Uterine sarcoma - current perspectives

Low-Grade Endometrial Stromal Sarcoma and Uterine Adenosarcoma: A Comparison of Clinical Manifestations and Outcomes

Objective: Our study aimed to assess factors associated with progression free survival (PFS) and overall survival (OS) in low grade endometrial stromal sarcoma (LG-ESS) and uterine adenosarcoma, and to determine the differences in clinical manifestations and outcomes between the two diseases. Methods: A total of 132 patients were enrolled in this retrospective study at Peking Union Medical College Hospital from 1998 to 2016. The associations of clinical and pathological factors with PFS and OS were evaluated. Results: Of the 132 included patients, 104 had LG-ESS and 28 had uterine adenosarcoma. All patients were followed up for at least 1.5 years. There were significant differences between LG-ESS and uterine adenosarcoma in terms of age distribution (41.05±10.5 vs 46.11±14.96 years, P=0.042), delivery time (nulliparity=0: 18.27% vs 35.71%, P=0.046), history of the uterine leiomyoma (65.38% vs 39.29%, P=0.012), and polypoid tumor growth (14.42% vs 60.71%, P=0.007). According to the pathological findings, the proportion of uterine adenosarcoma patients with uterine leiomyoma (60.71%) was significantly higher than that for the LG-ESS patients (32.69%) (P=0.007). Uterine adenosarcoma seemed to be associated with longer PFS and OS than LG-ESS (PFS: 42.69±29.94 vs 50.50±40.50 months; OS: 58.72±37.29 vs 69.46±47.58 months), but the differences were not statistically significant. Multivariate Cox regression showed that age, menopause, history of uterine leiomyoma, stage, and hormone therapy were independent risk factors with respect to PFS, whereas age and stage were risk factors affecting OS in LG-ESS patient. Peritoneal lavage cytology and radiotherapy were risk factors affecting PFS and peritoneal lavage cytology for OS in patients with uterine adenosarcoma. Conclusion: The patients with advanced LG-ESS had poor prognosis. Age and history of uterine leiomyoma were associated with poor PFS, while menopause and hormone therapy were protective factors associated with improved PFS in patients with LG-ESS. Peritoneal lavage cytology and radiotherapy did not improve prognosis of uterine adenosarcoma.

Different methylation levels in the KLF4, ATF3 and DLEC1 genes in the myometrium and in corpus uteri mesenchymal tumours as assessed by MS-HRM

Mesenchymal tumours of the corpus uteri comprise common benign lesions - leiomyomas and very rare malignant variants - sarcomas. It can be difficult to distinguish between the particular types of mesenchymal tumours pre-surgically. Primarily, leiomyomas and the very aggressive leiomyosarcomas can be easily misdiagnosed when using only imaging devices. Therefore, a reliable non-invasive marker for these tumour types would provide greater certitude for patients that the lesion remains benign. Our collection comprises 76 native leiomyomas, an equal number of healthy myometrium samples and 49 FFPE samples of various types of sarcomas. The methylation level was assessed by MS-HRM method and we observed differences in the methylation level between healthy, benign and (semi)malignant tissues in the KLF4 and DLEC1 genes. The mean methylation levels of leiomyomas compared to myometrium and leiomyosarcomas were 70.7% vs. 6.5% vs. 39.6 % (KLF4) and 66.1% vs. 14.08% vs. 37.5% (DLEC1). The ATF3 gene was differentially methylated in leiomyomatous and myometrial tissues with 98.1% compared to 76.6%. The AUC values of the predictive logistic regression model for discrimination between leiomyomas and leiomyosarcomas based on methylation levels were 0.7829 (KLF4) and 0.7719 (DLEC1). Finally, our results suggest that there should be distinct models for the methylation events in benign leiomyomas and sarcomas, and that the KLF4 and DLEC1 genes can be considered potential methylation biomarkers for uterine leiomyomas.

