Clinical management of uterine sarcomas

Entropy-based adaptive nuclear texture features are independent prognostic markers in a total population of uterine sarcomas

Nuclear texture analysis measures the spatial arrangement of the pixel gray levels in a digitized microscopic nuclear image and is a promising quantitative tool for prognosis of cancer. The aim of this study was to evaluate the prognostic value of entropy-based adaptive nuclear texture features in a total population of 354 uterine sarcomas. Isolated nuclei (monolayers) were prepared from 50 µm tissue sections and stained with Feulgen-Schiff. Local gray level entropy was measured within small windows of each nuclear image and stored in gray level entropy matrices, and two superior adaptive texture features were calculated from each matrix. The 5-year crude survival was significantly higher (P < 0.001) for patients with high texture feature values (72%) than for patients with low feature values (36%). When combining DNA ploidy classification (diploid/nondiploid) and texture (high/low feature value), the patients could be stratified into three risk groups with 5-year crude survival of 77, 57, and 34% (Hazard Ratios (HR) of 1, 2.3, and 4.1, P < 0.001). Entropy-based adaptive nuclear texture was an independent prognostic marker for crude survival in multivariate analysis including relevant clinicopathological features (HR = 2.1, P = 0.001), and should therefore be considered as a potential prognostic marker in uterine sarcomas. © The Authors. Published 2014 International Society for Advancement of Cytometry

Pharmacological treatment for uterine leiomyosarcomas

INTRODUCTION

Pharmacological treatment plays a major role in the management of advanced, persistent or recurrent uterine leiomyosarcoma (LMS), whereas its usefulness in the adjuvant setting is still debated. A thorough literature search was undertaken using the Pubmed databases. Systematic reviews and controlled trials on medical treatment of uterine LMS were collected and critically analyzed. Other study types were secondarily considered when pertinent.

AREAS COVERED

Doxorubicin (DOX), ifosfamide and dacarbazine have been long used in the treatment of this malignancy. Novel active agents are represented by gemcitabine, docetaxel, trabectedin, pazopanib and aromatase inhibitors, whereas the role of eribulin, bevacizumab, aflibercept and mammalian target of rapamycin inhibitors is still investigational.

EXPERT OPINION

DOX alone, gemcitabine alone, DOX + dacarbazine and gemcitabine + docetaxel may be treatment options for first-line and second-line therapies. However, the clinical benefit of the combination chemotherapy versus single-agent chemotherapy is still debated. Trabectedin is a promising agent for recurrent uterine LMS, able to obtain a prolonged disease control, with 3-month and 6-month progression-free survival rates exceeding 50 and 30%, respectively, and with sometimes unexpectedly durable responses. Pazopanib is the only approved targeted therapy. Hormone therapy with aromatase inhibitors may be a therapeutic option in heavily treated patients with slowly progressive, steroid receptor-positive tumors. Whenever possible, women with recurrent uterine LMS should be encouraged to enter well-designed clinical trials aimed to detect novel active agents.

Growth differentiation factor-15 as biomarker in uterine sarcomas

OBJECTIVE

The aim of this study was to investigate and validate circulating growth differentiation factor-15 (GDF-15) as a discriminating biomarker between highly malignant uterine sarcomas and benign uterine leiomyomas. In addition, we investigated whether GDF-15 differed between uterine sarcomas and benign adnexal tumors, ovarian or endometrial cancer, and borderline tumors of the ovary.

MATERIALS AND METHODS

Preoperative blood samples from 19 women with a diagnosis of uterine sarcoma were analyzed for GDF-15 with immunoassay and compared with samples from 50 patients operated on for leiomyoma uteri and with samples from 20 premenopausal and 20 postmenopausal controls. Our previously presented preoperative GDF-15 concentrations in women with borderline (n = 43), benign (n = 144), and malignant ovarian tumors (n = 125), as well as endometrial cancer (n = 510), were used for comparison.

RESULTS

The median circulating GDF-15 concentration was elevated in the uterine sarcoma group (943 ng/L) compared with the myoma uteri group (647 ng/L), the premenopausal and postmenopausal controls (363 and 545 ng/L), and the women with benign ovarian tumors (591 ng/L, all P ≤ 0.007) but was not significantly different from the ovarian borderline tumor (718 ng/L) or ovarian (1242 ng/L) or endometrial cancer (1076 ng/L) groups.High GDF-15 levels were significantly associated with leiomyosarcomas (P = 0.036), advanced disease (International Federation of Gynecology and Obstetrics stage III/IV, P = 0.013), large tumors (≥10 cm, P = 0.009), and poor survival (P = 0.022).

CONCLUSIONS

Circulating GDF-15 may be a promising novel biomarker for the preoperative identification of malignant pelvic disease. Further large prospective studies are needed to evaluate the clinical usefulness of GDF-15 as a discriminator between benign leiomyomas and aggressive sarcomas and as a marker to guide surgical and systemic therapy.

Molecular mechanisms of endometrial stromal sarcoma and undifferentiated endometrial sarcoma as premises for new therapeutic strategies

Endometrial stromal sarcoma (ESS) and undifferentiated endometrial sarcoma (UES) are very rare gynecologic malignancies. Due to the rarity and heterogeneity of these tumors, little is known about their epidemiology, pathogenesis, and molecular pathology. Our previous studies have described deregulation of histone deacetylases expression in ESS/UES samples. Some of these enzymes can be inhibited by substances which are already approved for treatment of cutaneous T-cell lymphoma. On the basis of published data, they may also provide a therapeutic option for ESS/UES patients. Our review focuses on molecular mechanisms of ESS/UES. It describes various aspects with special emphasis on alteration of histone deacetylation and its possible relevance for novel therapies.

