51
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52
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Endometrial stromal sarcomas and related neoplasms: new developments and diagnostic considerations. Pathology 2018; 50:162-177. [DOI: 10.1016/j.pathol.2017.11.086] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 11/05/2017] [Indexed: 12/21/2022]
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53
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Zhang R, Gu P, Liu Q, Li B, Bai W. Analysis of diagnosis and treatment of complicated cervical severe adhesion atresia after removal of endometrial stromal nodule: A case report. Medicine (Baltimore) 2017; 96:e8979. [PMID: 29310409 PMCID: PMC5728810 DOI: 10.1097/md.0000000000008979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Endometrial stromal nodule (ESN) is a rare benign endometrial stroma tumor.Experiences are helpful for avoiding and treating similar postoperative complications (cervical adhesions and atresia). PATIENT CONCERNS When appearing in the cervical, this tumor can easily lead to complications after the surgical resection. The diagnosis and postsurgery complication of a young woman's ESN was reported here. DIAGNOSES The postoperative pathological diagnosis was ESN. INTERVENTIONS A 29-year-old young woman was diagnosed and treated for ESN in cervical parts with postsurgery complications of cervical complex adhesion atresia. OUTCOMES The complication was complex cervix adhesion atresia with very special imaging performance-the cervix and the palace imaged as "Twisted and Angled Staircase." This particular cervix adhesion was challenging for operation. We achieved a successful treatment through the carefully designed surgical procedure including the application of hysteroscopy and laparoscopy. LESSONS The lower uterine segment and cervix should be paid attention during suturing in this situation. Close and positive follow-ups should be planned after the endometrial stromal resection. The reconstruction of the tunnel is a solution for the problem of menstruation.
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Affiliation(s)
- Rui Zhang
- Department of Obstetrics and Gynecology, Beijing Shijitan Hospital of Capital Medical University
| | - Pei Gu
- Department of Obstetrics and Gynecology, Beijing Shijitan Hospital of Capital Medical University
| | - Qi Liu
- Beijing Shijingshan Hospital
| | - Bin Li
- MRI room, Beijing Shijitan Hospital of Capital Medical University, Beijing, China
| | - Wenpei Bai
- Department of Obstetrics and Gynecology, Beijing Shijitan Hospital of Capital Medical University
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54
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Kuhn E, Ayhan A. Diagnostic immunohistochemistry in gynaecological neoplasia: a brief survey of the most common scenarios. J Clin Pathol 2017; 71:98-109. [PMID: 29183921 DOI: 10.1136/jclinpath-2017-204787] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/02/2017] [Accepted: 11/03/2017] [Indexed: 02/06/2023]
Abstract
Immunohistochemistry is a valuable adjunct in routine gynaecological pathology. The molecular revolution has redesigned knowledge of gynaecological cancers and refined histological classification. The direct consequence has been the progressive introduction of new immunostainings for diagnostic and classification purposes. Hence, we review the routine diagnostic use of immunohistochemistry in the field of gynaecological neoplasia. We reviewed the immunomarkers useful in gynaecological pathology according to literature revision, our personal experience and research findings. We discuss the application of immunohistochemistry to reach the most accurate diagnosis in morphologically equivocal cases of gynaecological pathology and present the appropriate panel of immunomarkers in the most common scenarios of gynaecological pathology. This short review provides an updated overview of the essential immunohistochemical markers currently used in the diagnostics of gynaecological malignancies along with their molecular rationale.
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Affiliation(s)
- Elisabetta Kuhn
- Pathology Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy.,Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy.,Laboratory of Technology for Advanced Therapies (LTTA), University of Ferrara, Ferrara, Italy
| | - Ayse Ayhan
- Departments of Pathology, Hamamatsu and Hiroshima Universities Schools of Medicine, Seirei Mikatahara Hospital, Hamamatsu, Japan.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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55
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Usui G, Hashimoto H, Matsumoto J, Akahane M, Tsunoda H, Sasajima Y, Horiuchi H. Pulmonary Metastasis of Undifferentiated Uterine Sarcoma Forming Fluid-Containing Cyst. Int J Surg Pathol 2017; 26:180-184. [DOI: 10.1177/1066896917728795] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Undifferentiated uterine sarcoma (UUS) is a high-grade sarcoma with no specific differentiation; however, it exhibits variable positivity for CD10 as an immunohistochemical marker of endometrial stroma, suggesting immunohistochemical differentiation into endometrial stroma. It has been reported that some low-grade endometrial stromal sarcoma pulmonary metastatic foci show cystic changes; however, whether pulmonary metastatic UUS foci are solid or cystic remains undescribed. A 63-year-old woman underwent a hysterectomy. The subsequent pathologic diagnosis was UUS. After the operation, she was treated with chemotherapy; however, pulmonary solitary shadow was radiologically detected. Eight months after the gynecologic operation, her pulmonary lesion was surgically resected. Pathologically, the lesion consisted of a cyst containing serous fluid with thick whitish wall composed of tumor cells, which led to the diagnosis of metastatsis of UUS. The cyst seemed to be formed via secondary degeneration. She remains healthy without recurrence 28 months after her first visit to our hospital.
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Affiliation(s)
| | | | | | | | | | - Yuko Sasajima
- NTT Medical Center Tokyo, Tokyo, Japan
- Teikyo University, Tokyo, Japan
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56
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Chiang S, Lee CH, Stewart CJR, Oliva E, Hoang LN, Ali RH, Hensley ML, Arias-Stella JA, Frosina D, Jungbluth AA, Benayed R, Ladanyi M, Hameed M, Wang L, Kao YC, Antonescu CR, Soslow RA. BCOR is a robust diagnostic immunohistochemical marker of genetically diverse high-grade endometrial stromal sarcoma, including tumors exhibiting variant morphology. Mod Pathol 2017; 30:1251-1261. [PMID: 28621321 PMCID: PMC5916794 DOI: 10.1038/modpathol.2017.42] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 03/28/2017] [Accepted: 03/29/2017] [Indexed: 12/22/2022]
Abstract
Recognition of high-grade endometrial stromal sarcoma is important because of its aggressive clinical behavior. Morphologic features of YWHAE-NUTM2 high-grade endometrial stromal sarcoma may overlap with other uterine sarcoma types. BCOR immunoexpression was studied in these tumors and their morphologic mimics to assess its diagnostic utility. BCOR immunohistochemical staining was performed on archival tissue from 28 high-grade endometrial stromal sarcomas with classic morphology (20 YWHAE-NUTM2, 5 ZC3H7B-BCOR, 3 BCOR-ZC3H7B), 3 high-grade endometrial stromal sarcomas with unusual morphology and unknown gene rearrangement status, 66 low-grade endometrial stromal sarcomas, 21 endometrial stromal nodules, 38 uterine leiomyosarcomas, and 19 uterine leiomyomas. Intensity of nuclear staining and percentage of positive tumor cells were recorded. Strong diffuse nuclear BCOR staining (defined as >95% of tumor cells) was seen in the round cell component of all 20 (100%) classic YWHAE-NUTM2 high-grade endometrial stromal sarcomas and the 3 unusual high-grade endometrial stromal sarcomas which prompted FISH studies confirming YWHAE rearrangement in 2 tumors. Genomic PCR confirmed the presence of BCOR exon 16 internal tandem duplication in the third case. Diffuse BCOR staining was strong in three and weak in one BCOR-rearranged high-grade endometrial stromal sarcoma while absent in the remaining four BCOR-rearranged tumors. BCOR staining was weakly positive in <5% of tumor cells in 4 of 66 (6%) low-grade endometrial stromal sarcomas and 1 of 18 (6%) endometrial stromal nodules and weakly to moderately positive in <5-40% of tumor cells in 6 of 31 (19%) leiomyosarcomas. No BCOR staining was seen in the remaining low-grade endometrial stromal sarcomas, endometrial stromal nodules, leiomyosarcomas, or any of the leiomyomas. BCOR immunohistochemical staining is a highly sensitive marker for YWHAE-NUTM2 high-grade endometrial stromal sarcoma with both classic and unusual morphology and identifies a subset of high-grade endometrial stromal sarcoma with BCOR alterations, including BCOR rearrangement and internal tandem duplication.
