Vulvar epithelioid sarcoma in pregnancy

Clinicopathological Characteristics, Treatment, and Survival in Patients Diagnosed With Proximal-Type Epithelioid Sarcoma: A Case Report and Systematic Review

Epithelioid sarcoma is a rare entity that shows a predilection for the young and middle-aged population. There are two subtypes, i.e., the distal or conventional type, which is located in distal extremities, and the proximal type, located in proximal areas of the extremities, pelvis, perineal, and genital region. The latter is characterized by more aggressive behavior, a higher recurrence rate, and poor prognosis. Histopathological and immunohistochemical diagnoses are key to correct and timely treatment and a higher survival rate. We report a case of a 41-year-old man who presented a palpable progressive growth mass in the hypogastrium. The disease time was of nine months, and the tumor was resected, but it recurred a few months later in the same location. Computed tomography (CT) scans showed images suggestive of lung metastasis and the patient had to undergo a second surgery. He received eight cycles of chemotherapy and a subsequent CT scan control showed the progression of the disease, so a new chemotherapy regimen was established. The patient received three cycles of chemotherapy without improvement, so he decided to discontinue treatment. His last outpatient medical consultation was in January 2022. A systematic review of the studies published in PubMed and Google Scholar was performed. We identified 291 articles, but only 41 reports and case series were included, with a total of 55 patients. It is important to include this type of tumor in the differential diagnosis of epithelial tumors due to its aggressive behavior. Correct and timely diagnosis is crucial to obtain lower recurrence rates, lower mortality, and higher survival rates in these patients.

Epithelioid sarcoma and its outcome: a retrospective analysis from a tertiary care center in North India

Aim

Clinicopatholgical findings and outcomes in epithelioid sarcoma (ES) patients.

Materials & methods

ES patients registered in sarcoma clinic from 2015 to 2021.

Results

There were 20 patients with median age of 26 years. Majority had distal ES (70%) and advanced disease (85%). In patients with advanced disease lymph nodes were involved in 65%, lungs in 58% and others in 35%. Among 14 patients who underwent biopsy outside our institute, nine (64.2 %) had been initially misdiagnosed. Response rates to doxorubicin (n = 12), pazopanib (n = 6), gemcitabine/docetaxel (n = 5), tazemetostat (n = 3) and immunotherapy (n = 2) used in various lines were 16, 16, 20, 33 and 0%, respectively.

Conclusion

Our patients had an advanced-stage and distal ES, with a modest response to chemotherapy.

Vulvar Yolk Sac Tumors Are Somatically Derived SMARCB1 (INI-1)-Deficient Neoplasms

So-called primary yolk sac tumors of the vulva are very rare and often have an aggressive disease course. Their molecular features have not been previously characterized. There is also a well-documented group of SMARCB1 (INI-1)-deficient vulvar neoplasms, which includes proximal-type epithelioid sarcoma and myoepithelial carcinoma. Until now, "vulvar yolk sac tumors" and SMARCB1-deficient neoplasms were considered unrelated diseases. After reviewing an index case of a vulvar yolk sac tumor with loss of SMARCB1 by immunohistochemistry, we retrospectively identified 2 additional cases diagnosed as vulvar yolk sac tumors. Patient ages were 34, 32, and 25 years old, and 2 tumors were associated with a pregnancy. All 3 cases showed morphology typical of a yolk sac tumor, and by immunohistochemistry all were positive for SALL4, glypican-3, keratins, and lacked CD34 positivity. All tumors also demonstrated loss of SMARCB1 in tumor cells. Targeted molecular profiling was performed in 2 cases and identified 2 copy deletion of SMARCB1, without genomic alterations typically seen in gonadal yolk sac tumors. In the third case, isochromosome 12p was not identified by fluorescence in situ hybridization. All 3 patients had either local recurrences or distant metastases, and 2 died of disease. One patient had progressive disease while receiving the enhancer of zeste homolog 2 inhibitor tazemetostat. Overall, these findings suggest that vulvar tumors with pure yolk sac-like morphology may represent morphologic variants of SMARCB1-deficient tumors and not veritable germ cell neoplasia. This potential reclassification may have both prognostic and treatment implications and warrants study of additional extragonadal yolk sac tumors.

Successful management of vulvar proximal-type epithelioid sarcoma in pregnancy

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Vulvar proximal-type epithelioid sarcoma during pregnancy is extremely rare.