Reversion of Hormone Treatment Resistance with the Addition of an mTOR Inhibitor in Endometrial Stromal Sarcoma

Background. Endometrial stromal sarcomas (ESS) are a subtype of gynaecological sarcomas characterized by the overexpression of hormone receptors. Hormone treatment is widely used in ESS but primary or acquired resistance is common. The mammalian target of rapamycin (mTOR) pathway has been suggested to play a key role in the mechanisms of hormone resistance. Recent studies in breast and prostate cancer demonstrate that this resistance can be reversed with the addition of an mTOR inhibitor. This phenomenon has never been reported in ESS. Methods. We report the outcome of one patient with pretreated, progressing low grade metastatic ESS treated with medroxyprogesterone acetate in combination with the mTOR inhibitor sirolimus. Results. Partial response was achieved following the addition of sirolimus to the hormone treatment. Response has been maintained for more than 2 years with minimal toxicity and treatment is ongoing. Conclusion. This case suggests that the resistance to the hormone manipulation in ESS can be reversed by the addition of an mTOR pathway inhibitor. This observation is highly encouraging and deserves further investigation.

Conservative management of endometrial stromal sarcoma at stage III: A case report

Endometrial stromal sarcoma (ESS) is a rare malignant tumor of the uterus. The standard treatment is surgery, such as total hysterectomy with bilateral salpingo-oophorectomy. The use of adjuvant treatment, including chemotherapy, radiation therapy and endocrine therapy, remains controversial, so it is uncommon for conservative management to be performed in patients with low-grade ESS. The present study reports the case of a 19-year-old female with ESS at stage III who underwent a local mass resection by laparoscopic surgery. A high dose of progestin (medroxyprogesterone acetate) therapy was then administered. Conservative management resulted in complete remission of the low-grade ESS, with no sign of recurrence at the 33-month follow-up.

Differentiation of aggressive and indolent subtypes of uterine sarcoma using maximum standardized uptake value

Objective

The aim of the study was to elucidate the differential metabolic activities in aggressive and indolent subtypes of uterine sarcomas, which may aid in managing these heterogeneous tumours.

Methods

We retrospectively analysed the PET/computed tomography scans of consecutive patients (N=18) diagnosed with uterine sarcoma at our unit. The patients were divided into indolent (N=4) and aggressive (N=14) tumour groups, and the maximum standardized uptake values (SUV_max) of all lesions (n=134) were measured. The SUV_max of the lesions were compared between the two tumour groups using the Mann–Whitney U-test. We calculated the optimal cutoff value as determined by receiver operating characteristic analysis. A P-value less than 0.05 was considered statistically significant.

Results

The mean SUV_max of aggressive (n=104) and indolent tumours (n=30) were significantly different (8.0±7.3 vs. 1.9±0.9 respectively; P<0.001). A cutoff of SUV_max greater than 4.0 was able to exclude indolent tumours, with 100% specificity and positive predictive value (sensitivity 72%, negative predictive value 50% and accuracy 78%; area under the curve 97%). By applying this same cutoff value on the most metabolic active lesion in each patient, we were able to correctly classify all but one patient into either the aggressive or indolent tumour group with 100% specificity and positive predictive value (sensitivity 93%, negative predictive value 80% and accuracy 94%).

Conclusion

Aggressive and indolent uterine sarcoma subtypes have differential metabolic activities that can be used to classify them and this can aid in patient management for preoperative surgical planning and treatment stratification.

Hormonal treatment in recurrent and metastatic gynaecological cancers: a review of the current literature

For many years hormonal treatment has played a role in the treatment of a selected group of patients with a variety of recurrent or metastatic gynaecological cancers, including ovarian and endometrial carcinomas, endometrial stromal sarcomas and granulosa cell tumours. Hormonal agents that are typically used include luteinizing-hormone-releasing hormone analogues, progestogens, selective oestrogen-receptor-modulating drugs such as tamoxifen, and more recently aromatase inhibitors. The rates of response to these drugs differ considerably depending on the tumour type, disease grade and stage as well as the type of drug used. Patients with granulosa cell tumours and endometrial stromal sarcomas have the highest response rates; owing to the rarity of these tumour types, the documented response rates are based on case reports and small series. Response rates in patients with recurrent and metastatic endometrial and ovarian carcinoma have been lower. It has been suggested that patients with well-differentiated and hormone-receptor-positive carcinomas are more likely to benefit from hormonal treatment. However, the data to support this are limited, and at times conflicting, with very few prospective studies to date. This review updates the evidence for the use of hormonal treatment in patients with potentially hormone responsive recurrent and metastatic gynaecological cancers.

Wilms' tumor gene 1 immunotherapy in pelvic gynecological malignancies

Pelvic gynecological malignancies account for 6% of all cancers. In the relapsed state, classical treatments are limited. There is an urgent need for new and personalized treatment. Wilms' tumor gene 1 (WT1) is the most important tumor-associated antigen. Although highly present in gynecological tumors, active immunotherapy against it is still underexplored. This review gives an insight into the importance of WT1 in pelvic gynecological malignancies and the first taken steps into the world of WT1 immunotherapy.