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Affiliation(s)
- Sarah Chiang
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cheng-Han Lee
- Department of Pathology, British Columbia Cancer Agency, Vancouver, BC, Canada
- Department of Pathology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Colin J. R. Stewart
- Department of Pathology, King Edward Memorial Hospital, Perth, Western Australia, Australia
| | - Esther Oliva
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Lien N. Hoang
- Department of Pathology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Rola H. Ali
- Department of Pathology, Kuwait University Health Sciences Center, Kuwait City, Kuwait
| | - Martee L. Hensley
- Department of Medicine, Gynecologic Medical Oncology Service, Memorial Sloan Kettering Cancer Center
| | | | - Denise Frosina
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Achim A. Jungbluth
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ryma Benayed
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marc Ladanyi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Meera Hameed
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lu Wang
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yu-Chien Kao
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pathology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | | | - Robert A. Soslow
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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57
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Validation of a Mitotic Index Cutoff as a Prognostic Marker in Undifferentiated Uterine Sarcomas. Am J Surg Pathol 2017. [DOI: 10.1097/pas.0000000000000894] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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58
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Abstract
The 2014 World Health Organization (WHO) classification of uterine tumors revealed simplification of the classification by fusion of several entities and the introduction of novel entities. Among the multitude of alterations, the following are named: a simplified classification for precursor lesions of endometrial carcinoma now distinguishes between hyperplasia without atypia and atypical hyperplasia, the latter also known as endometrioid intraepithelial neoplasia (EIN). For endometrial carcinoma a differentiation is made between type 1 (endometrioid carcinoma with variants and mucinous carcinoma) and type 2 (serous and clear cell carcinoma). Besides a papillary architecture serous carcinomas may show solid and glandular features and TP53 immunohistochemistry with an "all or null pattern" assists in the diagnosis of serous carcinoma with ambiguous features. Neuroendocrine neoplasms are categorized in a similar way to the gastrointestinal tract into well differentiated neuroendocrine tumors and poorly differentiated neuroendocrine carcinomas (small cell and large cell types). Leiomyosarcomas of the uterus are typically high grade and characterized by marked nuclear atypia and lively mitotic activity. Low grade stromal neoplasms frequently show gene fusions, such as JAZF1/SUZ12. High grade endometrial stromal sarcoma is newly defined by cyclin D1 overexpression and the presence of the fusion gene YWHAE/FAM22 and must be distinguished from undifferentiated uterine sarcoma. Carcinosarcomas (malignant mixed Mullerian tumors MMMT) show biological and molecular similarities to high-grade carcinomas.
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59
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Ritterhouse LL, Howitt BE. Molecular Pathology: Predictive, Prognostic, and Diagnostic Markers in Uterine Tumors. Surg Pathol Clin 2017; 9:405-26. [PMID: 27523969 DOI: 10.1016/j.path.2016.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This article focuses on the diagnostic, prognostic, and predictive molecular biomarkers in uterine malignancies, in the context of morphologic diagnoses. The histologic classification of endometrial carcinomas is reviewed first, followed by the description and molecular classification of endometrial epithelial malignancies in the context of histologic classification. Taken together, the molecular and histologic classifications help clinicians to approach troublesome areas encountered in clinical practice and evaluate the utility of molecular alterations in the diagnosis and subclassification of endometrial carcinomas. Putative prognostic markers are reviewed. The use of molecular alterations and surrogate immunohistochemistry as prognostic and predictive markers is also discussed.
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Affiliation(s)
- Lauren L Ritterhouse
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Brooke E Howitt
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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60
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Novel High-grade Endometrial Stromal Sarcoma: A Morphologic Mimicker of Myxoid Leiomyosarcoma. Am J Surg Pathol 2017; 41:12-24. [PMID: 27631520 DOI: 10.1097/pas.0000000000000721] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endometrial stromal sarcomas (ESS) are often underpinned by recurrent chromosomal translocations resulting in the fusion of genes involved in epigenetic regulation. To date, only YWHAE-NUTM2 rearrangements are associated with distinctive high-grade morphology and aggressive clinical behavior. We identified 3 ESS morphologically mimicking myxoid leiomyosarcoma of the uterus and sought to describe their unique histopathologic features and identify genetic alterations using next-generation sequencing. All cases displayed predominantly spindled cells associated with abundant myxoid stroma and brisk mitotic activity. Tumors involved the endometrium and demonstrated tongue-like myometrial infiltration. All 3 were associated with an aggressive clinical course, including multisite bony metastases in 1 patient, progressive peritoneal disease after chemotherapy in another, and metastases to the lung and skin in the last patient. All 3 ESS were found to harbor ZC3H7B-BCOR gene fusions by targeted sequencing and fluorescence in situ hybridization. On the basis of the review of these cases, we find that ESS with ZC3H7B-BCOR fusion constitutes a novel type of high-grade ESS and shares significant morphologic overlap with myxoid leiomyosarcoma.
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61
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Przybyl J, Kowalewska M, Quattrone A, Dewaele B, Vanspauwen V, Varma S, Vennam S, Newman AM, Swierniak M, Bakuła-Zalewska E, Siedlecki JA, Bidzinski M, Cools J, van de Rijn M, Debiec-Rychter M. Macrophage infiltration and genetic landscape of undifferentiated uterine sarcomas. JCI Insight 2017; 2:94033. [PMID: 28570276 DOI: 10.1172/jci.insight.94033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 05/02/2017] [Indexed: 12/18/2022] Open
Abstract
Endometrial stromal tumors include translocation-associated low- and high-grade endometrial stromal sarcomas (ESS) and highly malignant undifferentiated uterine sarcomas (UUS). UUS is considered a poorly defined group of aggressive tumors and is often seen as a diagnosis of exclusion after ESS and leiomyosarcoma (LMS) have been ruled out. We performed a comprehensive analysis of gene expression, copy number variation, point mutations, and immune cell infiltrates in the largest series to date of all major types of uterine sarcomas to shed light on the biology of UUS and to identify potential novel therapeutic targets. We show that UUS tumors have a distinct molecular profile from LMS and ESS. Gene expression and immunohistochemical analyses revealed the presence of high numbers of tumor-associated macrophages (TAMs) in UUS, which makes UUS patients suitable candidates for therapies targeting TAMs. Our results show a high genomic instability of UUS and downregulation of several TP53-mediated tumor suppressor genes, such as NDN, CDH11, and NDRG4. Moreover, we demonstrate that UUS carry somatic mutations in several oncogenes and tumor suppressor genes implicated in RAS/PI3K/AKT/mTOR, ERBB3, and Hedgehog signaling.
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Affiliation(s)
- Joanna Przybyl
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA.,Department of Molecular and Translational Oncology, Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland.,Department of Human Genetics, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - Magdalena Kowalewska
- Department of Molecular and Translational Oncology, Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland.,Department of Immunology, Biochemistry and Nutrition, Medical University of Warsaw, Warsaw, Poland
| | - Anna Quattrone
- Department of Human Genetics, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - Barbara Dewaele
- Department of Human Genetics, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - Vanessa Vanspauwen
- Department of Human Genetics, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - Sushama Varma
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Sujay Vennam
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Aaron M Newman
- Institute for Stem Cell Biology and Regenerative Medicine.,Department of Medicine, Division of Oncology, Stanford Cancer Institute, Stanford University, Stanford, California, USA
| | - Michal Swierniak
- Human Cancer Genetics, Center of New Technologies, CENT, University of Warsaw, Warsaw, Poland
| | | | - Janusz A Siedlecki
- Department of Molecular and Translational Oncology, Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland
| | - Mariusz Bidzinski
- Department of Gynecologic Oncology, Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland.,The Faculty of Medicine and Health Sciences, Jan Kochanowski University, Kielce, Poland
| | - Jan Cools
- KU Leuven and Flanders Interuniversity Institute for Biotechnology (VIB), Leuven, Belgium
| | - Matt van de Rijn
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Maria Debiec-Rychter
- Department of Human Genetics, KU Leuven and University Hospitals Leuven, Leuven, Belgium
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62
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Mukhopadhyay M, Das C, Parvin T, Basu K. Undifferentiated Uterine Sarcoma: An Uncommon Case Report. J Clin Diagn Res 2017; 11:ED03-ED04. [PMID: 28511398 DOI: 10.7860/jcdr/2017/24924.9370] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 12/08/2016] [Indexed: 12/15/2022]
Abstract
Endometrial Stromal Sarcomas (ESS) are rare uterine malignancy of mesodermal origin. A 65-year-old female presented with postmenopausal bleeding in the Department of Gynaecology in our hospital. Computed Topography (CT) revealed an enlarged uterus with areas of low attenuation. On gross appearance endometrial cavity was distorted with an irregular friable necrotic mass. Histopathologically, it was diagnosed as undifferentiated uterine sarcoma. Rhabdoid, osteoid and cartilaginous differentiation were found along with osteoclast like giant cells. Immunohistochemistry was strongly positive for CD10.
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Affiliation(s)
| | - Chhanda Das
- Assistant Professor, Department of Pathology, IPGME&R, Kolkata, West Bengal, India
| | - Tamanna Parvin
- Postgraduate Student, Department of Pathology, IPGME&R, Kolkata, West Bengal, India
| | - Keya Basu
- Associate Professor, Department of Pathology, IPGME&R, Kolkata, West Bengal, India
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63
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Hanley KZ, Birdsong GG, Mosunjac MB. Recent Developments in Surgical Pathology of the Uterine Corpus. Arch Pathol Lab Med 2017; 141:528-541. [PMID: 28353387 DOI: 10.5858/arpa.2016-0284-sa] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
There have been several updates recently on the classification of uterine tumors. Endometrial carcinomas have traditionally been divided into 2 types, but some are difficult to classify and do not fit readily into either of the currently recognized categories. The Cancer Genome Atlas Research Network has recently defined 4 new categories of endometrial cancer on the basis of mutational spectra, copy number alteration, and microsatellite instability, which might provide independent prognostic information beyond established risk factors. The Society of Gynecologic Oncology, moreover, now recommends systematic screening of every patient with endometrial cancer for Lynch syndrome. The new definition of high-grade endometrial stromal sarcoma disregards the number of mitotic figures as a primary diagnostic criterion and instead specifies moderate atypia still resembling stromal origin but lacking the pleomorphism of undifferentiated uterine sarcoma; these tumors also harbor a JAZF1-SUZ12 gene rearrangement. Mitotic count, atypia, and coagulative necrosis are the main histologic criteria that define leiomyosarcoma. Determining the type of necrosis can be very challenging in patients receiving various treatment modalities for symptomatic fibroids before myomectomy, since key histologic features of ischemic-type necrosis are often absent. Ancillary stains including p16, p53, MIB-1, trichrome, and reticulin may be helpful in tumors harboring necrosis that is difficult to classify. Minimally invasive gynecologic surgeries have introduced histologic artifacts that complicate the diagnosis. It is essential to recognize these as procedure-related artifacts to avoid upstaging tumors and triggering unnecessary adjuvant treatment.