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Immediate and agressive treatment is essential even in pregnancy, and vulvectomy during pregnancy is considered safe.

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Further reserch is required to discuss about the effectiveness of adjuvant therapy.

Vulvar proximal-type epithelioid sarcoma during pregnancy is extremely rare; only two reports are available to date. Herein, we describe a 36-year-old woman who presented with a pigeon-egg-sized solid mass with cystic component on the left labia majora at 18 weeks of gestation. The patient underwent tumor resection at 23 weeks of gestation and was diagnosed with epithelioid sarcoma, proximal-type. At 29 weeks of gestation, elective cesarean section, radical local resection of the vulva and vagina, and inguinal lymphadenectomy were performed. After surgery, she underwent six courses of adjuvant chemotherapy (doxorubicin 60 mg/m² and cisplatin 50 mg/m²) every four weeks. The patient and her baby survived with neither recurrence nor complications until 5 years. Aggressive management for proximal-type epithelioid sarcoma, such as early termination of pregnancy and operation, can improve maternal outcomes.

SMARCB1/INI1-deficient tumors of adulthood

The SMARCB1/INI1 gene was first discovered in the mid-1990s, and since then it has been revealed that loss of function mutations in this gene result in aggressive rhabdoid tumors. Recently, the term "rhabdoid tumor" has become synonymous with decreased SMARCB1/INI1 expression. When genetic aberrations in the SMARCB1/INI1 gene occur, the result can cause complete loss of expression, decreased expression, and mosaic expression. Although SMARCB1/INI1-deficient tumors are predominantly sarcomas, this is a diverse group of tumors with mixed phenotypes, which can often make the diagnosis challenging. Prognosis for these aggressive tumors is often poor. Moreover, refractory and relapsing progressive disease is common. As a result, accurate and timely diagnosis is imperative. Despite the SMARCB1/INI1 gene itself and its implications in tumorigenesis being discovered over two decades ago, there is a paucity of rhabdoid tumor cases reported in the literature that detail SMARCB1/INI1 expression. Much work remains if we hope to provide additional therapeutic strategies for patients with aggressive SMARCB1/INI1-deficient tumors.

Update on SWI/SNF-related gynecologic mesenchymal neoplasms: SMARCA4-deficient uterine sarcoma and SMARCB1-deficient vulvar neoplasms

Our knowledge regarding the role of genes encoding the chromatin remodeling switch/sucrose non-fermenting (SWI/SNF) complex in the initiation and progression of gynecologic malignancies continues to evolve. This review focuses on gynecologic tumors in which the sole or primary genetic alteration is in SMARCA4 or SMARCB1, two members of the SWI/SNF chromatin remodeling complex. In this review, we present a brief overview of the classical example of such tumors, ovarian small cell carcinoma of hypercalcemic type, and then a detailed review and update of SMARCB1-deficient and SMARCA4-deficient tumors of the uterus and vulva.

An extremely rare elderly case of proximal epithelioid sarcoma of the vulva: case report with a review of literatures

We experienced an extremely rare case of proximal epithelioid sarcoma (PES) of the vulva in a 77-year-old woman. After history taking and physical examination, the patient was tentatively diagnosed as having Bartholin’s cyst in the right labium. Based on histopathological and immunohistochemical (IHC) findings, however, a final diagnosis of PES of the vulva was made. After receiving CyberKnife treatment, the patient survived but with recurrent episodes and poor prognosis. In conclusion, our case indicates that patients with PES of the vulva should be appropriately managed with radiotherapy after a differential diagnosis based on histopathological and IHC findings.

Vulvar sarcoma outcomes by histologic subtype: a Surveillance, Epidemiology, and End Results (SEER) database review

OBJECTIVE

Vulvar cancers account for 5% of all gynecologic malignancies; only 1%-3% of those vulvar cancers are primary vulvar sarcomas. Given the rarity of vulvar sarcomas, outcome data specific to histopathologic subtypes are sparse. The aim of this study was to identify clinical and pathologic factors of primary vulvar sarcomas that are associated with survival and may inform treatment decisions.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was searched for women diagnosed with vulvar sarcoma between 1973 and 2018. We identified 315 patients and reviewed their demographic, clinicopathologic, surgical, and survival information. Statistical analyses included χ² and t-tests, Kaplan-Meier survival, and Cox regression analyses.