Hormone dependency in metastatic low-grade leiomyosarcoma following uterine smooth muscle tumour of uncertain malignant potential

Uterine leiomyosarcoma (ULMS) usually follows an aggressive clinical course, although a small proportion of ULMS exhibit a more indolent course, which in turn reflects heterogeneity within this disease and the need to identify and characterise this distinct subgroup. The role of hormone therapy in ULMS is yet to be elucidated. We report a patient with well-differentiated metastatic ULMS on hormone replacement therapy (HRT) at the time of the diagnosis. The withdrawal of the HRT led to a significant decrease in the tumour burden and symptomatic improvement. The patient further benefited from aromatase inhibitor treatment once the benefit from the HRT withdrawal reached a plateau. The present case report describes for the first time hormone-dependency for tumour growth in a ULMS. We propose that a subset of ULMS that follow a protracted/indolent course might depend on hormone stimulation for tumour proliferation, and antihormone treatment can therefore be useful in these patients.

Successful pregnancy following conservative management of low-grade endometrial stromal sarcoma: A case report

It is uncommon that fertility is preserved in young nulliparous females with low-grade endometrial stromal sarcoma (ESS). Therefore, successful pregnancy following such conservative management has been rarely reported in previous literature. A 25-year-old female (gravida, 0; para, 0) underwent hysteroscopic surgery and was pathologically diagnosed with an endometrial stromal nodule. The patient underwent fertility-preserving local resection and uterine reconstruction, with a final pathological diagnosis of low-grade ESS. Endocrine therapy was then administered. Conservative management resulted in the complete remission of low-grade ESS. The patient naturally conceived and successfully delivered a healthy baby at 42 weeks' gestation by cesarean section, ~30 months following diagnosis with low-grade ESS. In conclusion, conservative management, including fertility-preserving local mass resection and endocrine therapy, can be effective for low-grade ESS and may yield a favorable outcome for young nulliparous females desiring fertility preservation.

Treatment of pure uterine sarcoma at the Institut Català D'Oncologia

AIM

The aim of this retrospective study was to investigate the clinical and histopathological characteristics of the disease and treatment outcome of patients with pure uterine sarcomas.

BACKGROUND

Uterine sarcomas are especially rare tumours, comprising only 3-5% of uterine cancers. They are characterized by histopathological diversity, rapid clinical progression, and poor prognosis. Optimal management consists of complete surgical removal and adjuvant radiotherapy may improve the prognosis.

MATERIALS AND METHODS

All patients with pure uterine sarcoma histology treated at our centre, the Institut Català D'Oncologia in Barcelona Spain, between 2002 and 2010 were reviewed.

RESULTS

Records of 17 patients treated at our hospital over an 8-year period were obtained. Nine patients (53%) had leiomyosarcoma, 7 (41%) had endometrial stromal sarcoma, and 1 patient had unclassified sarcoma. All patients were treated with external beam radiation after surgical excision. Mean age was 62 years (range, 51-69 years). Of the 17 patients, 13 (76%) presented with stage I disease, 2 (12%) were stage II, and 2 (12%) stage III. The overall actuarial 2-year survival estimate was 82.5%. Two patients experienced local relapse. The 2-year local control rate was 90%. A total of 5 patients experienced either local or metastatic relapse. The 2-year progression free survival rate was 58%.

CONCLUSION

In our experience, combined treatment (surgery and adjuvant radiation therapy) is effective with acceptable side effects. Larger and multicenter studies are needed to assess treatment outcome for pure uterine sarcoma histology.

[Uterine leiomyosarcoma: epidemiology, pathology, biology, diagnosis, prognosis and treatment]

Uterine leiomyosarcoma is a rare disease with a poor prognosis. The rarity of this tumor needs a specialized management in tertiary reference centers in order to provide patients with optimal diagnostic, prognostic and therapeutic care. The pathological diagnosis relies on the presence of three characteristics in proliferating smooth muscle cells: necrosis, cytologic atypia and mitosis. Despite progress in the knowledge of the biology of these tumors, no oncogenic driver has been found. Prognosis depends mainly on the age of the patient, race, FIGO stage, mitotic index and hormonal receptor expression in the tumor. Surgery is one of the cornerstones of management and cytotoxic chemotherapy is the mainstay of treatment in metastatic disease with a potential role in the adjuvant setting. In locally advanced or metastatic disease, prognosis is poor with a median overall survival of about 12 to 14 months despite a 30% response rate to polychemotherapy regimens. Anti-angiogenics and hormonal therapy have a role to play in the setting of metastatic disease. It is mandatory to include such patients in clinical trials aiming to improve the therapeutic management of these patients. Multimodal therapy can improve the prognosis of selected patients too.

Therapeutic effect of dienogest on adenosarcoma arising from endometriosis: a case report

Dienogest is a novel synthesized progestin used for treatment of endometriosis. This is the first case report describing a therapeutic effect of dienogest on a gynecologic malignancy. The patient was a 44-year-old woman with advanced adenosarcoma arising from the endometriosis in the rectovaginal space and infiltrating the left pelvic wall, left ureter, rectum and vagina. The residual tumor after tumor debulking surgery was resistant to both chemotherapy and radiotherapy. Dienogest was used as a substitute for medroxyprogesterone acetate because of the presence of deep vein thrombosis. Based on the RECIST criteria, partial response was obtained with oral dienogest therapy at six months and the serum CA125 level also decreased from 70 U/ml to 16 U/ml. The tumor remained stable up to 21 months. Thromboembolism or other adverse effects did not occur during the dienogest therapy. Dienogest may be useful for the treatment of adenosarcoma arising from endometriosis.

