]. Unopposed excessive estrogen is a risk factor not only for uterine endometrial carcinoma but also for UCS [11]. Expectedly, among the various histologic types of uterine corpus cancer, the incidence rate of UCS has also increased remarkably. Similar to our study, Matsuo et al. [19] and Liao et al. [20] investigated the SEER Program (1973–2013) and United States Cancer Statistics Public Use Database (2001–2017), respectively, and reported an increased incidence rate of UCS in the United States. Boll et al. [21] also reported an increase in incidence rate of UCS between 1989 and 2008 in the Netherlands from their nationwide population-based Netherlands Cancer Registry.
To identify UCS cases from the KCCR database, we used both topography and morphological codes. Nevertheless, changes in the pathological criteria of UCS during the study period might also be responsible for the marked increase in the incidence rate of UCS in Korean women. Traditionally, UCSs had been considered a subtype of uterine sarcoma, and there is a possibility that some cases of UCS might have been mistaken and not counted properly. Subsequent clinical, histopathological, immunohistochemical, ultrastructural, tissue culture, and molecular data suggest that (1) most, but not all, UCSs are monoclonal in origin, rather than true collision tumors; (2) the carcinomatous element is the “driving force” and that the sarcomatous component is derived from the carcinoma or from a stem cell that undergoes divergent differentiation; and (3) thus, UCSs should be considered metaplastic carcinomas and treatment for UCSs should be similar to high-grade endometrial carcinomas, rather than uterine sarcomas [6,22]. Such changes from a pathological perspective may have contributed to the recent increase in UCS diagnosis. Furthermore, the current use of immunohistochemical staining with various antibodies against sarcomatous and carcinomatous components might contribute to the improvement of diagnostic accuracy by distinguishing UCSs from undifferentiated endometrial carcinomas or undifferentiated uterine sarcomas. However, considering the rarity of UCS and its unique histological appearance, the number of such misdiagnosis cases seems to be low in the early days of the study period.
In the literature, UCSs usually occur in postmenopausal women, with a peak incidence at the ages of 60–70 years. The mean patient age at the initial diagnosis of UCS was 61.7 years in our study. The higher incidence rate of UCS in patients aged ≥60 years than in those aged <60 years might partly originate from long-term tamoxifen treatment [11]. In addition, we also recognized that a prior radiation history was significantly more frequent in patients aged ≥60 years than in those aged <60 years (5.1% vs. 1.9%, p=0.019). Previous studies have reported that women who have undergone pelvic radiation are at an increased risk of developing radiation-associated uterine corpus cancers, most representatively UCS [13,23]. Considering the latency period from initial therapy to the development of UCS, it is possible that prior pelvic radiation in young patients affected cancer development in old patients. Based on our study results, radiation history was not a prognostic factor for survival outcomes, which is also consistent with the result of a previous retrospective cohort study conducted by Pothuri et al. [13]. However, as Pothuri et al. [13] reported, radiation-associated UCS seems to have a preponderance of advanced-stage and high-risk features. In addition, physicians might hinder the prescription of radiation therapy for patients with radiation-associated UCS, owing to cumulative radiation toxicities.
UCSs are rare, but are known to have more aggressive behavior and are diagnosed at an advanced stage more frequently than uterine endometrial carcinomas. According to the SEER Program, the proportion of distant stage cases is significantly higher in UCS than in endometrial carcinomas (22% vs. 3%) [5]. Similarly, 21.6% of the study population was diagnosed at a distant stage. In the current study, although there was no difference in the SEER summary stage between patients aged <60 and ≥60 years, patients aged ≥60 years had significantly worse OS than those aged <60 years. Increasing age at diagnosis was also identified as a poor prognostic factor for disease recurrence and OS in early-stage UCS [24]. In our study, multi-modality treatment was less frequently administered in patients aged ≥60 years than in those aged <60 years, which was also found in women with advanced-stage endometrial cancer [25]. Multi-modality treatment is a burden for elderly patients with cancer and sometimes tends to be avoided. In our study, we could not determine the detailed comorbidities and performance status of the patients, which might have affected the administration of the multi-modality treatment. However, multi-modality treatment forms the basis of UCS management [9,10]. Therefore, the development of individualized treatment guidelines for elderly patients is required.
