[Low grade fibromixoid sarcoma: a purpose of 3 cases and review of the bibliography]

BACKGROUND

Low grade fibromyxoid sarcoma or tumor Evans is a variety of soft tissue sarcoma that represents 1% of all malignancies. More common in limbs and trunk (50%), we present 3 new cases of retroperitoneal reviewing their characteristics and performing a literature review.

CLINICAL CASE

In the retroperitoneal location highlights the poor specificity of clinical symptoms, demonstrating, according to their growth and size, as an abdominal tumor, usually painless, or by compression and/or invasion of nearby structures. In cases that present the most important finding was the presence of a palpable abdominal tumor without other symptoms despite remarkable infiltration of other organs that should be included in surgical resection.

CONCLUSIONS

We emphasize the difficulty of correct diagnosis preoperatively because preoperative studies are inconclusive and only the histological and immuno-histo-typing chemistry allow precise identification.

Clinicopathological study of primary superficial leiomyosarcomas

BACKGROUND

Primary superficial leiomyosarcomas (PSL) are rare malignant lesions that are subdivided into cutaneous and subcutaneous tumors. Primary cutaneous and subcutaneous leiomyosarcomas differ not only as to primary site of origins, but also to differences in prognosis. Guidelines for management and follow-up are not clearly defined in the literature.

MATERIAL AND METHOD

Retrospective review was conducted from the patient's chart between January 2000 and December 2009. Histopathology, immunohistochemistry, and clinical and surgical records were reviewed.

RESULTS

The authors found five cases of PSL and divided them into two cases of cutaneous leiomyosarcomas and three cases ofsubcutaneous leiomyosarcomas. Overall, mean age of the patients was 42.4 years, male: female ratio was 4:1. Clinical presentations were painless mass. Wide excisions were performed in three cases with 2 cm margins. No local recurrence was found in the period of follow-up (6 months to 3 years). One case presented with bony metastasis five years after operation.

CONCLUSION

PSL are rare tumors. Surgical resection remains the main option for curative treatment. Wide excision with at least 2 cm peripheral margins and a depth that includes subcutaneous tissue and fascia are recommended. The natural history of these tumors is not clearly defined. All patients should be followed-up for a period of at least five years after treatments. The authors hoped that further study of these tumors would result in better treatments and follow-up guidelines to be a benefit to such patients in the future.

Isolated cutaneous metastasis of uterine leiomyosarcoma: case report and review of literature

A 54 year old lady presented for routine excision of a scalp lesion thought clinically to represent a sebaceous cyst of the right occiput. 4 years earlier she underwent total abdominal hysterectomy and right salpingo-oophorectomy for 3 large uterine fibroids. Histo-pathological examination of the hysterectomy specimen revealed an incidental low-grade leiomyosarcoma. Staging imaging was negative for metastatic disease. She made an uneventful recovery and was treated further by adjuvant pelvic radiotherapy.She noticed an uncomfortable and unsightly cystic swelling on her occiput four years after hysterectomy and was referred for routine excision of what was believed to be a benign lesion. The lesion was excised and sent for histopathological examination. Microscopic analysis including immuno-histochemistry demonstrated an ER and PR positive metastatic deposit of leiomyosarcoma. The margins of excision were histologically clear of disease.At Multi-Disciplinary Team (MDT) discussion a diagnosis of metastatic scalp deposit from previous uterine leiomyosarcoma was made. Re-staging CT brain, thorax, abdomen and pelvis and MRI brain were negative for local recurrence or distant metastases. She is currently undergoing radiotherapy to the scalp and surrounding tissues and will be followed up closely by the involved teams.To the best of our knowledge, this is the first case described in the worldwide literature of isolated cutaneous metastasis to the scalp of uterine leiomyosarcoma without evidence of disseminated disease at other sites.

VIRTUAL SLIDES

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1311834987345566.

Muscular metastasis from mesocolic and duodenal leiomyosarcoma. A case report and a review of the literature

BACKGROUND

Mesenteric and duodenal leiomyosarcomas are very rare malignancies. Muscular metastases from leiomyosarcoma are even more rare. Surgery is the only chance of cure and should be attempted whenever possible. The relief of symptoms and the prevention of recurrences are ultimately the aims of surgery. We present a unique case of mesocolic and duodenal leiomyosarcoma with muscular metastases.