Role of surgery in gynaecological sarcomas

Gynaecological sarcomas account for 3-4% of all gynaecological malignancies and have a poorer prognosis compared to gynaecological carcinomas. Pivotal treatment for early-stage uterine sarcoma is represented by total hysterectomy. Whereas oophorectomy provides survival advantage in endometrial stromal sarcoma is still controversial. When the disease is confined to the uterus, systematic pelvic and para-aortic lymphadenectomy is not recommended. Removal of enlarged lymph-nodes is indicated in case of disseminated or recurrent disease, where debulking surgery is considered the standard of care. Fertility sparing surgery for uterine leiomyosarcoma is not supported by strong evidence, whilst available data on fertility sparing treatment for endometrial stromal sarcoma are more promising. For ovarian sarcomas, in the absence of specific data, it is reasonable to adapt recommendations existing for uterine sarcomas, also regarding the role of lymphadenectomy in both early and advanced stage disease. Specific recommendations on cervical sarcomas' surgery are lacking. Existing data on surgical approach vary from radical hysterectomy to fertility-preserving surgery in the form of trachelectomy or wide local excision, however no definite conclusions can be drafted on the recommended surgical approach. For vulval sarcomas, complete surgical excision with at least 2 cm of free margin is considered to be the primary treatment which is associated with good prognosis. The aim of this review is to provide highest quality evidence to guide gynaecologic oncologists throughout surgical management of gynaecological sarcomas.

Non-puerperal uterine inversion associated with adenosarcoma of the uterus: A case report

Introduction

Uterine inversion is an uncommon condition characterized by the invagination of the fundus of the uterus through the vagina and is extremely rare in non-pregnancy settings. Non-puerperal uterine inversion is usually precipitated by tumours exerting traction force on the fundus of the uterus, turning the uterus partially or completely inside out. It is most frequently associated with benign tumours such as submucosal leiomyomas; however, malignant tumours are a rare association.

Case Presentation

A 67-year-old woman, G18P18, presented to the emergency department with a bleeding mass that had acutely prolapsed out of the vagina. She had a two-year history of postmenopausal bleeding but had not sought medical advice. She underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Pathological evaluation revealed an adenosarcoma of the uterine fundus, measuring 6 cm in its largest diameter, which invaded the myometrium only superficially. The patient recovered well from the operation with no complications and was referred to an oncologist for further treatment. A computerized tomography scan with intravenous contrast showed no evidence of metastasis.

Conclusion

Uterine sarcoma is a malignant tumour of the uterus that typically presents with vaginal bleeding, and rarely as prolapsed uterine inversion. Uterine inversion rarely occurs outside the puerperal setting; however, when it does occur, the possibility of an underlying malignancy should not be neglected.

Treatment of Rare Epithelial Ovarian Tumors

Traditionally, the management of epithelial ovarian cancer has been approached using a one-size-fits-all mentality. This strategy does not acknowledge the differences in epidemiology and clinical behavior of many of the histologic and molecular subgroups of ovarian cancer, specifically the rare histologies. While cytoreductive surgery followed by adjuvant platinum and taxane-based chemotherapy is the mainstay of primary treatment of epithelial ovarian cancer as a group, further investigation of novel therapeutics is critical for improving outcomes of these rare histologies. This article focuses on the management of non-high grade serous histologies of ovarian cancer.

High-grade endometrial stromal sarcoma: a retrospective study of factors influencing prognosis

OBJECTIVES

The aim of this study was to evaluate the factors associated with progress-free survival (PFS) and overall survival (OS) in patients with high-grade endometrial stromal sarcoma (HG-ESS).

PATIENTS AND METHODS

A total of 40 patients were enrolled in this study at the Peking Union Medical College Hospital, Beijing, China, from 2006 to 2016. The study retrospectively analyzed clinical and pathological data, and associations of these variables with PFS and OS were evaluated.

RESULTS

The age of the patients at the time of diagnosis ranged from 16 to 73 years. Abnormal vaginal bleeding was the most commonly observed symptom. The tumor size ranged from 2 to 19 cm. The tumor locations were as follows: vulva (1 case), ovary (2 cases), broad ligament (2 cases), cervix (7 cases), and uterus (28 cases). A total of 34 (85%) and 6 (15%) patients underwent complete and ovarian preservation surgery, respectively. Notably, 33 (82.5%), 13 (32.5%), and 5 (12.5%) patients received adjuvant chemotherapy, radiation therapy, and hormone treatment, respectively. Lymph node dissection was performed in 15 (37.5%) patients (positive rate: 7.4%), 16 (40%) patients underwent omentectomy (positive rate: 10%), and 12 (30%) patients underwent peritoneal lavage cytology (positive rate: 0%). Eighteen (45%) patients had lymphovascular space invasion, 13 (32.5%) patients had uterine fibroids, and 11 (27.5%) patients were diagnosed with endometriosis. Moreover, the levels of CA125 in the serum were measured prior to and following treatment. The median PFS and OS were 9 and 24 months, respectively. Eventually, 29 (72.5%) patients experienced relapse and 19 (47.5%) patients expired due to the disease.