Interestingly, we found no improvement in OS between patients diagnosed with UCS in 1999–2008 and 2009–2018, suggesting that there has been relatively little improvement with therapeutic agents for UCS. In contrast, the management of uterine endometrial carcinoma has been rapidly evolving with the introduction of immune checkpoint inhibitors based on promising results from clinical trials. According to the phase III KEYNOTE-775/Study 309 trial, lenvatinib plus pembrolizumab significantly resulted in better progression-free survival and OS compared to chemotherapy in patients with recurrent endometrial cancer who had relapsed after a previous platinum-based chemotherapy regimen [26]. However, patients with UCS and uterine sarcomas were excluded from this trial. According to a single-arm phase I GARNET trial, dostarlimab demonstrated durable antitumor activity in both mismatch repair deficient/high microsatellite instability (objective response rate [ORR]=43.5%) and mismatch repair proficient/microsatellite-stable endometrial cancers (ORR=14.1%), with a manageable safety profile [27]. However, only 2 patients with UCS were included in this study. Currently, ongoing PORTEC-4a, a randomized trial of molecular profile-based adjuvant treatment for patients with high-intermediate risk endometrial cancer, only enrolls patients with endometroid histologic type [28]. In contrast, the RAINBO umbrella program, which investigates new adjuvant therapies in patients with endometrial cancer, includes all histologic types (ClinicalTrials.gov Identifier: NCT05255653).
Due to its low incidence rate, UCS has not only been understudied but has also been excluded from clinical trials. Such an imbalance of opportunity often causes a gap in relative survival. Considering that evidence on the use of immune checkpoint inhibitors remains limited in patients with UCS and they have little chance to be enrolled in clinical trials owing to their rarity, further efforts to determine the optimal management of UCS are required at the multicenter level.
Since The Cancer Genomic Atlas reported results from an integrative genomic analysis of endometrial carcinoma (n=373) and broadened insights into the genomic landscape of endometrial carcinoma in 2013 [29], the molecular classification of uterine corpus cancer has become a topic of interest. In 2017, Cherniack et al. [8] performed integrated genomic and proteomic analysis of UCS (n=57) and found extensive copy number alterations and frequent mutations in specific genes, such as TP53, similar to endometroid and serous uterine carcinomas . In 2019, Gotoh et al. [30] conducted targeted sequencing, DNA methylome analysis, and transcriptome analysis of UCS samples (n=92) and identified 4 molecular subtypes that resemble those observed in endometrial carcinoma. They also found that sarcoma differentiation was associated with epithelial-to-mesenchymal transition-related gene expression and DNA methylation changes, supporting the hypothesis of clonal origin of UCS with metaplastic conversion. Beyond the molecular characterization of UCS, researchers are now investigating the clinical actionability of molecular targets in UCS, which might be associated with improved survival outcomes.
Although the current study clearly reported trends in the incidence and survival rates of primary UCS over 20 years in Korea using the KCCR database, which covers almost all cases, it also has some limitations. First, from the KCCR database, we could not obtain more comprehensive demographic characteristics, International Federation of Gynecology and Obstetrics stage, and specific treatment details. For example, surgical extent and completeness, chemotherapy regimens, radiation doses, and delivery methods were unavailable for verification. Second, progression-free survival and other survival outcomes could not be inferred. Therefore, more extensive nationwide data collection and further improvement in data accessibility are necessary. Lastly, central pathology review was not conducted in this study. Instead, pathologic examination was performed in each institution. As the study period was quite long (2 decades), we cannot exclude the possibility that pathologic diagnosis might vary slightly from institution to institution.
In conclusion, our study results demonstrate that the incidence rate of UCS increased significantly from 1999 to 2018 in Korea. Advanced stage and old age (≥60 years) at diagnosis might be poor prognostic factors for survival, but not prior radiation history. Further studies are warranted to develop novel therapeutic agents and optimal management strategies to improve survival outcomes of patients with UCS.
Footnotes
Funding: This work was supported by the National Cancer Center of Korea (Grant No. 2211110).
Conflict of Interest: No potential conflict of interest relevant to this article was reported.
- Conceptualization: J.K.W., L.M.C.
- Data curation: H.J.
- Formal analysis: H.J., J.K.W.
- Funding acquisition: J.K.W.
- Investigation: K.S.I., K.J.H., L.C., J.K.W., L.M.C.
- Methodology: K.S.I., H.J., J.K.W., L.M.C.
- Project administration: J.K.W., L.M.C.
- Resources: J.K.W., L.M.C.
- Software: J.K.W.
- Supervision: J.K.W.
- Validation: K.J.H., L.C., H.J., L.M.C.
- Visualization: K.S.I., H.J.
- Writing - original draft: K.S.I.
- Writing - review & editing: K.S.I., K.J.H., L.C., H.J., J.K.W., L.M.C.
SUPPLEMENTARY MATERIALS
Age-standardized incidence curve for primary uterine carcinosarcoma.
Comparisons of OS according to the year of diagnosis.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Age-standardized incidence curve for primary uterine carcinosarcoma.
Comparisons of OS according to the year of diagnosis.