Endometrial stromal sarcoma: a systematic review

OBJECTIVE

To summarize available studies with respect to evaluation and management of patients with endometrial stromal sarcoma and undifferentiated endometrial sarcoma.

DATA SOURCES

We conducted an electronic search of research articles published in English between January 1, 1981, and January 1, 2013, using MEDLINE, PubMed, and ClinicalTrials.gov (www.clinicaltrials.gov) databases.

METHODS OF STUDY SELECTION

Of the 115 studies initially identified, 86 were chosen after limiting the review to those articles focusing on endometrial stromal sarcoma and crossreferencing to eliminate duplication. Review articles were excluded. Of the 86 studies meeting eligibility criteria, 84 were retrospective, one was a prospective phase II trial, and one was a phase III randomized study. Data were extracted systematically. Each of the reviewers assessed the quality of each study independently.

TABULATION, INTEGRATION, AND RESULTS

Data were abstracted using standard abstraction templates to summarize study findings. Given the rarity of this tumor, we report available data with respect to epidemiology, pathogenesis, prognostic factors, and treatment. Endometrial stromal sarcoma and undifferentiated endometrial sarcoma comprise an estimated 1% of all uterine cancers and less than 10% of all uterine mesenchymal neoplasms. Hysterectomy and bilateral salpingo-oophorectomy is the cornerstone of treatment for early-stage (I or II) disease. Surgical resection when feasible may also be appropriate for patients presenting with advanced-stage tumors. The value of adjuvant therapy for early-stage disease remains unproven. Hormone therapy continues to be the most efficacious treatment modality for patients with advanced-stage or recurrent disease.

CONCLUSION

Endometrial stromal sarcoma and undifferentiated endometrial sarcoma are rare tumors. Surgical resection is appropriate for patients with early-stage (I or II) disease and those with resectable, advanced-stage (III or IV) tumors. Hormone therapy may be appropriate in treating advanced and recurrent disease.

Gene expression signatures of primary and metastatic uterine leiomyosarcoma

Leiomyosarcoma (LMS) is the most common uterine sarcoma. Although the disease is relatively rare, it is responsible for considerable mortality due to frequent metastasis and chemoresistance. The molecular events related to LMS metastasis are unknown to date. The present study compared the global gene expression patterns of primary uterine LMSs and LMS metastases. Gene expression profiles of 13 primary and 15 metastatic uterine LMSs were analyzed using the HumanRef-8 BeadChip from Illumina. Differentially expressed candidate genes were validated using quantitative real-time polymerase chain reaction (PCR) and immunohistochemistry. To identify differently expressed genes between primary and metastatic tumors, we performed one-way analysis of variance with Benjamini-Hochberg correction. This led to identification of 203 unique probes that were significantly differentially expressed in the 2 tumor groups by greater than 1.58-fold with P < .01, of which 94 and 109 were overexpressed in primary and metastatic LMSs, respectively. Genes overexpressed in primary uterine LMSs included OSTN, NLGN4X, NLGN1, SLITRK4, MASP1, XRN2, ASS1, RORB, HRASLS, and TSPAN7. Genes overexpressed in LMS metastases included TNNT1, FOLR3, TDO2, CRYM, GJA1, TSPAN10, THBS1, SGK1, SHMT1, EGR2, and AGT. Quantitative real-time PCR confirmed significant anatomical site-related differences in FOLR3, OSTN, and NLGN4X levels; and immunohistochemistry showed significant differences in TDO2 expression. Gene expression profiling differentiates primary uterine LMSs from LMS metastases. The molecular signatures unique to primary and metastatic LMSs may aid in understanding tumor progression in this cancer and in providing a molecular basis for prognostic studies and therapeutic target discovery.

Phase 2 trial of aromatase inhibition with letrozole in patients with uterine leiomyosarcomas expressing estrogen and/or progesterone receptors

BACKGROUND

Advanced uterine leiomyosarcoma (ULMS) is an incurable disease. A significant percentage of cases of ULMS express estrogen and/or progesterone receptors (ER and/or PR). To the authors' knowledge, the role of estrogen suppression in disease management is not known.

METHODS

The authors performed a single-arm phase 2 study of the aromatase inhibitor letrozole at a dose of 2.5 mg daily in patients with unresectable ULMS with ER and/or PR expression confirmed by immunohistochemistry. Tumor assessments were performed at baseline, 6 weeks, 12 weeks, and every 8 weeks thereafter. Toxicity was monitored throughout treatment. The primary endpoint was the progression-free survival at 12 weeks.

RESULTS

A total of 27 patients was accrued, with a median of 2 prior treatment regimens (range, 0-9 treatment regimens). The median duration of protocol treatment was 2.2 months (range, 0.4 months-9.9 months). The 12-week progression-free survival rate was 50% (90% confidence interval, 30%-67%). The best response was stable disease in 14 patients (54%; 90% CI, 36%-71%). Three patients, all of whom had tumors expressing ER and PR in > 90% of tumor cells, continued to receive letrozole for > 24 weeks. The most common reason for treatment discontinuation was disease progression (85%). Letrozole was found to be well tolerated.

CONCLUSIONS

Letrozole met protocol-defined criteria as an agent with activity in patients with advanced ULMS. Patients with the longest progression-free survival rate were those whose tumors strongly and diffusely expressed ER and PR.