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Affiliation(s)
| | | | - Marina B Mosunjac
- From the Department of Pathology and Laboratory Medicine, Emory University Hospital, Atlanta, Georgia (Dr Hanley); and the Department of Pathology and Laboratory Medicine, Grady Memorial Hospital, Atlanta, Georgia (Drs Birdsong and Mosunjac)
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64
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Choi YJ, Jung SH, Kim MS, Baek IP, Rhee JK, Lee SH, Hur SY, Kim TM, Chung YJ, Lee SH. Genomic landscape of endometrial stromal sarcoma of uterus. Oncotarget 2016; 6:33319-28. [PMID: 26429873 PMCID: PMC4741768 DOI: 10.18632/oncotarget.5384] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 09/18/2015] [Indexed: 12/30/2022] Open
Abstract
Although recurrent gene fusions such as JAZF1-JJAZ1 are considered driver events for endometrial stromal sarcoma (ESS) development, other genomic alterations remain largely unknown. In this study, we performed whole-exome sequencing, transcriptome sequencing and copy number profiling for five ESSs (three low-grade ESS (LG-ESS) and two undifferentiated uterine sarcomas (UUSs)). All three LG-ESSs exhibited either one of JAZF1-SUZ12, JAZF1-PHF1 and MEAF6-PHF1 fusions, whereas the two UUSs did not. All ESSs except one LG-ESS exhibited copy number alterations (CNAs), many of which encompassed cancer-related genes. In UUSs, five CNAs encompassing cancer-related genes (EZR, CDH1, RB1, TP53 and PRKAR1A) accompanied their expressional changes, suggesting that they might stimulate UUS development. We found 81 non-silent mutations (35 from LG-ESSs and 46 from UUSs) that included 15 putative cancer genes catalogued in cancer-related databases, including PPARG and IRF4 mutations. However, they were non-recurrent and did not include any well-known mutations, indicating that point mutations may not be a major driver for ESS development. Our data show that gene fusions and CNAs are the principal drivers for LG-ESS and USS, respectively, but both may require additional genomic alterations including point mutations. These differences may explain the different biologic behaviors between LG-ESS and UUS. Our findings suggest that ESS development requires point mutations and CNAs as well as the gene fusions.
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Affiliation(s)
- Youn Jin Choi
- Department of Pathology, College of Medicine, The Catholic University of Korea, Seoul 137-701, Republic of Korea
| | - Seung-Hyun Jung
- Department of Cancer Evolution Research Center, College of Medicine, The Catholic University of Korea, Seoul 137-701, Republic of Korea.,Department of Integrated Research Center for Genome Polymorphism, College of Medicine, The Catholic University of Korea, Seoul 137-701, Republic of Korea
| | - Min Sung Kim
- Department of Pathology, College of Medicine, The Catholic University of Korea, Seoul 137-701, Republic of Korea
| | - In-Pyo Baek
- Department of Cancer Evolution Research Center, College of Medicine, The Catholic University of Korea, Seoul 137-701, Republic of Korea.,Department of Integrated Research Center for Genome Polymorphism, College of Medicine, The Catholic University of Korea, Seoul 137-701, Republic of Korea
| | - Jae-Keun Rhee
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul 137-701, Republic of Korea
| | - Sung Hak Lee
- Department of Hospital Pathology, College of Medicine, The Catholic University of Korea, Seoul 137-701, Republic of Korea
| | - Soo Young Hur
- Department of Obstetrics/Gynecology, College of Medicine, The Catholic University of Korea, Seoul 137-701, Republic of Korea
| | - Tae-Min Kim
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul 137-701, Republic of Korea
| | - Yeun-Jun Chung
- Department of Cancer Evolution Research Center, College of Medicine, The Catholic University of Korea, Seoul 137-701, Republic of Korea.,Department of Integrated Research Center for Genome Polymorphism, College of Medicine, The Catholic University of Korea, Seoul 137-701, Republic of Korea.,Department of Microbiology, College of Medicine, The Catholic University of Korea, Seoul 137-701, Republic of Korea
| | - Sug Hyung Lee
- Department of Pathology, College of Medicine, The Catholic University of Korea, Seoul 137-701, Republic of Korea.,Department of Cancer Evolution Research Center, College of Medicine, The Catholic University of Korea, Seoul 137-701, Republic of Korea
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65
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Analysis of MDM2 Amplification in 43 Endometrial Stromal Tumors: A Potential Diagnostic Pitfall. Int J Gynecol Pathol 2016; 34:576-83. [PMID: 26444253 DOI: 10.1097/pgp.0000000000000187] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
MDM2 amplification is known to occur in a variety of neoplasms and its detection by fluorescence in situ hybridization is helpful in distinguishing well-differentiated and dedifferentated liposarcoma from classic lipoma. We recently evaluated a mesenteric mass initially diagnosed as dedifferentiated liposarcoma, largely due to the neoplasm's myxoid morphology and MDM2 expression by immunohistochemistry, from a 46-yr-old woman with a history of uterine low-grade endometrial stromal sarcoma (LG-ESS) with a JAZF1 rearrangement. Our workup of the mesenteric mass revealed a JAZF1 rearrangement and a revised diagnosis of metastatic LG-ESS with myxoid change was rendered. Retrospective testing of the mesenteric mass was negative for MDM2 amplification, an uncommon, but known diagnostic pitfall in MDM2 expression by immunohistochemistry. As MDM2 amplification is not specific for the diagnosis of liposarcoma, we investigated its occurrence in 43 cases of endometrial stromal tumors: 14 uterine LG-ESS, 11 metastatic or recurrent uterine LG-ESS, 8 undifferentiated uterine sarcomas, 5 endometrial stromal nodules, and 4 high-grade ESS with YHWAE rearrangement. In addition, 40 of the 43 cases had previously undergone fluorescence in situ hybridization analysis of JAZF1, PHF1, and YHWAE. Two of the 43 cases (5%) had MDM2 amplification: one was a uterine LG-ESS (JAZF1 rearrangement) and the other was a undifferentiated uterine sarcoma (polysomy intact JAZF1, PHF1, and YHWAE), both metastatic to the lung. Both cases positive for MDM2 amplification showed MDM2 expression by immunohistochemistry. At last follow-up, both patients had died of disease (19 and 60 mo). Our study is the first to demonstrate MDM2 amplification in endometrial stromal tumor. Awareness of MDM2 amplification in endometrial stromal tumor is critical; particularly in locations more common to liposarcoma, to avoid diagnostic errors.
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66
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Affiliation(s)
- Jaime Prat
- Department of Pathology, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - 'Nomonde Mbatani
- Department of Obstetrics and Gynecology, Groote Schuur Hospital/University of Cape Town, Cape Town, South Africa
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67
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Hrzenjak A. JAZF1/SUZ12 gene fusion in endometrial stromal sarcomas. Orphanet J Rare Dis 2016; 11:15. [PMID: 26879382 PMCID: PMC4754953 DOI: 10.1186/s13023-016-0400-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 02/08/2016] [Indexed: 12/11/2022] Open
Abstract
Endometrial stromal sarcomas (ESSs) belong to the rarest uterine malignancies (prevalence category <1-9/1,000,000). According to the new 2014 World Health Organisation (WHO) classification, they are separated into four categories; benign endometrial stromal nodules (ESNs), low grade endometrial stromal sarcomas (LG-ESSs), high-grade endometrial stromal sarcomas (HG-ESSs) and undifferentiated uterine sarcomas (UUSs). Due to heterogeneous histopathologic appearance these tumors still represent diagnostic challenge, even for experienced pathologists. ESSs are genetically very heterogeneous and several chromosomal translocations and gene fusions have so far been identified in these malignancies. To date the JAZF1/SUZ12 gene fusion is by far the most frequent and seems to be the cytogenetic hallmark of ESN and LG-ESS. Based on present literature data this gene fusion is present in approximately 75 % of ESN, 50 % of LG-ESS and 15 % of HG-ESS cases. The frequency of JAZF1/SUZ12 appearance varies between classic ESS and different morphologic variants. This gene fusion is suggested to become a specific diagnostic tool, especially in difficult borderline cases. In combination with the recently described YWHAE/FAM22 gene fusion the JAZF1/SUZ12 fusion could be used to differentiate between LG-ESS and HG-ESS. The purpose of this review is to summarize literature data published in last two and a half decades about this gene fusion, as a contribution to our understanding of ESS genetics and pathogenesis.
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Affiliation(s)
- Andelko Hrzenjak
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria. .,Ludwig Boltzmann Institute for Lung Vascular Research, Medical University of Graz, Graz, Austria.