RESULTS

The most common histopathologies of vulvar sarcomas were dermatofibrosarcomas (85/315, 27%) and leiomyosarcomas (72/315, 22.9%). Rhabdomyosarcomas (18/315, 5.7%), liposarcomas (16/315, 5.1%), and malignant fibrous histiocytomas (16/315, 5.1%) were less frequent. The majority of patients underwent surgery (292/315, 92.7%), which included lymph node dissections in 21.6% (63/292). Survival and lymph node involvement varied significantly with histologic subtype. The 5-year disease-specific survival for dermatofibrosarcomas, liposarcomas, and fibrosarcomas was 100% and only 60.3% and 62.5% for malignant fibrous histiocytomas and rhabdomyosarcomas, respectively. None of the patients with (dermato)fibrosarcomas, liposarcomas, or leiomyosarcomas had positive lymph nodes, in contrast to rhabdomyosarcomas and malignant fibrous histiocytomas with 77.8% and 40% positive lymph nodes, respectively. The 5-year disease-specific survival for women with positive lymph nodes was 0%.

CONCLUSIONS

Vulvar sarcomas are heterogeneous with survival highly dependent on the histopathologic subtype. While surgical excision is the mainstay of treatment for all vulvar sarcomas, staging lymphadenectomy should be deferred for (dermato)fibrosarcomas, liposarcomas, and leiomyosarcomas as there were no cases of lymph nodes metastases.

Ultrasonography findings of proximal-type epithelioid sarcoma of the vulva: A case report

Proximal-type epithelioid sarcoma (PES) of the vulva is an exceedingly rare malignant soft tissue tumor. We herein present the case of a 41-year-old female patient who presented to our hospital with complaints of a painless mass in the right mons pubis that she had first noticed 3 years prior. Ultrasonographic (US) and color Doppler ultrasonographic (CDUS) examination revealed a solid mass with well-defined, homogeneous hypoechoic structure and quite hypervascular on CDUS. The results of the immunohistochemical examination confirmed the diagnosis of vulvar PES (myxoid variant). The patient was treated with wide local excision and remained recurrence- and metastasis-free at 9 months postoperatively. Although cases of PES in the pelvic region had been previously reported, to the best of our knowledge, the US or CDUS findings of PES of the vulva have not been described to date.

Epithelioid sarcoma of the vulva and its clinical implication: A case report and review of the literature

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We present a case of vulva epithelioid sarcoma, and review the articles.

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The rarity of this disease causes delay in diagnosis and lack of guideline for optimal treatment.

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Physicians should have high suspicions in diagnosing this vulvar disease using prompt biopsy without delay.

Vulvar sarcomas: Short guideline for histopathological recognition and clinical management. Part 1

Malignant tumors of the female reproductive system are a serious health and social problem, as they are the second most common cause of death among women, after breast cancer. Their incidence has increased dramatically during recent years, probably due to the different sexual habits and changes in the prevalence of HIV/ AIDS and HPV virus carriers, among other factors. Vulvar tumors represent only 4% of all gynecological neoplasms, and they are fourth in frequency after tumors of the cervix, uterus, and ovary. Ninety eight percent of all vulvar tumors are benign and only 2% are malignant. The overall incidence of tumors with vulvar location is between two and seven cases per 100,000 women, and it increases with age, while the death rate is estimated at 0.7 per 100,000 women. Sarcomas of the vulva comprise approximately 1-3% of all vulvar cancers, with leiomyosarcomas, epithelioid sarcomas, and rhabdomyosarcomas being the most common among them. They are characterized by rapid growth, high metastatic potential, frequent recurrences, aggressive behavior, and high mortality rate. In this paper, we present the most common forms of sarcomas of the vulva (leiomyosarcoma, epithelioid sarcoma, malignant rhabdoid tumor, rhabdomyosarcoma) in order to emphasize the broad differential diagnosis, rare appearance, non-specific clinical picture, aggressive course, and high mortality.