Current concepts in the imaging of uterine sarcoma

Recent advances in genetics and pathology have improved our understanding of diagnosis and staging of uterine sarcomas. The major types of uterine sarcomas include leiomyosarcoma, low-grade endometrial stromal sarcoma, undifferentiated endometrial sarcoma, adenosarcoma and carcinosarcoma. The distinctive biological behavior and poor overall survival of uterine sarcoma create challenges in the management of these tumors. We herein present a comprehensive review of taxonomy, epidemiology, pathology, imaging findings and natural history of a wide spectrum of uterine sarcomas.

Curcumin targets the AKT-mTOR pathway for uterine leiomyosarcoma tumor growth suppression

BACKGROUND

Uterine leiomyosarcomas generally do not respond well to standard chemotherapy. We previously demonstrated that curcumin, the active ingredient derived from the herb Curcuma longa, inhibits uterine leiomyosarcoma cells in vitro via the inhibition of the AKT-mammalian target of rapamycin (mTOR) pathway. As a preclinical investigation, we performed an in vivo study using female nude mice to confirm the therapeutic potential of curcumin against uterine leiomyosarcoma.

METHODS

Human leiomyosarcoma cells, SK-UT-1, were inoculated in female nude mice to establish subcutaneous tumors. Either vehicle control or 250 mg/kg curcumin was administered intraperitoneally every day for 14 consecutive days, and the mice were then killed. The tumors were measured every 2-3 days. The tumors were processed for immunohistochemical analyses to detect total AKT, phosphorylated AKT, total mTOR, phosphorylated mTOR, and phosphorylated S6. To detect apoptosis, the tumors were stained for cleaved PARP and TUNEL. Ki-67 immunohistochemistry was performed to determine cell viability of the tumors.

RESULTS

Compared with the control, curcumin reduced uterine leiomyosarcoma tumor volume and mass significantly with a concordant decrease in mTOR and S6 phosphorylation. However, AKT phosphorylation was not significantly altered. Cleaved PARP and TUNEL staining increased significantly with curcumin administration, indicating the induction of apoptosis. There was no difference in Ki-67 staining between the two groups.

CONCLUSION

Curcumin inhibited uterine leiomyosarcoma tumor growth in vivo by targeting the AKT-mTOR pathway for inhibition.

MED12 mutations in leiomyosarcoma and extrauterine leiomyoma

Leiomyoma and leiomyosarcoma share morphological features and smooth muscle differentiation, and both arise most frequently within the uterine corpus of middle-aged women. However, they are considered biologically unrelated tumors due to their disparate clinical, cytogenetic, and molecular features. MED12, the mediator complex subunit 12 gene, has been recently implicated as an oncogene in as many as 70% of sporadic uterine leiomyoma. In the present study, we show MED12 hotspot exon 2 mutations in extrauterine leiomyoma (3 of 19 cases) and in leiomyosarcoma (3 of 13 uterine cases). We also show that MED12 mutations are found in both primary and metastatic leiomyosarcoma. Immunoblotting studies demonstrated MED12 protein expression in 100% of leiomyomas (13) and leiomyosarcomas (20), irrespective of MED12 exon 2 mutation status or histological grade. These findings indicate that MED12 has oncogenic roles in a broad range of smooth muscle neoplasia, including tumors arising in extrauterine locations.

Antiproliferative effect of pheophorbide a-mediated photodynamic therapy and its synergistic effect with doxorubicin on multiple drug-resistant uterine sarcoma cell MES-SA/Dx5

Prolonged cancer chemotherapy is associated with the development of multidrug resistance (MDR), which is a major cause of treatment failure. Photodynamic therapy (PDT) has been applied as anticancer therapy and a means of circumventing MDR. The antiproliferative effect of pheophorbide a-mediated photodynamic therapy (Pa-PDT) has been demonstrated in several human cancer cell lines, including the uterine sarcoma cell line, MES-SA. This study set out to evaluate, first, the therapeutic potential of Pa-PDT on MES-SA/Dx5 uterine sarcoma cells and, subsequently, the effectiveness of combination therapy using Pa-PDT with doxorubicin (Dox). Our results showed that Pa-PDT was able to circumvent MDR in the P-glycoprotein (P-gp) overexpressing human uterine sarcoma cell line, MES-SA/Dx5. Intracellular accumulation of Pa and Pa-PDT-induced cell death was not abrogated by MDR phenotype, when compared to the parental cell line, MES-SA. Combined therapy using Pa-PDT and Dox, a common chemotherapeutic drug, was found to be synergistic in the cell line, MES-SA/Dx5. Both activity and expression of MDR1 and P-gp were reduced by Pa-PDT treatment and such reductions were attenuated by α-tocopherol, the scavenger of reactive oxygen species (ROS), suggesting that the effect of Pa-PDT was mediated by the generation of intracellular ROS. In conclusion, our findings demonstrated the therapeutic potential of Pa-PDT alone or in combination with Dox in combating multidrug-resistant malignancies.

microRNAs in uterine sarcomas and mixed epithelial-mesenchymal uterine tumors: a preliminary report