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68
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Nucci MR. Practical issues related to uterine pathology: endometrial stromal tumors. Mod Pathol 2016; 29 Suppl 1:S92-103. [PMID: 26715176 DOI: 10.1038/modpathol.2015.140] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 11/05/2015] [Indexed: 01/10/2023]
Abstract
Uterine mesenchymal tumors continue to be a challenge to diagnose due to their non-specific clinical presentation, often non-distinctive gross appearance, varied (and many times overlapping) morphologic appearance, and unsuspected pitfalls in immunohistochemical expression. This review will focus on endometrial stromal tumors and those features that help in their distinction. In particular, a practical approach to the diagnosis of endometrial stromal neoplasia will be covered including recognition as a stromal process in a biopsy/curettage and distinction from a highly cellular leiomyoma. In addition, distinction of a stromal nodule from a low-grade endometrial stromal sarcoma (LGESS) and stromal sarcoma with limited infiltration in a hysterectomy specimen will be covered. The salient features that help distinguish a LGESS from a uterine tumor resembling ovarian sex-cord tumor as well as high-grade endometrial stromal sarcoma, the latter a tumor recently reintroduced in the WHO classification will also be discussed. Finally, a practical approach to the diagnosis of undifferentiated uterine sarcoma (UUS) will be presented.
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Affiliation(s)
- Marisa R Nucci
- Division of Women's and Perinatal Pathology, Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
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69
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Potential Therapeutic Targets in Uterine Sarcomas. Sarcoma 2015; 2015:243298. [PMID: 26576131 PMCID: PMC4632006 DOI: 10.1155/2015/243298] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 09/30/2015] [Indexed: 12/30/2022] Open
Abstract
Uterine sarcomas are rare tumors accounting for 3,4% of all uterine cancers. Even after radical hysterectomy, most patients relapse or present with distant metastases. The very limited clinical benefit of adjuvant cytotoxic treatments is reflected by high mortality rates, emphasizing the need for new treatment strategies. This review summarizes rising potential targets in four distinct subtypes of uterine sarcomas: leiomyosarcoma, low-grade and high-grade endometrial stromal sarcoma, and undifferentiated uterine sarcoma. Based on clinical reports, promising approaches for uterine leiomyosarcoma patients include inhibition of VEGF and mTOR signaling, preferably in combination with other targeted or cytotoxic compounds. Currently, the only targeted therapy approved in leiomyosarcoma patients is pazopanib, a multitargeted inhibitor blocking VEGFR, PDGFR, FGFR, and c-KIT. Additionally, preclinical evidence suggests effect of the inhibition of histone deacetylases, tyrosine kinase receptors, and the mitotic checkpoint protein aurora kinase A. In low-grade endometrial stromal sarcomas, antihormonal therapies including aromatase inhibitors and progestins have proven activity. Other potential targets are PDGFR, VEGFR, and histone deacetylases. In high-grade ESS that carry the YWHAE/FAM22A/B fusion gene, the generated 14-3-3 oncoprotein is a putative target, next to c-KIT and the Wnt pathway. The observation of heterogeneity within uterine sarcoma subtypes warrants a personalized treatment approach.
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Abstract
"Invasive micropapillary serous carcinoma" has been proposed as a synonym for low-grade serous carcinoma by some expert pathologists. In contrast, Singer and colleagues reported that some serous carcinomas with conspicuous invasive micropapillary pattern (SC-IMPs) can show high-grade nuclear atypia. However, the molecular features of such tumors have not been well documented. The aim of this study was to demonstrate and emphasize the fact that high-grade serous carcinoma confirmed by immunohistochemistry and molecular analysis can show conspicuous invasive micropapillary pattern. We selected 24 "SC-IMPs" and investigated: (1) their morphologic features; (2) the immunostaining pattern of p53 protein; and (3) KRAS/BRAF/TP53 gene mutations. The 24 SC-IMPs were subdivided into low-grade and high-grade tumors based primarily on the nuclear atypia, with the mitotic rate used as a secondary feature: low grade (n=5) and high grade (n=19). Low-grade SC-IMPs were characterized by low-mitotic activity, absence of abnormal mitosis, presence of serous borderline tumor, occasional BRAF mutation, and infrequent TP53 mutation. High-grade SC-IMPs were characterized by high-mitotic activity, presence of abnormal mitosis, conventional high-grade serous carcinoma, frequent TP53 mutation, and lack of KRAS/BRAF mutation. We demonstrated that high-grade serous carcinoma confirmed by aberrant p53 immunostaining and molecular analysis can show conspicuous invasive micropapillary pattern, validating Singer and colleague's report. Serous carcinoma with conspicuous invasive micropapillary pattern should not be readily regarded as low-grade serous carcinoma. Nuclear grade is the most important diagnostic feature in the SC-IMPs.
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71
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Gynecologic Cancer InterGroup (GCIG) consensus review for high-grade undifferentiated sarcomas of the uterus. Int J Gynecol Cancer 2015; 24:S73-7. [PMID: 25341584 DOI: 10.1097/igc.0000000000000281] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
High-grade undifferentiated sarcomas (HGUSs) are rare uterine malignancies arising from the endometrial stroma. They are poorly differentiated sarcomas composed of cells that do not resemble proliferative-phase endometrial stroma. High-grade undifferentiated sarcomas are characterized by aggressive behavior and poor prognosis. Cyclin D1 has been reported as a diagnostic immunomarker for high-grade endometrial stromal sarcoma with an YWHAE-FAM22 rearrangement. YWHAE-FAM22 endometrial stromal sarcomas (ESS) represent a clinically aggressive subtype of ESS classified as high-grade endometrial sarcomas, and its distinction from the usual low-grade ESS with JAZF1 rearrangement and from HGUS with no identifiable molecular aberration may be important in guiding clinical management. Median age of the patients is between 55 and 60 years. The most common symptoms are vaginal bleeding, abdominal pain, and increasing abdominal girth.Disease is usually advanced with approximately 70% of the patients staged III to IV according to the International Federation of Gynecology and Obstetrics classification. Preferential metastatic locations include peritoneum, lungs, intra-abdominal lymph nodes, and bone. Median progression-free survival ranged from 7 to 10 months, and median overall survival ranged from 11 to 23 months. There is no clear prognostic factor identified for HGUS, not even stage. The standard management for HGUS consists of total hysterectomy and bilateral salpingo-oophorectomy. Systematic lymphadenectomy is not recommended. Adjuvant therapies, such as chemotherapy and radiotherapy, have to be discussed in multidisciplinary staff meetings.
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Gynecologic Cancer InterGroup (GCIG) consensus review for endometrial stromal sarcoma. Int J Gynecol Cancer 2015; 24:S67-72. [PMID: 25033257 DOI: 10.1097/igc.0000000000000205] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Endometrial stromal sarcoma (ESS) accounts for approximately 20% of all uterine sarcomas and presents, at a mean age, around 50 years of age. Half of the patients are premenopausal. ESS often manifests as an endometrial polyp and 60% of cases present with FIGO stage I disease. The natural history is one of slow growing indolent disease. Typical microscopic findings include a uniform population of endometrial stromal-type cells invading the myometrium and myometrial vessels. Imaging studies cannot reliably diagnose ESS preoperatively, so surgical resection for a presumed fibroid is a common scenario. Hysterectomy is the cornerstone of treatment for localized ESS, but morcellation should be avoided. Systematic lymphadenectomy in ESS does not improve the outcome. Leaving the ovaries in situ does not worsen survival and this is of importance especially for young women. The data support the current practice to administer adjuvant hormonal treatment, although several questions remain, such as optimal doses, regimens (progestins or aromatase inhibitors) and duration of therapy. Repeat surgery for recurrent disease that is indolent and hormone sensitive appears to be an acceptable approach. Systemic treatment for recurrent disease is mainly hormonal.
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73
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Genomic characterization of endometrial stromal sarcomas with array comparative genomic hybridization. Exp Mol Pathol 2015; 98:367-74. [PMID: 25758203 DOI: 10.1016/j.yexmp.2015.03.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 03/06/2015] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The endometrial stromal sarcoma (ESS) is a very rare uterine sarcoma, counting for 1-3% of all gynecologic malignancies. ESS represents 0.2-8% of all uterine malignant tumors and accounts for about 10% of all uterine sarcomas. With regard to chromosomal aberrations, very little is known about benign and malignant endometrial stromal tumors. METHODS 30 tumors, consisting of 4 cases of benign endometrial stromal nodule (ESN), 22 cases of low-grade ESS and 4 cases of undifferentiated endometrial sarcoma (UES), were analyzed by array-comparative genomic hybridization (aCGH). RESULTS ESN did not show many copy number changes (CNCs) by aCGH. Frequent losses could be identified on chromosomes 7p and 19, and gains on chromosomes 1q, 6p and 8q. Low-grade ESS presented as a very heterogeneous group. 90% (20/22) of cases displayed aberrations. Most frequent changes were losses on chromosomes 7 and 22, and gains on chromosome 1q or 11. UES showed a high number of chromosomal aberrations and on every chromosome CNCs were detected. Most frequent changes were losses on chromosomes 1q, 2q (3/4, 75%) and 13, and gains on chromosomes 1q and 17p. CONCLUSION Our data shows an increasing number of CNCs from ESN to low-grade ESS and to UES. However, the chromosomal aberrations differ considerably between the investigated ESN-, low-grade ESS- and UES cases and thus, a linear tumor progression seems to be unlikely.