CASE REPORT

A 61 year old woman was treated by radical resection including left neftectomy and left hemicolectomy for a leiomyosarcoma of the left mesocolon. Three years after the first surgery a leiomyosarcoma of the duodenal wall was diagnosed. Following a careful evaluation that ruled out the presence of other secondary locations, she underwent pancreatoduodenectomy. Three months later she observed a small, mildly painful swelling in the left thigh, rapidly growing to a diameter of 4 cm over a month period. The MRI showed a low-signal intensity malignancy in T2-weighted images whereas the lesion was homogeneously enhanced by Gadolinium on T1-weighted imaging. The histological examination after excision confirmed the clinical suspicion of a metastasis from high grade leiomyosarcoma. Successively the patient underwent a palliative chemotherapy treatment with epirubicin and ifosfamide for three cycles. The patient experienced a progression of disease with multiple pulmonary and encephalic metastases five months later.

CONCLUSION

Muscular metastases from leiomyosarcoma are occasionally described in the literature. The apparition of muscular metastases is considered a negative prognostic factor and shortly precedes massive distant diffusion of the malignancy. Denervation syndrome can be a risk factor for muscular metastases. To our knowledge, this is the first report of a skeletal-muscle metastasis following mesenteric and duodenal leiomyosarcoma.

Local recurrence and multi-organ metastasis of primary retroperitoneal leiomyosarcoma in unusual locations after surgical resection

We report a case of retroperitoneal leiomyosarcoma in a 52-year-old woman, who developed local recurrence, pulmonary, hepatic, peritoneal, pancreatic, subcutaneous and intramuscular metastases two years after surgical resection of the primary tumor. Metastasis to the pancreas, subcutaneous or muscular tissue is very rare; however, presence of a lesion in these locations in a known case of leiomyosarcoma might indicate a metastatic tumor deposit.

The use of lumbar sympathetic blockade at L4 for management of malignancy-related bladder spasms

BACKGROUND

Cancer-related bladder spasms may be a rare but severe symptom of bladder or metastatic cancer or its related treatments. Various treatments described in the literature include systemic medications, intravesical or epidural medications, or even sacral neurolectomies.

OBJECTIVE

We present 3 patients who have suffered from bladder spasm either from invasion of the bladder wall by tumor (2 patients) or from intravesical chemotherapeutic treatment.

DESIGN

Case Report.

SETTING

Cancer pain management hospital.

METHODS

For each patient, we describe the use of lumbar sympathetic block to successfully treat the bladder spasms. Sympathetic blockade was performed at the left anterolateral border of lumbar vertebra L4. We used 10 mL of local anesthetic (0.25% bupivacaine) delivered in 2 mL aliquots, each given after negative aspiration for heme. Each procedure was performed with fluoroscopic guidance (both AP and lateral views) with the use of iodine contrast (Omnipaque-180) to confirm the location of the medication and its resulting spread.

RESULTS

All 3 patients had a reduction in the frequency and intensity of spasms, with 2 out of 3 patients not having a recurrence of the spasms for up to 2 months post procedure and follow up.

LIMITATIONS

Case Report.

CONCLUSION

Lumbar sympathetic blockade could be a useful treatment for recurrent bladder spasm in the oncologic population. Based on these findings, we feel that the branches of the sympathetic nerve set at L4 may be a good target for neurolytic procedures, such as radiofrequency ablation, for long term treatment of bladder spasms. Further research is necessary to determine the efficacy of this technique for the treatment of bladder spasms in the oncologic population.

Pancreaticoduodenectomy for metastasis of uterine leiomyosarcoma to the pancreas

Metastasis of uterine leiomyosarcoma to the pancreas is rare. A 46-year-old woman was diagnosed with uterine leiomyosarcoma and underwent surgery. Thereafter, recurrences in the lung and subsequently in the pancreas were diagnosed. These lesions were resected and diagnosed as metastasis of uterine leiomyosarcoma. We report a rare case of uterine leiomyosarcoma with metastasis to the lung and pancreas, both of which were resected using aggressive surgery.