Uterine sarcomas and mixed epithelial–mesenchymal uterine tumors are a heterogeneous group of rare tumors for which there are very few diagnostic markers available. As aberrant microRNA (miRNA) expression patterns represent putative diagnostic cancer markers, we aimed to identify miRNA expression profiles of the major uterine sarcoma subtypes and mixed epithelial–mesenchymal tumors of the uterus. Eighty-eight miRNAs were assessed by quantitative RT-PCR in cancerous and non-cancerous tissue samples collected from 29 patients with endometrial sarcoma, leiomyosarcoma, and mixed epithelial–mesenchymal tumors. Tumor and control samples significantly (P < 0.05) differed in the expression of miR-23b, miR-1, let-7f, and let-7c in endometrial sarcomas, and miR-1, let-7c, miR-133b, let-7b, miR-143, let-7a, let-7d, let-7e, let-7g, miR-222, let-7i, and miR-214 in mixed epithelial–mesenchymal tumors. All the significantly changed miRNAs were down-regulated in the malignant tissues as compared to their normal counterparts. This may suggest their tumor suppressor role in these malignancies. No statistically significant changes in miRNA expression levels were found between leiomyosarcoma tumors and controls. The identified miRNAs warrant further studies as valuable candidate markers for the differential diagnosis of uterine sarcomas from benign uterine lesions and between uterine sarcoma subtypes.

18F-FES and 18F-FDG PET for differential diagnosis and quantitative evaluation of mesenchymal uterine tumors: correlation with immunohistochemical analysis

The aim of this study was to investigate the relationship between the tumor uptake of 16α-(18)F-fluoro-17β-estradiol ((18)F-FES) and (18)F-FDG using PET and expressions of sex hormone receptors, such as estrogen receptor (ER), as well as glucose transporter 1 (GLUT-1) and Ki-67 analyzed by the immunohistochemistry method in mesenchymal uterine tumors.

METHODS

Forty-seven patients with mesenchymal uterine tumors were studied with (18)F-FES and (18)F-FDG PET. Postoperative pathologic diagnosis revealed 33 uterine leiomyomas and 14 uterine sarcomas. Tissue samples were assayed for expression of ERα, ERβ, progesterone receptor (PR), PR-B, GLUT-1, and Ki-67 by an immunohistochemistry method. Standardized uptake values (SUVs) for (18)F-FES and (18)F-FDG were compared with the semiquantitative immunoreactive score (0-12) and quantitative labeling index (LI) for Ki-67 in immunohistochemistry.

RESULTS

(18)F-FES uptake was significantly lower (P < 0.001) and the (18)F-FDG uptake and SUV ratio of (18)F-FDG to (18)F-FES ((18)F-FDG/(18)F-FES ratio) (P < 0.005 and P < 0.001, respectively) were significantly higher in uterine sarcomas than in leiomyomas. Immunohistochemistry analysis showed significantly higher expressions of ERα, PR, and PR-B in uterine leiomyomas than in sarcomas. The Ki-67 LI was significantly greater in uterine sarcomas than in leiomyomas. Correlation analysis for all tumors showed positive correlations between (18)F-FES SUV and immunohistochemistry scores of ERα, PR (P < 0.001), and PR-B (P < 0.005) as well as between (18)F-FDG SUV and GLUT-1 and Ki-67 (P < 0.001). However, the (18)F-FDG/(18)F-FES ratio showed significantly negative correlations with ERα, PR (P < 0.001), and PR-B (P < 0.005) and a positive correlation with Ki-67 LI (P < 0.001). In uterine sarcomas, ERα and (18)F-FES SUV showed a positive correlation (P < 0.001) in a low SUV range, and the (18)F-FDG/(18)F-FES ratio showed positive correlations with ERβ and GLUT-1 expression (P < 0.005).

CONCLUSION

(18)F-FES and (18)F-FDG PET showed correlations between tracer uptake and expressions of sex hormone receptors, GLUT-1, and Ki-67 in mesenchymal uterine tumors. The (18)F-FDG/(18)F-FES ratio was correlated with Ki-67, GLUT-1, and ERβ in uterine sarcoma. Functional PET imaging and PET parameters would be useful noninvasive biomarkers for the assessment of tumor hormone receptor expression, glucose metabolism, and proliferation and for differential diagnosis of uterine leiomyoma and sarcoma.

Systematic chemotherapy for inoperable, locally advanced, recurrent, or metastatic uterine leiomyosarcoma: a systematic review

The goal of this systematic review was to investigate and compare the treatment effects of systemic chemotherapy (i.e. doxorubicin, gemcitabine, gemcitabine plus docetaxel, or trabectedin) in women with inoperable, locally advanced, recurrent, or metastatic uterine leiomyosarcoma. A 2005 systematic review (searching the literature from 1980 to June 2004) on systemic therapy in advanced uterine sarcoma was used as the basis for this updated review. MEDLINE and EMBASE (from January 2004 to June 2011), the Cochrane Library, some main guideline websites and the American Society of Clinical Oncology and the Connective Tissue Oncology Society annual meeting abstracts were searched. One arm from a randomised controlled trial (RCT), four single-arm phase II trials and one abstract were included in this systematic review. The studies of gemcitabine plus docetaxel have reported numerically longer median overall survival (14.7-17.9 months versus 12.1 months) and numerically higher objective response rates (27-53% versus 25%) than those reported in the study of doxorubicin alone. The combination of gemcitabine plus docetaxel resulted in more toxicity than doxorubicin alone. The available study for single-agent gemcitabine reported a tumour response rate of 21%, which is not superior to the 25% response rate with doxorubicin alone. One abstract (pooling data from two RCTs) failed to show the superiority of gemcitabine plus docetaxel over gemcitabine alone for tumour response rate (23% versus 18%) and progression-free survival (6 versus 4.9 months). To date, there is insufficient evidence to support or refute the use of trabectedin in the target patients. Doxorubicin, gemcitabine, and gemcitabine plus docetaxel are treatment options in women with inoperable, locally advanced, recurrent, or metastatic uterine leiomyosarcoma as first- or second-line therapy. Well-designed and good-quality RCTs are required to investigate the efficacy of chemotherapy and quality of life in target patients with uterine leiomyosarcoma.