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74
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Malignant solitary fibrous tumor with high-grade nuclear atypia: An alternate entity for the undetermined tumor group. Pathol Res Pract 2015; 211:117-24. [DOI: 10.1016/j.prp.2014.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 11/19/2014] [Accepted: 12/01/2014] [Indexed: 11/19/2022]
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Affiliation(s)
- Cheng-Han Lee
- Department of Laboratory Medicine and Pathology; Royal Alexandra Hospital; University of Alberta; Edmonton AB Canada
| | - Marisa R Nucci
- Department of Pathology; Brigham and Women's Hospital; Boston MA USA
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Ali RH, Rouzbahman M. Endometrial stromal tumours revisited: an update based on the 2014 WHO classification. J Clin Pathol 2015; 68:325-32. [PMID: 25595274 DOI: 10.1136/jclinpath-2014-202829] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 12/20/2014] [Indexed: 12/26/2022]
Abstract
Endometrial stromal tumours (EST) are rare tumours of endometrial stromal origin that account for less than 2% of all uterine tumours. Recent cytogenetic and molecular advances in this area have improved our understanding of ESTs and helped refine their classification into more meaningful categories. Accordingly, the newly released 2014 WHO classification system recognises four categories: endometrial stromal nodule (ESN), low-grade endometrial stromal sarcoma (LGESS), high-grade endometrial stromal sarcoma (HGESS) and undifferentiated uterine sarcoma (UUS). At the molecular level, these tumours may demonstrate a relatively simple karyotype with a defining chromosomal rearrangement (as in the majority of ESNs, LGESSs and YWHAE-rearranged HGESS) or demonstrate complex cytogenetic aberrations lacking specific rearrangements (as in UUSs). Herein we provide an update on this topic aimed at the practicing pathologist.
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Affiliation(s)
- Rola H Ali
- Department of Clinical Pathology, Faculty of Medicine, Health Sciences Center, Kuwait University, Kuwait, Kuwait
| | - Marjan Rouzbahman
- Department of Anatomical Pathology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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77
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Kaspar HG, Crum CP. The Utility of Immunohistochemistry in the Differential Diagnosis of Gynecologic Disorders. Arch Pathol Lab Med 2015; 139:39-54. [DOI: 10.5858/arpa.2014-0057-ra] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context
Immunohistochemistry has assumed an increasing role in the identification and characterization of gynecologic disorders including lesions with deceptively bland morphology, uncommon and underdiagnosed neoplasms, and neoplasms with specific genetic alterations associated with overexpression or loss of expression of specific proteins. The diagnostic accuracy has been significantly improved owing to the discovery and increasing experience with the tumor-associated biomarkers, and the increasing demand for precise tumor classification to assess suitability for the expanding therapeutic modalities including clinical trials.
Objective
To differentiate lesions of the gynecologic tract through the use of effective immunohistochemical panels.
Data Sources
Literature review and authors' personal practice experience.
Conclusions
The application of diagnostic and prognostic immunohistochemical panels has enabled pathologists to better guide therapeutic decisions and to better predict the clinical outcome. It is now well established that the use of ancillary testing, including immunohistochemistry, has a significant power in the identification, differentiation, and classification of reactive, premalignant, and malignant gynecologic disorders. This article discusses the utilities and pitfalls of the commonly used immunohistochemical markers in the context of overlapping morphologic features encountered in the uterus, ovaries, and fallopian tubes.
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Affiliation(s)
- Hanna G. Kaspar
- From the Department of Laboratory Medicine, Geisinger Health System, Wilkes-Barre, Pennsylvania (Dr Kaspar)
| | - Christopher P. Crum
- and the Department of Pathology, Division of Women's and Perinatal Pathology, Brigham and Women's Hospital, Boston, Massachusetts (Dr Crum)
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78
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Tokinaga A, Furuya M, Niino H, Udaka N, Asai-Sato M, Sekido H, Miyagi E. Colonic low-grade endometrial stromal sarcoma and orthotopic endometrial stromal tumor with limited infiltration sharing the JAZF1-SUZ12 gene fusion. Pathol Int 2014; 64:178-82. [PMID: 24750188 DOI: 10.1111/pin.12151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 02/21/2014] [Indexed: 01/17/2023]
Abstract
Endometrial stromal tumors (ESTs) are composed of cells resembling endometrial stroma, and are divided into benign and malignant types based on morphology. Endometrial stromal nodule (ESN) is a benign localized tumor, and endometrial stromal sarcoma (ESS) is an infiltrative and potentially metastatic neoplasm. A series of genetic aberrations contribute to pathological diagnosis of ESTs. At present, subsets of ESN and ESS-low grade (ESS-LG) are characterized as JAZF1-SUZ12/JJAZ1 gene fusion. The ESTs that show higher grade atypia but lack nuclear pleomorphism include YWHAE-FAM22 ESS. Here we report an unusual case of ESTs. Sudden colonic perforation occurred to the patient, and emergency surgery was performed. Pathological findings suggested metastatic ESS. Thorough medical examination of the genital organs detected a 1 cm-sized well-demarcated uterine tumor. Microscopically, the tumor lacked infiltrative features, conforming to the definition of ESN. Both lesions demonstrated identical cytology and shared JAZF1-SUZ12 gene fusion. Endometriosis was not found in any areas of the resected organs, strongly suggesting that the uterine orthotopic tumor metastasized. The current case uncovered the problems of differential diagnosis between ESN and ESS-LG. We demonstrate detailed pathological features of the two lesions, and discuss the possibility of orthotopic EST with limited infiltration to develop into ESS-LG.
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Affiliation(s)
- Aya Tokinaga
- Department of Obstetrics and Gynecology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Abstract
Endometrial stromal tumors are rare uterine mesenchymal neoplasms that have intrigued pathologists for years, not only because they commonly pose diagnostic dilemmas, but also because the classification and pathogenesis of these tumors has been widely debated. The current World Health Organization recognizes 4 categories of endometrial stromal tumor: endometrial stromal nodule (ESN), low-grade endometrial stromal sarcoma (LG-ESS), high-grade endometrial stromal sarcoma (HG-ESS), and undifferentiated uterine sarcoma (UUS). uterine sarcoma. These categories are defined by the presence of distinct translocations as well as tumor morphology and prognosis. Specifically, the JAZF1-SUZ12 (formerly JAZF1-JJAZ1) fusion identifies a large proportion of ESN and LG-ESSs, whereas the YWHAE-FAM22 translocation identifies HG-ESSs. The latter tumors appear to have a prognosis intermediate between LG-ESS and UUS, which exhibits no specific translocation pattern. This review (1) presents the clinicopathologic features of endometrial stromal tumors; (2) discusses their immunophenotype; and (3) highlights the recent advances in molecular genetics which explain their pathogenesis and lend support for a new classification system.
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80
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High-grade endometrial stromal sarcomas: a clinicopathologic study of a group of tumors with heterogenous morphologic and genetic features. Am J Surg Pathol 2014; 38:1161-72. [PMID: 25133706 DOI: 10.1097/pas.0000000000000256] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The existence of a "high-grade endometrial stromal sarcoma" category of tumors has been a controversial subject owing to, among other things, the difficulty in establishing consistent diagnostic criteria. Currently, the recommended classification for such tumors is undifferentiated uterine/endometrial sarcoma. Interest in this subject has recently increased markedly with the identification of recurrent molecular genetic abnormalities. At Mayo Clinic, a group of neoplasms has been observed that morphologically resemble, either cytologically or architecturally, classic "low-grade" endometrial stromal sarcoma but feature obvious deviations, specifically, 17 tumors with unequivocally high-grade morphology. These high-grade tumors displayed 3 morphologic themes: (1) tumors with a component that is identical to low-grade ESS that transitions abruptly into an obviously higher-grade component; (2) tumors composed exclusively of high-grade cells with uniform nuclear features but with a permeative pattern of infiltration; (3) tumors similar to the second group but with a different, yet characteristic, cytomorphology featuring enlarged round to ovoid cells (larger than those found in low-grade ESS) with smooth nuclear membranes and distinct chromatin clearing but lacking prominent nucleoli. We collected clinicopathologic data, applied immunohistochemical studies, and also tested tumors by fluorescence in situ hybridization for abnormalities in JAZF1, PHF1, YWHAE, and CCND1. Tumors from these 3 groups were found to be immunohistochemically and genetically distinct from one another. Most notable was the fact that category 3 contained all the cases that tested positive for YWHAE rearrangement, did not show any classic translocations for JAZF1, PHF1, or CCND1, often presented at a high stage, and behaved aggressively. This study demonstrates the morphologic, immunophenotypic, and molecular genetic heterogeneity that exists within "undifferentiated endometrial sarcomas" as currently defined and lends credence to the effort of subclassifying some tumors as truly "high-grade endometrial stromal sarcomas." Our study also shows that, in the context of undifferentiated endometrial sarcomas, recognition of cytomorphologic features on routine hematoxylin and eosin-stained sections may be used to select tumors with specific molecular genetic changes-that is, translocations involving YWHAE. Our conclusions will help further efforts towards proper sub-classification of these tumors which will aid in diagnosis and potentially affect clinical management.