Uterine smooth muscle tumors of uncertain malignant potential: a case presentation

A 42-year-old virgin woman was admitted to our clinic with increasing menorrhagia and dysmenorrhea for several months. A pelvic ultrasound scan showed a 9 × 7 cm heterogeneous mass in the uterine cavity. Pelvic magnetic resonance imaging showed a large non-homogeneous tumor mass measuring 97 × 56 mm in the uterine cavity. After intravenous contrast material, cystic necrotic areas with marked contrast enhancement were observed in the solid lesion. Tumor markers were all within normal ranges. The patient underwent laparotomy, and total hysterectomy and bilateral salpingo-oophorectomy were performed. Our case was diagnosed as uterine smooth muscle tumor of uncertain malignant potential (STUMP). The patient was put on a close clinical follow-up schedule, and is doing well without recurrence in 2 years later. Patients with STUMP should be counseled regarding the potential for recurrence as leiomyosarcoma, and may require closer surveillance than a yearly examination and may need a consultation with a gynecologic oncologist.

Rectal leiomyosarcoma: report on two cases and a practical approach to differential diagnosis

Rectal leiomyosarcoma is an uncommon malignancy. Herein, we describe the clinicopathological features and biological behaviour of these tumours, and provide a practical approach to differential diagnosis, particularly with gastrointestinal stromal tumours (GIST). We report two cases in elderly men. In the first, the lesion was 2 cm from the anal sphincter, while it was located in the rectal ampulla in the second case. Histologically, both tumours were characterized by pleiomorphic, large spindle cells, presenting numerous mitoses and marked nuclear atypia. Immunohistochemical analysis showed that tumour cells coexpressed both actin and desmin, whereas CD117 and S100 protein were negative. The final diagnosis was leiomyosarcoma. One of the patients died of pulmonary metastasis within six months. The second patient had bone metastasis, but was lost to follow up. This report underlines the potential diagnostic problems raised by rectal leiomyosarcoma and emphasizes the role of immunohistochemistry in achieving correct diagnosis, which has important clinical, therapeutic and prognostic consequences.

Leiomyosarcoma metastatic to the thyroid diagnosed by fine needle aspiration cytology

The thyroid gland is a known but an unusual site for metastatic tumours from various primary sites. Primary smooth muscle tumours of thyroid are rare. Leiomyosarcoma of the thyroid gland whether of primary or metastatic origin should be distinguished from anaplastic carcinoma. Few cases of leiomyosarcoma metastatic to thyroid, diagnosed by fine needle aspiration cytology (FNAC) have been documented. We are reporting this case to highlight the importance of FNAC as a tool for diagnosing sarcomas and to plan further management accordingly. Ancillary techniques can be applied on FNAC and give comparative results to tissue sections.

Efficacy of the progesterone receptor antagonist mifepristone for palliative therapy of patients with a variety of advanced cancer types

BACKGROUND

Mifepristone has been demonstrated to improve longevity and quality of life in mice with spontaneous murine cancer without progesterone receptors and in human colon cancer. The present study evaluated the palliative effect of mifepristone in a variety of different types of human cancer.

PATIENTS AND METHODS

Mifepristone was given at 200 mg daily orally with permission from the Food and Drug Administration to people with widely metastatic human cancer no longer responsive to other chemotherapy regimens.

RESULTS

Improvement in pain and energy and/or length of life was found in thymic epithelial cell carcinoma, transitional cell carcinoma of the renal pelvis, leiomyosarcoma, pancreatic carcinoma, malignant fibrous histiocytoma and another case of adenocarcinoma of the colon.

CONCLUSION

Our data demonstrate a palliative role for the use of mifepristone in cancer therapy. Progesterone receptor antagonists should be given a therapeutic trial in larger controlled studies of various malignancies in humans.

Whipple's procedure for an oligometastasis to the pancreas from a leiomyosarcoma of the thigh

BACKGROUND

Pancreatic tumours are most frequently primary, with lesions secondary to metastasis uncommon.