CONCLUSION

Patients with advanced HG-ESS (stage II-IV) were associated with poor prognosis. The minimum value of CA125 and endometriosis were independent risk factors for PFS. The stage of disease, size of the tumor, minimum and average values of CA125, menopause, history of uterine leiomyoma, and endometriosis were independent risk factors for OS. The combination of surgery with radiotherapy and chemotherapy may improve the PFS of patients in the early stage of the disease.

A Case of High-grade Endometrial Stromal Sarcoma: A Poignant Allegory

Endometrial stromal sarcomas (ESS) are rare tumors of endometrial stromal origin that account for approximately 1% of all uterine malignant neoplasms and are responsible for a significant proportion of mortality due to uterine malignancies. There are immense case reports on low-grade ESS, but there is a paucity of data on high-grade ones, probably, because these cases generally present in advanced stages and have a high case fatality rate. Moreover, there have been several refinements in the classification of these tumors. We, herein, provide an update on this topic and discuss the poignant outcome of a case of high-grade ESS.

Management of uterine sarcomas and prognostic indicators: real world data from a single-institution

Background

Uterine sarcomas consist a heterogeneous group of mesenchymal gynecological malignancies with unclear therapeutic recommendations and unspecific but poor prognosis, since they usually metastasize and tend to recur very often, even in early stages.

Methods

We retrospectively analyzed all female patients with uterine sarcomas treated in our institution over the last 17 years. Clinico-pathological data, treatments and outcomes were recorded. Kaplan-Meier curves were plotted and time-to-event analyses were estimated using Cox regression.

Results

Data were retrieved from 61 women with a median age of 53 (range: 27–78) years, at diagnosis. Fifty-one patients were diagnosed with leiomyosarcoma (LMS), 3 with high grade endometrial stromal sarcoma (ESS), 5 with undifferentiated uterine sarcoma (UUS), 1 with Ewing sarcoma (ES) and 1 with Rhabdomyosarcoma (RS). 24 cases had stage I, 7 stage II, 14 stage III and 16 stage IV disease. Median disease-free survival (DFS) in adjuvant approach was 18.83 months, and median overall survival (OS) 31.07 months. High mitotic count (> 15 mitoses) was significantly associated with worse OS (P < 0.001) and worse DFS (P = 0.028).

Conclusions

Mitotic count appears to be independent prognostic factor while further insights are needed to improve adjuvant and palliative treatment of uterine sarcomas.

Uterine artery embolization in the treatment of symptomatic fibroids - state of the art 2018

Uterine fibroids are considered to be the most common benign tumours in females. The vast majority of these tumours are incidental findings and do not require any treatment. Symptomatic fibroids, with ailments such as abnormal uterine bleeding, dysmenorrhoea, pelvic pain, impaired urination, bowel dysfunction, infertility, and recurrent pregnancy loss, are indicated for medical treatment. Surgery remains a first-line treatment of symptomatic uterine fibroids; however, minimally invasive techniques and pharmacological management have become more available and popular. Among minimally invasive techniques uterine artery embolization (UAE) is the most well-established uterine preserving treatment. UAE was first introduced in obstetrics and gynaecology in 1987 and since then many studies have shown the safety and efficacy of UAE in fibroid treatment with low rates of complications. In this review we present a novel approach to UAE, which reflects the current state of knowledge based on recent clinical trials and long-term post-procedural follow-up.

Uterine Adenosarcoma with Sarcomatous Overgrowth: A Case Report of Aggressive Disease in a 16-Year-Old Girl and a Literature Review

BACKGROUND

Uterine adenosarcoma with sarcomatous overgrowth (ASSO) is a rare and aggressive disease. A case of a 16-year-old girl with uterine ASSO is reported herein. The patient received surgical resection and chemotherapy and remained alive without disease 11 months after the surgery.