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81
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Gremel G, Liew M, Hamzei F, Hardell E, Selling J, Ghaderi M, Stemme S, Pontén F, Carlson JW. A prognosis based classification of undifferentiated uterine sarcomas: identification of mitotic index, hormone receptors and YWHAE-FAM22 translocation status as predictors of survival. Int J Cancer 2014; 136:1608-18. [PMID: 25130488 DOI: 10.1002/ijc.29141] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 06/22/2014] [Accepted: 07/16/2014] [Indexed: 01/07/2023]
Abstract
Undifferentiated uterine sarcomas (UUS) are rare tumors with a heterologous biology and a poor prognosis. The goal of this study was to examine clinicopathology, biomarkers and YWHAE-FAM22 translocation status, in the prognosis of these tumors. Twenty-six cases of UUS were included. All original slides were rereviewed and age at diagnosis, tumor stage, "Kurihara" diagnosis, mitotic index, presence of necrosis and grade of nuclear atypia were recorded. Additionally, a tissue microarray was constructed from 22 of the cases, and the protein biomarkers P53, P16, Ki-67, Cyclin-D1, ER, PR and ANLN were evaluated by immunohistochemistry. All tumors were evaluated for the presence of a YWHAE-FAM translocation; the translocation was demonstrated in the three Cyclin-D1 positive tumors. Follow-up data in the form of overall survival were available on all patients. These tumors could be divided into two prognostic groups, a high mitotic index group (10 cases, M = 36.8, SD = 5.4) and a low mitotic index group (16 cases, M = 8.7, SD = 5.8). These two groups showed a statistically significant difference in prognosis. The expression of ER, PR or presence of the YWHAE-FAM22 translocation correlated with low mitotic index and an additionally improved prognosis, although the number of cases was small. These results indicate that UUS can be divided into two prognostic groups using mitotic index as a primary criteria, followed by expression of either ER, PR or the presence of a YWHAE-FAM22 translocation as a secondary criteria. This study demonstrates the presence of statistically significant prognostic subgroups within UUS, and provides treatment insights.
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Affiliation(s)
- Gabriela Gremel
- Department of Immunology, Genetics and Pathology, Uppsala University, S-751 85, Uppsala, Sweden; Science for Life Laboratory, Uppsala University, S-751 85, Uppsala, Sweden
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82
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High-Grade Undifferentiated Sarcomas of the Uterus: Diagnosis, Outcomes, and New Treatment Approaches. Curr Oncol Rep 2014; 16:405. [DOI: 10.1007/s11912-014-0405-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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83
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Ríos I, Rovirosa Á, Morales J, Gonzalez-Farre B, Arenas M, Ordi J, Pahisa J, Biete A. Undifferentiated uterine sarcoma: a rare, not well known and aggressive disease: report of 13 cases. Arch Gynecol Obstet 2014; 290:993-7. [DOI: 10.1007/s00404-014-3311-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 06/02/2014] [Indexed: 12/17/2022]
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84
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Abstract
Immunohistochemistry may be helpful in the diagnosis of mesenchymal uterine tumors. This article reviews the immunoreactions used most frequently in the diagnosis of uterine smooth muscle tumors, endometrial stromal tumors, undifferentiated endometrial sarcomas, UTROSCTs, PEComas, adenomyomas, adenosarcomas and carcinosarcomas.
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Affiliation(s)
- Emanuela D'Angelo
- Department of Pathology, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Floor C-2, Sant Quintí, 87-89, 08041 Barcelona, Spain.
| | - Jaime Prat
- Department of Pathology, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Floor C-2, Sant Quintí, 87-89, 08041 Barcelona, Spain.
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85
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Stewart CJR, Leung YC, Murch A, Peverall J. Evaluation of fluorescencein-situhybridization in monomorphic endometrial stromal neoplasms and their histological mimics: a review of 49 cases. Histopathology 2014; 65:473-82. [DOI: 10.1111/his.12406] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 02/28/2014] [Indexed: 12/31/2022]
Affiliation(s)
- Colin J R Stewart
- Department of Histopathology; King Edward Memorial Hospital; Perth WA Australia
- School of Women's and Infants Health; University of Western Australia; Perth WA Australia
| | - Yee C Leung
- School of Women's and Infants Health; University of Western Australia; Perth WA Australia
| | - Ashleigh Murch
- Department of Diagnostic Genomics; PathWest Laboratory Medicine; Queen Elizabeth II Medical Centre; Perth WA Australia
| | - Joanne Peverall
- Department of Diagnostic Genomics; PathWest Laboratory Medicine; Queen Elizabeth II Medical Centre; Perth WA Australia
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86
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Stemme S, Ghaderi M, Carlson JW. Diagnosis of endometrial stromal tumors: a clinicopathologic study of 25 biopsy specimens with identification of problematic areas. Am J Clin Pathol 2014; 141:133-9. [PMID: 24343747 DOI: 10.1309/ajcpxd0tpysnvi8i] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES To assess the difficulties associated with diagnosing endometrial stromal tumors (ESTs) on endometrial biopsy. METHODS We examined 25 endometrial biopsy specimens from 19 consecutive women diagnosed with either endometrial stromal nodule (n = 3) or endometrial stromal sarcoma (n = 16). RESULTS Rereview of the biopsy specimens revealed a stromal fragment suspicious for an EST in 16, of which eight had received a benign diagnosis on initial review. Most ESTs had an aglandular stromal fragment that was 5 mm or larger. Stromal fragments of this size were not encountered in the control material. Problematic areas included highly cellular leiomyoma and a lack of attention to the stromal compartment. CONCLUSIONS Most endometrial stromal tumors present with large aglandular stromal fragments (≥5 mm). These fragments are large enough that difficulties in diagnosis appear to be due to a lack of attention to the stromal compartment.
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Affiliation(s)
- Sten Stemme
- Department of Pathology and Cytology, Karolinska University Hospital, Stockholm, Sweden
| | - Mehran Ghaderi
- Department of Pathology and Cytology, Karolinska University Hospital, Stockholm, Sweden
| | - Joseph W. Carlson
- Department of Pathology and Cytology, Karolinska University Hospital, Stockholm, Sweden
- Institution for Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
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Feng W, Malpica A, Skaland I, Gudlaugsson E, Robboy SJ, Dalen I, Hua K, Zhou X, Baak JPA. Can proliferation biomarkers reliably predict recurrence in World Health Organization 2003 defined endometrial stromal sarcoma, low grade? PLoS One 2013; 8:e75899. [PMID: 24146786 PMCID: PMC3795675 DOI: 10.1371/journal.pone.0075899] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Accepted: 08/19/2013] [Indexed: 01/27/2023] Open
Abstract
An estimated 1500–3000 invasive Endometrial Stromal Sarcomas (ESS) cases annually occur worldwide. Before 2003, ESS was divided as low and high grade ESS based on mitotic activity. In 2003 the WHO changed the names, excluded mitoses and made nuclear atypia and necrosis the essential diagnostic criteria to distinguish ESS, Low Grade (ESS-LG, recurrence-free survival >90%) and Undifferentiated Endometrial Sarcoma (UES, poor prognosis). We have evaluated in WHO2003 defined ESS-LG whether proliferation biomarkers predict recurrence. Using survival analysis, the prognostic value of classical mitosis counts (Mitotic Activity Index, MAI) in haematoxyllin-eosin (H&E) sections, and immunohistochemical proliferation biomarkers (Ki-67 and PhosphoHistone-3 (PPH3)) were examined in 24 invasive endometrial stromal sarcomas. Three of 24 (12.5%) ESS-LG recurred. The MAI, PPH3 and Ki-67 were all prognostic (P = 0.001, 0.002 and 0.03). MAI values were >3 in the recurrent cases, but never exceeded 10 (the classical threshold for low and high grade). Non-recurrent cases had 0≤MAI≤3. PPH3 and Ki67 counts can be easier to perform than MAI and therefore helpful in the diagnosis of ESS, Low Grade. In conclusion, in this small study of WHO2003 defined ESS-LG, high levels of proliferation as measured by MAI, PPH3 and Ki-67 are predictive of recurrence. Larger studies are required to confirm these results.
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Affiliation(s)
- Weiwei Feng
- Department of Gynecology and Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- * E-mail: (WF); (JPAB)
| | - Anais Malpica
- Departments of Pathology and Gynecologic Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, United States of America
| | - Ivar Skaland
- Department of Pathology, Stavanger University Hospital, Stavanger, Norway
| | - Einar Gudlaugsson
- Department of Pathology, Stavanger University Hospital, Stavanger, Norway
| | - Stanley J. Robboy
- Departments of Pathology and Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Ingvild Dalen
- Department of Research, Stavanger University Hospital, Stavanger, Norway
| | - Keqin Hua
- Department of Gynecology and Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Xianrong Zhou
- Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Jan P. A. Baak
- Department of Pathology, Stavanger University Hospital, Stavanger, Norway
- Clinical Institute, Medical-Odontologic Faculty, University of Bergen, Bergen, Norway
- * E-mail: (WF); (JPAB)
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88
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YWHAE rearrangement identified by FISH and RT-PCR in endometrial stromal sarcomas: genetic and pathological correlations. Mod Pathol 2013; 26:1390-400. [PMID: 23599159 DOI: 10.1038/modpathol.2013.69] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 01/09/2013] [Accepted: 01/09/2013] [Indexed: 11/09/2022]
Abstract
Endometrial stromal sarcomas represent the second most common mesenchymal uterine tumor. The 2003 WHO classification distinguishes low-grade and undifferentiated endometrial stromal sarcomas with different prognoses. Endometrial stromal sarcomas are a genetically heterogeneous group of sarcomas harboring different cytogenetic anomalies. Recently, a fusion between the YWHAE and FAM22A/B genes subsequent to a t(10;17) (q22;p13) has been described in endometrial sarcomas with high-grade histology. We examined YWHAE rearrangements by FISH break-apart and RT-PCR in a series of 27 undifferentiated uterine stromal sarcoma without JAZF1 rearrangements. Immunohistochemistry (IHC) was carried out with a panel of antibodies (estrogen (ER) and progesterone (PR) receptors, CD10, Cyclin D1, β-catenin, p53, and Ki-67). We identified a subgroup of endometrial sarcomas with high-grade histology and uniform morphology harboring YWHAE rearrangements. FISH break-apart was interpretable in 20 cases (74%). Twelve cases (60%) showed <10% of tumor cells with a YWHAE rearrangement, 4 cases (20%) showed between 10 and ≤20%, and 4 (20%) >20%. RT-PCR was tested on 24/27 cases (88%) and 19 cases were interpretable (79%). Five cases (26%) showed a specific fusion transcript YWHAE-FAM22A/B sequence. The best concordance rate between FISH and RT-PCR (94%) was obtained with the threshold of 20% of cells with a YWHAE rearrangement. The YWHAE-rearranged cases showed high-grade morphology with uniform appearance, spindle or round epithelioid cells, low ER and PR, CD10 expression, and a high and diffuse positivity for Cyclin D1, p53, and nuclear β-catenin negativity. Cyclin D1 was the most sensitive marker for high-grade endometrial sarcomas with YWHAE rearrangement. All undifferentiated uterine sarcomas with pleomorphic appearances did not harbor any YWHAE rearrangements, except for one case. Overall, for endometrial sarcoma cases with high-grade morphology we recommend to test for YWHAE rearrangements by FISH break-apart, a cost- and time-efficient method, and to complete the investigation by RT-PCR in borderline cases.