Immunohistochemical Analysis for Therapeutic Targets and Prognostic Markers in Low-Grade Endometrial Stromal Sarcoma

Objective

To investigate potential therapeutic targets and prognostic markers for low-grade endometrial stromal sarcoma (LGESS).

Materials and Methods

Thirty-nine patients with LGESS were included in this study. Using tissue microarrays, the immunohistochemical expression levels of 5 therapeutic targets (epidermal growth factor receptor, human epidermal growth factor 2, vascular endothelial growth factor receptor, platelet-derived growth factor receptor [PDGFR], and c-kit) and 3 proteins involved in cell proliferation (p16, p53, and ki67) were investigated. The associations between these targets, markers, other clinicopathological factors, disease-free survival (DFS), and overall survival (OS) were analyzed.

Results

Epidermal growth factor receptor and human epidermal growth factor 2 were not expressed in these 39 patients. Vascular endothelial growth factor receptor, PDGFR, c-kit, p16, p53, and ki67 were expressed in 10 (25.6%), 28 (71.8%), 32 (82.1%), 18 (46.2%), 4 (10.3%), and 21 (53.8%) patients, respectively. The expression of each marker was not significantly associated with other clinicopathological factors. On multivariate analysis, p53 and ki67 were associated with significantly poorer DFS and OS. The 5-year DFS rates were 88%, 46%, and 0% for the p53(−)/ki67(−) group (n = 18), p53(−)/ki67(+) group (n = 17), and p53(+)/ki67(+) group (n = 4) (P = 0.002), respectively; the 5-year OS rates were 100%, 71%, and 0%, respectively (P < 0.001). The time to recurrence was longer (P = 0.123), and more patients had distant recurrence in the p53(+)/ki67(+) group (P = 0.063).

Conclusions

In patients with LGESS, c-kit and PDGFR were expressed in higher portions of patients, suggesting that imatinib mesylate should be investigated as a potential targeting agent. Both p53 and ki67 demonstrated strong prognostic implications, suggesting that further evaluation using these markers is required.

Liver metastasis of endometrial stromal sarcoma

Resection of liver metastases from gynaecological tumours is uncommon. Endometrial stromal sarcomas (ESS) are low incidence gynecological tumours which can originate in previous sites of endometriosis or following metaplasia of the pelvic peritoneal wall, and which are exceptionally associated with liver metastasis. We present a 68-year-old woman with a ESS and metachronic liver metastasis treated by liver resection. There is very little literature on clinical management about liver metastasis from ESS, but extrapolating the data obtained with liver metastasis from sarcomas and uterine tumours, we should recommend resection as this is considered a resectable extrauterine metastasis. In cases with more sites of extrauterine disease, liver resection should also be performed if the other sites are resectable.

Gene expression signatures differentiate uterine endometrial stromal sarcoma from leiomyosarcoma

OBJECTIVE

Endometrial stromal sarcoma (ESS) and leiomyosarcoma (LMS) are the two most common uterine sarcomas, but both are rare tumors. The aim of the present study was to compare the global gene expression patterns of ESS and LMS.

METHODS

Gene expression profiles of 7 ESS and 13 LMS were analyzed using the HumanRef-8 BeadChip from Illumina. Differentially expressed candidate genes were validated using quantitative real-time PCR and immunohistochemistry.

RESULTS

Unsupervised hierarchical clustering using all 54,675 genes in the array separated ESS from LMS samples. We identified 549 unique probes that were significantly differentially expressed in the two malignancies by greater than 2-fold with 1% FDR cutoff using one-way ANOVA with Benjamini-Hochberg correction, of which 336 and 213 were overexpressed in ESS and LMS, respectively. Genes overexpressed in ESS included SLC7A10, EFNB3, CCND2, ECEL1, ITM2A, NPW, PLAG1 and GCGR. Genes overexpressed in LMS included CDKN2A, FABP3, TAGLN, JPH2, GEM, NAV2 and RAB23. The top 100 genes overexpressed in LMS included those coding for myosin light chain and caldesmon, but not the genes coding for desmin or actin. CD10 was not overexpressed in ESS. Results for selected genes were validated by quantitative real-time PCR and immunohistochemistry.

CONCLUSIONS

We present the first study in which gene expression profiling was shown to distinguish between ESS and LMS. The molecular signatures unique to each of these malignancies may aid in expanding the diagnostic battery for their differentiation, and may provide a molecular basis for prognostic studies and therapeutic target discovery.

Successful pregnancy after fertility-sparing local resection and uterine reconstruction for low-grade endometrial stromal sarcoma

BACKGROUND

Fertility-sparing management of endometrial stromal sarcoma has been demonstrated, but reports of pregnancy after such management are rare in our current body of literature.

CASE

A 16-year-old nulligravid adolescent girl presented with symptoms of menometrorrhagia and was found to have a 17-cm uterine mass. The patient underwent local resection of the mass with uterine reconstruction. Pathology revealed a low-grade endometrial stromal sarcoma. She was placed on high-dose daily megestrol acetate therapy and remained disease-free for 8 years before achieving pregnancy spontaneously. The patient underwent an uncomplicated pregnancy until 34 weeks of gestation, when she presented in preterm labor and underwent cesarean delivery of a liveborn male neonate, with no evidence of disease recurrence.

