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Guidelines covering uterine adenosarcoma

TL;DR — No society has issued a stand-alone, evidence-graded guideline whose only subject is uterine adenosarcoma, except the 2023 French GSF/TMRG document, which is histology-specific and still rests on retrospective series (Karabajakian 2023, PMID 37202293). ESGO/EURACAN/GCIG 2024 is the current European uterine-sarcoma guideline and includes an adenosarcoma subsection (Ray-Coquard 2024, PMID 39322612). GCIG 2014 remains the international consensus review dedicated to Müllerian adenosarcoma (Friedlander 2014, PMID 25341585). The accessible 2025 NCCN Insights paper concerns FIGO 2023 endometrial staging and systemic therapy for endometrial cancer, not adenosarcoma; the current parent guideline could not be independently retrieved (Abu-Rustum 2025, PMID 40763788). FIGO 2009 is the staging document (Prat 2009, PMID 19135669). Agreement among the verified adenosarcoma sources: surgery is the treatment; adjuvant therapy is not established for stage I without overgrowth. Disagreement is mostly about how far “can be considered” extends for chemotherapy in higher-risk disease — a wording difference, not a data difference.

Master comparison

Body Year Region Adenosarcoma-specific? Status
ESGO/EURACAN/GCIG uterine sarcoma 2024 Europe / international Subsection among uterine sarcoma histologies current
French GSF + Rare Gynecologic Tumor Group 2023 France Yes — dedicated current
GCIG consensus review, Müllerian adenosarcoma 2014 International Yes — dedicated current as consensus review; older than ESGO 2024
FIGO staging for uterine sarcomas 2009 Global Yes — distinct stage I current staging
NCCN Uterine Neoplasms v3.2025 Insights USA Accessible Insights paper is endometrial-focused; current parent-guideline adenosarcoma detail not independently retrieved dated access gap (Insights PMID does not update adenosarcoma)
ESMO-EURACAN-GENTURIS soft tissue and visceral sarcomas 2021 Europe Visceral sarcoma as a class; not histology-specific to adenosarcoma current for STS; superseded 2012/2008 ESMO STS
Italian SIGO consensus, uterine sarcomas 2020 Italy Uterine sarcoma as a class current national consensus
Ulrich / Denschlag practical review (PMID 30326467) 2018 Germany-facing Dedicated short review, not a society guideline adjacent

What they actually recommend about adenosarcoma

Surgery

All documents that mention adenosarcoma recommend complete surgical removal, typically hysterectomy ± BSO (Friedlander 2014, PMID 25341585; Karabajakian 2023, PMID 37202293; Nathenson 2016, PMID 27718181 as the review these guidelines cite). ESGO 2024: total hysterectomy is the standard for early uterine sarcoma generally; morcellation should be avoided (Ray-Coquard 2024, PMID 39322612). Lymphadenectomy is not routine in any of them; nodal metastasis rates of ~3% are the reason (Machida 2017, PMID 28109626). Fertility-sparing is not established as standard in ESGO or French GSF.

Adjuvant therapy — the live disagreement is small

Scenario ESGO 2024 French GSF 2023 GCIG 2014
Stage I, no SO Adjuvant endocrine therapy not recommended; adjuvant RT not recommended; post-operative chemotherapy not standard Role of hormone therapy, chemo, adjuvant RT not established No reported adenosarcoma-specific randomised outcome
Stage I with SO / high-grade Post-operative chemo not standard of care for stage I; after morcellation of high-grade/SO, chemo could be considered SO is the histopronostic factor that defines grade; adjuvant still “not established” SO worse outcome; no reported subgroup trial result
Stage II–IV completely resected Adjuvant chemo can be considered as an option because of poor prognosis Role not established No reported histology-specific trial result
Adjuvant RT, any stage I Not recommended Not established No adenosarcoma-specific RT-versus-no-RT result

ESGO’s “can be considered” for stage II–IV and for morcellated high-grade/SO is the most permissive current wording and is still an option, not a standard (Ray-Coquard 2024, PMID 39322612). French GSF is more uniformly agnostic (Karabajakian 2023, PMID 37202293). Neither cites a reported adenosarcoma-specific randomised result. A mixed-histology phase 3 registration included adenosarcoma but has unknown status and no posted results (NCT00162721, rechecked 2026-09-01). Nathenson’s review goes further than either guideline (“candidates for aggressive therapy with adjuvant chemotherapy” for high-risk) (Nathenson 2018, PMID 30169984).