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89
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Binesh F, Zahir ST, Akhavan A, Bovanlu TR. Endometrial stromal sarcoma of the uterus presenting as pulmonary metastasis. BMJ Case Rep 2013; 2013:bcr-2013-008565. [PMID: 23907964 DOI: 10.1136/bcr-2013-008565] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Endometrial stromal sarcoma (ESS) is a rare uterine sarcoma. Compared with other uterine malignancies, it occurs at an earlier age (42-58 years) and about 10-25% of the patients are premenopausal. The tumours have an indolent growth, with a tendency for late recurrence. Metastases are rarely detected before the diagnosis of the primary lesion. We report a case of ESS with pulmonary metastasis as a prodromal manifestation.
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Affiliation(s)
- Fariba Binesh
- Department of Pathology, Shahid Sadoughi University of Medical Sciences, Yazd, Islamic Republic of Iran
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90
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Tyrosine kinase receptor status in endometrial stromal sarcoma: an immunohistochemical and genetic-molecular analysis. Int J Gynecol Pathol 2013; 31:570-9. [PMID: 23018215 DOI: 10.1097/pgp.0b013e31824fe289] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Endometrial stromal sarcomas (ESS) are rare uterine malignant mesenchymal neoplasms, which are currently treated by surgery, as effective adjuvant therapies have not yet been established. Tyrosine kinase inhibitors have rarely been applied in ESS therapy, with few reports describing imatinib responsivity. The aim of this study was to analyze the status of different tyrosine kinase receptors in an ESS series, in order to evaluate their potential role as molecular targets. Immunohistochemistry was performed for EGFR, c-KIT, PDGFR-α, PDGFR-β, and ABL on 28 ESS. EGFR, PDGFR-α, and PDGFR-β gene expression was investigated by real-time polymerase chain reaction (qRT-PCR) on selected cases. "Hot-spot" mutations were screened for on EGFR, c-KIT, PDGFR-α, and PDGFR-β genes, by sequencing. All analysis was executed from formalin-fixed, paraffin-embedded specimens. Immunohistochemical overexpression of 2 or more tyrosine kinase receptors was observed in 18 of 28 tumors (64%), whereas only 5 tumors were consistently negative. Gene expression profiles were concordant with immunohistochemical overexpression in only 1 tumor, which displayed both high mRNA levels and specific immunoreactivity for PDGFR-α, and PDGFR-β. No activating mutations were found on the tumors included in the study. This study confirms that TKRs expression is frequently observed in ESS. Considering that the responsiveness to tyrosine kinase inhibitors is known to be related to the presence of specific activating mutations or gene over-expression, which are not detectable in ESS, TKRs immunohistochemical over-expression alone should not be considered as a reliable marker for targeted therapies in ESS. Specific post-translational abnormalities, responsible for activation of TKRs, should be further investigated.
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91
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Abstract
Smooth muscle and endometrial stromal tumours represent the two most common uterine mesenchymal neoplasms that may present diagnostic dilemmas for the practising surgical pathologist. Recent changes in morphological and staging criteria, as well as the discovery of new immunohistochemical markers, have improved the diagnosis and classification of these tumours. We highlight the difficulty in distinguishing tumour cell necrosis from infarct-type necrosis and the limited utility of p16 immunohistochemical expression in the diagnosis of leiomyosarcoma. We also discuss the controversial use of mitotic activity and necrosis as prognostic factors in endometrial stromal sarcomas. Emerging genetic information has also greatly expanded our understanding of 'sarcomagenesis' in both tumour types and may provide insight into potential therapeutic targets for the treatment of leiomyosarcoma and endometrial stromal sarcomas, harboring MED12 (mediator complex subunit 12) mutations and recurrent gene rearrangements, respectively. In this review, we discuss the core updates in the diagnosis and classification of uterine leiomyosarcomas and endometrial stromal sarcomas, highlighting new and important molecular genetic findings that may drive pathogenesis.
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Affiliation(s)
- Sarah Chiang
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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92
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Isphording A, Ali RH, Irving J, Goytain A, Nelnyk N, Hoang LN, Gilks CB, Huntsman DG, Nielsen TO, Nucci MR, Lee CH. YWHAE-FAM22 endometrial stromal sarcoma: diagnosis by reverse transcription–polymerase chain reaction in formalin-fixed, paraffin-embedded tumor. Hum Pathol 2013; 44:837-43. [DOI: 10.1016/j.humpath.2012.08.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 08/08/2012] [Accepted: 08/10/2012] [Indexed: 12/17/2022]
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93
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Prognostic factors and outcome of undifferentiated endometrial sarcoma treated by multimodal therapy. Int J Gynaecol Obstet 2013; 122:57-61. [PMID: 23597861 DOI: 10.1016/j.ijgo.2013.01.025] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 01/11/2013] [Accepted: 03/08/2013] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To describe the natural history, prognostic factors, and optimal treatment modalities of undifferentiated endometrial sarcoma (UES). METHODS A retrospective review was conducted of 30 patients with UES treated at Institut Gustave-Roussy, France, between January 1978 and December 2008. Clinical and pathologic variables, treatment modalities, and outcomes were assessed. RESULTS Disease was advanced in most cases: FIGO stage III-IV in 70% of patients. Overall, 29 patients (96.7%) underwent hysterectomy as part of the initial surgical treatment; however, only 18 (60.0%) attained complete macroscopic resection. The incidence of pelvic and/or para-aortic lymph-node involvement at primary surgery or first recurrence was 44.4%. Median postoperative follow-up was 5 years; progression-free survival (PFS) and overall survival (OS) were 9.7 and 23 months, respectively. No differences in OS and PFS were observed by staging subgroup (FIGO vs the American Joint Committee on Cancer). Only postoperative pelvic radiotherapy with or without brachytherapy correlated with improved PFS (19.1 vs 6.5 months; P=0.04) and OS (54.5 vs 16.7 months; P=0.01) in a univariate analysis. CONCLUSION Neither staging system was optimal for risk stratification. Multimodal therapy was recommended after surgery.
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94
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Endometrial Stromal Sarcomas With Sex Cord Differentiation Are Associated With PHF1 Rearrangement. Am J Surg Pathol 2013; 37:514-21. [DOI: 10.1097/pas.0b013e318272c612] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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95
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Sardinha R, Hernández T, Fraile S, Tresserra F, Vidal A, Gómez MC, Astudillo A, Hernández N, Saenz de Santamaría J, Ordi J, Gonçalves L, Ramos R, Balañá C, de Álava E. Endometrial stromal tumors: immunohistochemical and molecular analysis of potential targets of tyrosine kinase inhibitors. Clin Sarcoma Res 2013; 3:3. [PMID: 23497641 PMCID: PMC3599876 DOI: 10.1186/2045-3329-3-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 03/04/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The systemic treatment of malignant endometrial stromal tumors (EST) is not well established. A few reports describe objective responses to imatinib, which suggest a novel therapeutic strategy for these tumors. Due to these facts, we aimed to perform a retrospective analysis of possible molecular targets of tyrosine kinase inhibitors (TKI) in EST: KIT, PDGFRA and EGFR. METHODS 52 endometrial stromal sarcomas and 13 undifferentiated endometrial sarcomas were examined and reviewed. Mutational analysis were performed for exons 9, 11, 13, and 17 of the KIT gene, exons 12 and 18 of the PDGFRA gene and exons 18, 19, 20 and 21 of the EGFR gene. The incidence and distribution of the KIT, PDGFRA, and EGFR expression were examined by immunohistochemistry, and EGFR amplification was assessed by fluorescence in situ hybridization. RESULTS No mutations in KIT, PDGFRA and EGFR genes were detected. Overexpression of KIT, PDGFRA, EGFR, was detected in 2 (3%), 23 (35.4%), 7 (10.8%) cases respectively, whereas amplification of EGFR gene was not found. CONCLUSIONS Absence of significant expression, amplification and activating mutations on these tyrosine kinase receptors suggest that it is unlikely that EST can benefit from therapies such as TKI on the systemic setting.