CONCLUSION

Fertility-sparing management and close follow-up of low-grade endometrial stromal sarcoma may be a viable option for those desiring future fertility.

Involvement of proteasome β1i subunit, LMP2, on development of uterin leiomyosarcma

Background:

Although the majority of smooth muscle neoplasms found in the uterus are benign, uterine leiomyosarcoma is extremely malignant, with high rates of recurrence and metastasis. The development of gynecologic tumors is often correlated with secretion of female hormone; however, the development of human uterine leiomyosarcoma is not substantially correlated with hormonal conditions, and the risk factors are unclearly understood. Importantly, a diagnostic-biomarker, which distinguishes malignant human uterine leiomyosarcoma from benign tumor leiomyoma is yet to be established.

Aims:

It is necessary to analyze risk factors associated with human uterine leiomyosarcoma, in order to establish a diagnostic-biomarker and a clinical treatment method.

Patients and Methods:

Histology and Immunofluorescence Staining: Uteri obtained from LMP2^–/– mice or its parental mice (C57BL/6 mice) were fixed in 10% buffered formalin, incubated in 4% paraformaldehyde for 8 hours, and embedded in paraffin. Tissue sections (5 μm) were prepared and stained with H&E for routine histological examination or were processed further for immunofluorescence staining with appropriate antidodies. Furthermore, a total of 101 patients between 32 and 83 years of age and diagnosed as having smooth muscle tumors of the uterus were selected from pathological files. Immunohistochemistry staining for LMP2 was performed on serial human uterine leiomyosarcoma, leiomyoma and myometrium sections.

Results:

Homozygous deficient mice for a proteasome β1i subunit, LMP2 spontaneously develop uterine leiomyosarcoma, with a disease prevalence of ~40% by 14 months of age. Defective LMP2 expression in human uterine leiomyosarcoma was demonstrated, but present in human leiomyoma and myometrium.

Conclusions:

Loss in LMP2 expression may be one of the risk factors for human uterine leiomyosarcoma. LMP2 may be a potential diagnostic-biomarker and targeted-molecule for a new therapeutic approach.

Uterine sarcomas: then and now

OBJECTIVE

The purpose of this article is to provide an updated review of uterine sarcomas. The traditionally described neoplasms are reviewed as well as several recently characterized entities in terms of their imaging and clinical aspects. We attempt to provide a longitudinal imaging overview, from initial presentation to follow-up. Imaging features are also described of response to traditional therapeutic agents and newer targeted agents.

CONCLUSION

A greater understanding of the pathogenesis has improved our ability to image and treat uterine sarcomas, both at initial staging and on follow-up. Targeted therapy is assuming an increasingly important role in the management of these lesions. It is imperative for radiologists to be aware of response characteristics and potential complications of these agents as well as conventional chemotherapeutic agents.

Randomized multicenter and stratified phase II study of gemcitabine alone versus gemcitabine and docetaxel in patients with metastatic or relapsed leiomyosarcomas: a Federation Nationale des Centres de Lutte Contre le Cancer (FNCLCC) French Sarcoma Group Study (TAXOGEM study)

BACKGROUND

This study aimed to evaluate the efficacy and toxicity of single-agent gemcitabine versus gemcitabine plus docetaxel as second-line therapy in patients with uterine and nonuterine leiomyosarcoma (LMS).

PATIENTS AND METHODS

Patients had metastatic or unresectable LMS and had received one prior anthracycline-based regimen. A total of 90 patients received either single-agent gemcitabine (arm A; gemcitabine, 1,000 mg/m(2) i.v. for 100 minutes on days 1, 8, and 15 of a 28-day cycle) or a combination of gemcitabine and docetaxel (arm B; gemcitabine, 900 mg/m(2) i.v. for 90 minutes on days 1 and 8, plus docetaxel, 100 mg/m(2) i.v. for 1 hour on day 8 of a 21-day cycle with lenograstim). The primary endpoint was the objective response rate.

RESULTS

The objective response rates were 19% and 24% in arm A (gemcitabine) and arm B (gemcitabine plus docetaxel), respectively, for patients with uterine LMS. For patients with nonuterine LMS, the objective response rates were 14% and 5% for arms A and B, respectively. The median progression-free survival times for arms A and B were 5.5 months and 4.7 months, respectively, for patients with uterine LMS. For patients with nonuterine LMS, the median progression-free survival times were 6.3 months and 3.8 months for arms A and B, respectively. One toxic death occurred in arm B.

CONCLUSIONS

Both single-agent gemcitabine and gemcitabine plus docetaxel were found to be effective second-line therapies for leiomyosarcomas, with a 3-month progression-free survival rate of 40% for LMS with both uterine and nonuterine sites of origin. Single-agent gemcitabine yielded results similar to those of gemcitabine plus docetaxel in this trial, but patients using single-agent gemcitabine experienced less toxicity.

Primary intracranial β-human chorionic gonadotropin-producing leiomyosarcoma in a 2-year-old immunocompetent child

The authors present a rare case of primary intracranial leiomyosarcoma (LMS) in a young, immunocompetent boy. The patient presented with an expanding right forehead mass. Diagnostic workup revealed multiple large intracranial tumors. The largest mass was resected, and pathological analysis revealed LMS. Given the poor prognosis of this tumor, the family declined further care, and the child died 3 months later. Primary LMSs are extremely rare tumors in the pediatric population, especially in patients who are not immunocompromised.