Recurrent / metastatic

French GSF: re-treat relapses surgically aiming for complete resection; hormone therapy an option for low-grade ER/PR-overexpressing advanced disease; doxorubicin-based combinations for high-grade inoperable/metastatic (Karabajakian 2023, PMID 37202293). ESGO: endocrine therapy (aromatase inhibitor, progestogen, or GnRH analogue) for recurrent/metastatic ER/PR-positive low-grade adenosarcoma; do not give tamoxifen (agonist risk); radiotherapy can be used for palliation of recurrent/metastatic LG disease (Ray-Coquard 2024, PMID 39322612). These statements align. They rest on Nathenson 2017 (surgery association; doxorubicin/ifosfamide PFS) and on sarcoma-general endocrine practice, not on adenosarcoma RCTs (Nathenson 2017, PMID 29445312).

Staging

FIGO 2009 adenosarcoma stage I is invasion-based (IA no invasion, IB ≤½, IC >½), unlike LMS/ESS size-based stage I (Prat 2009, PMID 19135669). NCCN Insights 2025 discusses FIGO 2023 for endometrial carcinoma, which does not replace FIGO 2009 sarcoma staging (Abu-Rustum 2025, PMID 40763788).

Documents that cover uterine sarcoma generally, not adenosarcoma

ESMO 2021 (Gronchi, PMID 34303806) is the current STS/visceral-sarcoma CPG and supersedes ESMO 2012 (PMID 22997462) and 2008 (PMID 18456783). It is the right document for doxorubicin, trabectedin, pazopanib, follow-up cadence of sarcoma as a class. It is the wrong document to cite for adenosarcoma-specific adjuvant decisions. Italian SIGO 2020 is a national uterine-sarcoma consensus (Ferrandina 2020, PMID 32992154). Brooks 2004 and Benson 2017 are epidemiology/perspective, not guidelines.

Disagreements and gaps

  1. Adjuvant chemotherapy in resected high-risk disease. ESGO “option” versus French “not established” versus Nathenson review “candidates.” Same empty evidence base, different sentences.
  2. Ovarian preservation. Guidelines default to BSO; the SEER/institutional reassurance is too thin for a histology-specific recommendation (Nasioudis 2017, PMID 28541635; Li 2022, PMID 35005157). Guidelines are silent rather than opposed.
  3. Surveillance interval. None specifies an adenosarcoma schedule. Late recurrence (≥5 years in a third of Clement’s recurrences) is noted in reviews and not operationalised (Clement 1990, PMID 2156771).
  4. NCCN adenosarcoma detail remains a dated access gap. The 2025 Insights PMID does not update sarcoma-specific recommendations. On 2026-09-01 the auditor attempted both official NCCN uterine guideline PDF endpoints; each returned an HTML sign-in page rather than the guideline. Accordingly, this page makes no claim about current NCCN adenosarcoma recommendations beyond the verified scope of the Insights paper (Abu-Rustum 2025, PMID 40763788).
  5. No US society guideline dedicated to adenosarcoma. SGO has not issued a histology-specific document retrieved this session.

Watch list

  • ESGO/EURACAN/GCIG update after 2024 (the previous dedicated GCIG adenosarcoma review was 2014).
  • NCCN Uterine Neoplasms full guideline version after v3.2025, specifically the uterine sarcoma algorithm.
  • Publication of FUCHSia (NCT03926936) results, which would be the first prospective hormone-therapy dataset that named adenosarcoma in eligibility.
  • Any multi-institutional adjuvant study in SO-positive stage I — none registered as dedicated in this session’s ClinicalTrials.gov search.