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Affiliation(s)
- Ruth Sardinha
- Pathology Department, Hospital Espírito Santo E.P.E, Évora, Portugal
| | - Teresa Hernández
- Centro de Investigación del Cáncer-IBMCC USAL-CSIC, Salamanca, Spain
| | - Susana Fraile
- Centro de Investigación del Cáncer-IBMCC USAL-CSIC, Salamanca, Spain
| | - Francesc Tresserra
- Pathology Department, USP-Institut Universitari Dexeus, Barcelona, Spain
| | - August Vidal
- Pathology Department, Hospital de Bellvitge, Barcelona, Spain
| | - Maria Carmén Gómez
- Pathology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Aurora Astudillo
- Pathology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Nieves Hernández
- Anatomical Pathology Department, Hospital Universitario de la Laguna, Canarias, Spain
| | | | - Jaume Ordi
- Pathology Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Luis Gonçalves
- Pathology Department, Hospital do Espírito Santo E.P.E, Évora, Portugal
| | - Rafael Ramos
- Pathology Department, Hospital Son Espases, Palma de Mallorca, Spain
| | - Carmen Balañá
- Medical Oncology Service, Catalan Institute of Oncology - Hospital Germans Trias i Pujol, Badalona, Spain
| | - Enrique de Álava
- Centro de Investigación del Cáncer-IBMCC USAL-CSIC, Salamanca, Spain
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96
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Jakate K, Azimi F, Ali RH, Lee CH, Clarke BA, Rasty G, Shaw PA, Melnyk N, Huntsman DG, Laframboise S, Rouzbahman M. Endometrial sarcomas: an immunohistochemical and JAZF1 re-arrangement study in low-grade and undifferentiated tumors. Mod Pathol 2013; 26:95-105. [PMID: 22918161 DOI: 10.1038/modpathol.2012.136] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The current World Health Organization classification divides endometrial sarcomas into low-grade endometrial stromal sarcoma and undifferentiated endometrial sarcoma. Recent studies suggest undifferentiated endometrial sarcoma is a heterogeneous group and a subgroup with uniform nuclei is more akin to low-grade endometrial stromal sarcoma in terms of morphologic, immunohistochemical and genetic features. We classified endometrial sarcomas treated at our institution from 1998 to 2011 into low-grade endometrial stromal sarcoma and undifferentiated endometrial sarcoma, the latter being further categorized into a group with either uniform or pleomorphic nuclei. Morphological features, immunoprofile and fluorescence in situ hybridization rearrangements of JAZF1 and PHF1 genes were correlated with tumor category and outcome. A total of 40 cases were evaluated comprising 23 low-grade endometrial stromal sarcomas, 10 undifferentiated endometrial sarcomas with nuclear uniformity and 7 undifferentiated endometrial sarcomas with nuclear pleomorphism. Low-grade endometrial stromal sarcomas were more often estrogen and progesterone receptor positive (83%) compared with undifferentiated endometrial sarcoma with nuclear uniformity (10%) or with nuclear pleomorphism (0%) (P<0.001). Positivity for p53 was restricted to undifferentiated endometrial sarcomas with more frequent expression in the group with nuclear pleomorphism (57%) than with nuclear uniformity (10%) (P=0.06). Ki-67 proliferation index in >10% of tumor cells more frequent in undifferentiated endometrial sarcoma than low-grade endometrial stromal sarcoma (P=<0.001). JAZF1 rearrangement was detected in 32% of low-grade endometrial stromal sarcomas and in none of the undifferentiated sarcomas. Rearrangement of PHF1 was found in two patients, one with JAZF1-PHF1 fusion. There were no significant differences in clinical behavior between undifferentiated endometrial sarcoma with nuclear uniformity versus nuclear pleomorphism. In conclusion, we found undifferentiated endometrial sarcoma subtypes and low-grade endometrial stromal sarcoma have distinct immunohistochemical and cytogentic profiles. Our data do not show any difference in clinical behavior between subgroups in undifferentiated sarcomas.
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Affiliation(s)
- Kiran Jakate
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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97
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Cyclin D1 as a diagnostic immunomarker for endometrial stromal sarcoma with YWHAE-FAM22 rearrangement. Am J Surg Pathol 2012; 36:1562-70. [PMID: 22982899 DOI: 10.1097/pas.0b013e31825fa931] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Endometrial stromal sarcoma (ESS) characterized by YWHAE-FAM22 genetic fusion is histologically higher grade and clinically more aggressive than ESS with JAZF1-SUZ12 or equivalent genetic rearrangements, hence it is clinically important to recognize this subset of ESS. To identify diagnostic immunomarkers for this biologically defined ESS subset, we compared gene expression profiles between YWHAE-FAM22 ESS and JAZF1-rearranged ESS. These studies showed consistent upregulation of cyclin D1 in YWHAE-FAM22 ESS compared with JAZF1-SUZ12 ESS. Immunohistochemically, the high-grade round cell component of all 12 YWHAE-FAM22 ESS demonstrated diffuse (≥70%) moderate to strong nuclear cyclin D1 staining, and this diffuse positivity was not seen in 34 ESSs with JAZF1 and equivalent genetic rearrangements or in 21 low-grade ESS with no demonstrable genetic rearrangements. In a series of 243 non-ESS pure uterine mesenchymal and mixed epithelial-mesenchymal tumors, only 2 of 8 undifferentiated endometrial sarcomas with nuclear uniformity and 1 of 80 uterine leiomyosarcomas demonstrate diffuse cyclin D1 immunoreactivity. Both cyclin D1-positive undifferentiated endometrial sarcomas showed diffuse strong CD10 staining, which is consistently absent in the high-grade round cell component of YWHAE-FAM22 ESS. The low-grade spindle cell component of YWHAE-FAM22 ESS showed a spatially heterogenous cyclin D1 staining pattern that was weaker and less diffuse overall. Our findings indicate that cyclin D1 is a sensitive and specific diagnostic immunomarker for YWHAE-FAM22 ESS. When evaluating high-grade uterine sarcomas, cyclin D1 can be included in the immunohistochemical panel as an indicator of YWHAE-FAM22 ESS.
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98
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Somma A, Falleti J, Di Simone D, Marra A, Nazzaro G, Miranda M, Insabato L. Cystic variant of endometrial stromal sarcoma: report of two cases. Int J Surg Pathol 2012; 21:278-81. [PMID: 23045333 DOI: 10.1177/1066896912461528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endometrial stromal sarcoma is an uncommon tumor representing 0.2% of all uterine neoplasm and 15% to 26% of uterine sarcomas. Endometrial stromal sarcoma has a gross appearance as single nodule, multiple masses, or a poorly demarcated lesion with occasional cystic degeneration; rarely, it shows a cystic multilocular feature. We report 2 cases of endometrial stromal sarcoma with a prominent cystic appearance, forming multilocular cystic mass, detected by ultrasonography. The differential diagnosis among multicystic endometrial stromal sarcoma and cystic uterine tumors might be very difficult.
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Affiliation(s)
- Anna Somma
- Department of Biomophological and Functional Science, University Federico II, Naples, Italy
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99
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Tanner EJ, Garg K, Leitao MM, Soslow RA, Hensley ML. High grade undifferentiated uterine sarcoma: surgery, treatment, and survival outcomes. Gynecol Oncol 2012; 127:27-31. [PMID: 22750260 DOI: 10.1016/j.ygyno.2012.06.030] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 06/15/2012] [Accepted: 06/19/2012] [Indexed: 12/19/2022]
Abstract
OBJECTIVES High grade undifferentiated uterine sarcomas (HGUS) are rare, aggressive malignancies. Data regarding management are limited. We aimed to describe disease stage, response to treatment, and survival outcomes among patients with HGUS at our institution. METHODS We identified all patients with HGUS who received treatment at our institution from 1/2000 to 3/2011. Demographics, surgical procedures, disease stage, treatment response, and survival outcomes were abstracted from the medical records. RESULTS Twenty-one patients were identified. FIGO 2008 stage distribution was: I-7 (33%), II-1 (5%), III-2 (10%), IV-11 (52%). Eighteen of 21 patients (86%) undergoing primary surgical resection achieved a complete gross resection; however, progression within the abdominal cavity was identified in 11 patients (61%) by the time they underwent postoperative imaging. Of 13 patients who received first-line chemotherapy for measurable disease, the overall response rate was 62%. Responses were observed in patients treated with gemcitabine/docetaxel (6 of 8) and doxorubicin-based regimens (2 of 5). Progression-free and overall survivals for the entire cohort were 7.3 months and 11.8 months, respectively. In 14 patients with measurable disease at the time of treatment, 1-year survival was 35.7% versus 80% in 5 patients without measurable disease at time of treatment (P=0.112). Nine patients received second- or additional chemotherapy for progressive disease, with response rate of 19%. Time to progression was short among responders. CONCLUSIONS HGUS represents a distinct histologic subtype of uterine sarcoma with poor outcomes regardless of stage at diagnosis. A majority rapidly develops distant metastases despite surgical resection. Gemcitabine-docetaxel and doxorubicin-based treatment achieved objective, but short-lived, responses in patients with measurable disease.
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Affiliation(s)
- Edward J Tanner
- Department of Surgery, Gynecology Service, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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100
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