METHODS

This report describes the case of a 61-year-old man who underwent resection of a right thigh leiomyosarcoma 2 years prior to presentation with obstructive jaundice. Subsequent CT and endoscopic ultrasound (EUS) diagnosed metastatic leiomyosarcoma to the pancreatic head for which he underwent a Whipple's pancreaticoduodenectomy.

CONCLUSION

Metastasis from an extremity leiomyosarcoma to the pancreas is an extremely rare entity, which can be diagnosed by EUS and treated successfully by pancreaticoduodenectomy.

[Case of primary leiomyosarcoma of the seminal vesicle]

A 72-year-old male visited our hospital with a complaint of perineal and voiding pain. An elastic hard mass was palpated by rectal examination in the cranial lesion of prostate. On CT scan and MRI it was located at the site of the right seminal vesicle. Trans-rectal needle biopsy specimen showed leiomyosarcoma. Radical cystoprostatectomy with pelvic lymph node dissection was performed at Hokkaido University Hospital. Microscopic examination of the resected specimen revealed the tumor arose from the right seminal vesicle without involvement of the bladder and the prostate gland. Three months after the operation the tumor recurred at lung and pelvic lymph node. He died 10 month postoperatively. Autopsy finding showed many visceral organs metastases without local recurrence. In the past, nine cases of leiomyosarcoma of seminal vesicle were published in the literature. Including our case, pathological diagnosis by core needle biopsy was attempted in five cases, though accurate diagnosis was made in only two cases. In our case, Immunohistological study by SMA and desmin was useful for histological diagnosis preoperatively.

Cyclooxygenase 2 expression in soft tissue leiomyosarcoma

BACKGROUND

Cyclooxygenase 2 (COX2) expression is up-regulated and associated with adverse prognosis in select types of carcinoma. Although not extensively studied in skeletal or soft tissue sarcoma, expression of COX2 has been described in a variable number of gynecological and non-gynecological leiomyosarcomas. In this study, the prevalence and prognostic implications of COX2 expression in leiomyosarcoma were evaluated further.

MATERIALS AND METHODS

Immunohistochemical stains for COX2 were performed on 33 samples of soft tissue leiomyosarcoma and tested for their association with clinicopathological parameters and patient outcome.

RESULTS

COX2 staining was limited to tumor cells surrounding areas of tumor necrosis in 6 cases. There were no statistically significant correlations with the clinicopathological parameters studied, including local recurrence, distant metastasis, or disease-specific death.

CONCLUSION

The low frequency, restricted distribution and absence of prognostic implications of COX2 expression soft tissue leiomyosarcoma suggest that this enzyme may not be a useful pharmacological target in this clinical setting.

Extensive cardiac metastases secondary to uterine leiomyosarcoma

Uterine leiomyosarcoma metastatic to multiple cardiac chambers occurs infrequently. Over the past 4 decades, there have been only 11 reported cases of cardiac metastasis secondary to uterine leiomyosarcoma. Metastatic cardiac tumors are commonly diagnosed postmortem, although it may be possible to diagnose them during life. The authors report a rare case of a 48-year-old woman with uterine leiomyosarcoma who was diagnosed with extensive cardiac metastases (in the left atrium, right and left ventricles, pulmonary artery, and pulmonary vein). Although extensive cardiac metastases are suggestive of imminent death, aggressive treatment resulted in survival for >1 year for this patient, which underscores the importance of treatment in select patients.

The diagnostic hurdle of an elderly male with bone pain: how 18F-FDG-PET led to diagnosis of a leiomyosarcoma of the adrenal gland

It is uncommon for patients to present with bone metastases while the primary tumor is still unknown. The case of a patient with bone metastases as primary presentation of leiomyosarcoma, who was diagnosed after a 18F-FDG PET-CT and a CT-guided biopsy of the adrenal gland is described. If after routine physical, laboratory and radiological investigations no diagnosis can be made, 18F-FDG PET should be added to the conventional work-up of patients with unknown primary cancer. In this way, unnecessary and enduring suffering of symptomatic patients may be prevented.