Open questions

  • Should a future ESGO revision split “option” for adjuvant chemotherapy into SO-positive stage I versus stage II–IV, matching Carroll’s only comparative signal (Carroll 2014, PMID 25449308)?
  • Will FIGO 2023 endometrial staging bleed into sarcoma coding in registries and worsen, rather than improve, adenosarcoma stage mix?

References

  1. Ray-Coquard I, et al. ESGO/EURACAN/GCIG guidelines for the management of patients with uterine sarcomas. Int J Gynecol Cancer. 2024;34:1499-1521. PMID 39322612
  2. Karabajakian A, et al. Uterin adenosarcoma: French Guidelines of the French Sarcoma Group and the Rare Gynecologic Tumor Group. Bull Cancer. 2023;110:836-843. PMID 37202293
  3. Friedlander ML, et al. GCIG consensus review for mullerian adenosarcoma of the female genital tract. Int J Gynecol Cancer. 2014;24:S78-82. PMID 25341585
  4. Prat J. FIGO staging for uterine sarcomas. Int J Gynaecol Obstet. 2009;104:177-8. PMID 19135669
  5. Abu-Rustum NR, et al. NCCN Guidelines Insights: Uterine Neoplasms, Version 3.2025. J Natl Compr Canc Netw. 2025;23:284-291. PMID 40763788
  6. Gronchi A, et al. Soft tissue and visceral sarcomas: ESMO-EURACAN-GENTURIS Clinical Practice Guidelines. Ann Oncol. 2021;32:1348-1365. PMID 34303806
  7. ESMO / European Sarcoma Network Working Group. Soft tissue and visceral sarcomas: ESMO Clinical Practice Guidelines. Ann Oncol. 2012;23 Suppl 7:vii92-9. PMID 22997462
  8. Casali PG, et al. Soft tissue sarcomas: ESMO clinical recommendations. Ann Oncol. 2008;19 Suppl 2:ii89-93. PMID 18456783
  9. Ferrandina G, et al. Italian consensus conference on management of uterine sarcomas on behalf of S.I.G.O. Eur J Cancer. 2020;139:149-168. PMID 32992154
  10. Ulrich UA, Denschlag D. Uterine Adenosarcoma. Oncol Res Treat. 2018;41:693-696. PMID 30326467
  11. Nathenson MJ, et al. Uterine Adenosarcoma: a Review. Curr Oncol Rep. 2016;18:68. PMID 27718181
  12. Nathenson MJ, Conley AP. Prognostic factors for uterine adenosarcoma: a review. Expert Rev Anticancer Ther. 2018;18:1093-1100. PMID 30169984
  13. Nathenson MJ, et al. Treatment of Recurrent or Metastatic Uterine Adenosarcoma. Sarcoma. 2017;2017:4680273. PMID 29445312
  14. Machida H, et al. Significance of lymph node metastasis on survival of women with uterine adenosarcoma. Gynecol Oncol. 2017;144:524-530. PMID 28109626
  15. Nasioudis D, et al. Safety of ovarian preservation in premenopausal women with stage I uterine sarcoma. J Gynecol Oncol. 2017;28:e46. PMID 28541635
  16. Li JY, et al. Clinicopathologic characteristics and oncologic outcomes in adenosarcoma of gynecologic sites. Gynecol Oncol Rep. 2022;39:100913. PMID 35005157
  17. Clement PB, Scully RE. Mullerian adenosarcoma of the uterus: a clinicopathologic analysis of 100 cases. Hum Pathol. 1990;21:363-81. PMID 2156771
  18. Carroll A, et al. Uterine adenosarcoma: an analysis on management, outcomes, and risk factors for recurrence. Gynecol Oncol. 2014;135:455-61. PMID 25449308