CASE

A 16-year-old girl was diagnosed with uterine ASSO, International Federation of Gynecology and Obstetrics (2009) stage I c. She underwent total abdominal hysterectomy, bilateral salpingectomy, and chemotherapy. She remains alive and there was no evidence of tumor recurrence on follow-up physical, laboratory, and ultrasound scan examinations.

SUMMARY AND CONCLUSION

Surgery is the primary treatment for uterine ASSO, total abdominal or laparoscopic-assisted vaginal hysterectomy with or without bilateral salpingo-oophorectomy are recommended. Early surgical resection might increase survival of uterine adenosarcoma. Long-term follow-up of the patients is recommended because of the high chance of recurrence.

STUMP, a surprise finding in a large fibroid uterus in a 20-year-old woman

We report on a case of a 20-year-old nulliparous woman with menorrhagia associated with a smooth muscle tumor of uncertain malignant potential (STUMP) that was responsive to Goserelin. This case details the investigation and management of a young woman who desires ongoing fertility preservation. STUMP is a rare uterine tumor with a paucity of literature available regarding management and subsequent malignant potential, particularly in the case of a patient who desires fertility preservation.

Uterine sarcoma: a clinical case and a literature review

BACKGROUND

Uterine sarcomas are rare gynaecologic tumours representing 3-7% of all uterine malignancies. The aetiology of sarcomas is still unclear: it is thought, that chromosomal translocations have influence on wide histological variety of sarcomas. Presenting symptoms are vague and nonspecific. Usually sarcoma causes abnormal vaginal bleeding, can cause abdominal or pelvic pain, or manifests as a rapidly growing uterine tumour. The diagnosis of sarcoma is often made retrospectively after surgical removal of a presumed benign uterine neoplasm, because imaging modalities such as ultrasound, computed tomography, or magnetic resonance imaging cannot yet accurately and reliably distinguish between benign leiomyoma and malignant pathology. If there are certain clinical features that raise a suspicion of malignancy in the uterus, it is recommended to avoid the use of power morcellation through laparoscopic surgery in order to prevent disease dissemination.

MATERIALS AND METHODS

We present a clinical case of a 64-year-old patient, who was referred to hospital due to abdominal pain and tenesmus that lasted for two days. From a past medical history it was known that previously the patient had been diagnosed with uterine myoma. Transvaginal ultrasonography showed a 10.4 cm × 9.8 cm uterine tumour of nonhomogeneous structure with signs of necrosis and good vascularization. The patient refused urgent hysterectomy, that was advised to her. The patient was operated on one month later and total hysterectomy with bilateral salpingooforectomy was performed. Postoperative histological evaluation showed undifferentiated sarcoma uterus pT1b L/V0. Imaging modalities were made to evaluate possible dissemination of the disease. In the absence of signs of disease progression, the patient received radiotherapy and brachytherapy and was followed-up by doctors.

RESULTS AND CONCLUSIONS

Uterine sarcomas are highly malignant tumours that originate from smooth muscles and connective tissue elements of the uterus and make up 1% of all malignant gynaecological tumours and about 3-7% of all malignant uterine tumours. Imaging modalities cannot yet reliably distinguish benign myomas from malignant sarcomas. It is important not to damage the wholeness of uterus during operation in order to prevent dissemination of the disease in the abdominal cavity. The low-grade endometrial stromal sarcoma has the best survival prognosis, while carcinosarcoma and undifferentiated uterine sarcoma have the lowest survival rates.

Systemic treatment in adult uterine sarcomas

Uterine sarcomas (US) are rare mesenchymal tumours of the uterus and are divided mainly into uterine leiomyosarcoma (uLMS), low grade endometrial stromal sarcoma (LG-ESS), high grade endometrial stromal sarcoma (HG-ESS), adenosarcomas and high grade undifferentiated sarcoma (HGUS). US are often high-grade tumours with a high local recurrence rate and metastatic risk. We here discuss the current standard of care and knowledge of systemic therapy for adult uterine sarcomas, in particular uLMS, LG-ESS, HG-ESS and HGUS, in both the adjuvant as well as the metastatic setting.