Dilemmas in the management of patients with vulval epithelioid sarcoma: a literature review

Vulval sarcomas are an extremely rare type of soft tissue tumor, the principal properties of which are unpredictable symptoms and frequent recurrences. This review discusses the management options specific for cases of vulval epithelioid sarcoma. The PubMed, Scopus and Cochrane databases were systematically searched and 28 studies met the inclusion criteria for our narrative review. The mean age of the 31 included patients was 31 years (range: 17-84). Local excision (19 out of 31, 61.3%), radical vulvectomy (8 out of 31, 25.8%) and hemivulvectomy (4 out of 31, 12.9%) were the principal surgical treatments. Radiotherapy and chemotherapy were performed in 8 and 5 patients, respectively. Recurrence of the disease was present in 13 out of 31 (42%). The interval to recurrence ranged from 1 to 48 months. The main location of recurrences was the local tissues, the lymph nodes and the lung. The mean period of follow-up was 38.5 months (range: 2-146 months). Cure was considered to have taken place in 19 out of 31 (61.3%) patients; 10 out of 31 (32.6%) died, and 2 out of 31 (6.4%) at the end of follow-up were alive but not considered cured. The first and principal step for the proper treatment of vulval epithelioid sarcomas is awareness of their existence by the specialist involved. Extensive imaging is proposed for staging, while the creation of a national or international register of patients with this malignancy would enable a more consistent approach to its management.

Miscellaneous Pseudotumors and Mesenchymal Tumors of the Female Genital Tract

Benign and malignant soft tissue tumors and pseudotumors can rarely arise anywhere in the female genital tract. Their pathologic features as well as behavior typically overlap with those described in tumors involving typical locations. However, due to their rarity, not infrequently these tumors represent a diagnostic challenge. Their diagnosis should be based on careful gross examination, thorough sampling, and morphologic evaluation, applying a selected immunohistochemical panel and molecular studies. Accurate classification of these tumors is important because their clinical behavior, prognosis, and therapy differ markedly. This article outlines several mesenchymal lesions reported in the female genital tract, encompassing recent histologic, immunohistochemical, and molecular findings, with special emphasis on problems in the differential diagnosis.

Epithelioid sarcoma of the vulva in a 17-year-old pregnant woman

Epithelioid sarcoma of the vulva is an extremely rare neoplasm with aggressive behavior and poor outcome. Herein, we report a case of vulvar epithelioid sarcoma presenting in a 17-year-old very early in her pregnancy. The patient presented with an asymptomatic nodule of the right labia majora of 1-year duration. Computerized tomographic scans showed enlarged inguinal lymph nodes and numerous lung nodules. Positron emission tomography was performed and revealed no suspicious lesions for metastatic disease. The patient underwent local excision of her vulvar lesion. On the basis of morphology and extensive immunohistochemistry, the lesion was classified as epithelioid sarcoma. The patient was referred to radiation therapy and upon evaluation, she was found to be in her sixth week of gestation. The patient continued with her pregnancy and underwent a lymph node dissection, which was positive. We review the literature of only the well-documented cases extensively studied by immunohistochemical analysis. We summarize the clinical presentation, clinical impression, treatment modalities, and outcomes of these cases. On account of the rarity of this disease in the vulva, there is no clear consensus on treatment modalities, but it seems that early aggressive surgical resection is the treatment of choice, with the role of adjuvant therapy to be determined.

Magnetic resonance imaging findings of vulvar epithelioid sarcoma

We describe here a case of vulvar epithelioid sarcoma. Epithelioid sarcoma is a malignant appendicular skin tumor that is rarely of vulvar origin. Magnetic resonance imaging (MRI) revealed a solid mass with an ulcer-like lesion and multilobulated contour. To our knowledge, this is the first case of vulvar epithelioid sarcoma described in the MRI literature.

Old and new perspectives in the management of high-risk, locally advanced or recurrent, and metastatic vulvar cancer

During the last decades there has been a continuing evolution in the surgical approach of squamous cell carcinoma of the vulva that has been traditionally treated with radical vulvectomy and bilateral inguinal-femoral lymphadenectomy. Patients with T1 tumour are usually treated with radical local excision, if the lesion is unifocal and the remainder of the vulva is normal. Patients with T1a disease have no risk of groin metastases and do not need lymphadenectomy, whereas those with T1b disease need ipsilateral inguinal-femoral lymphadenectomy if the lesion is lateral, and bilateral lymphadenectomy if the lesion is midline. Modifications of the surgical technique of deep femoral lymphadenectomy and the mapping of sentinel node can offer new interesting therapeutic perspectives. Postoperative adjuvant pelvic and groin irradiation is warranted for patients with two or more or macroscopically involved groin nodes. Locally advanced squamous cell carcinoma of the vulva has been long surgically treated with en-block radical vulvectomy and bilateral inguinal-femoral lymphadenectomy plus partial resection of urethra, vagina or anum, or by exenteration, with severe postsurgical complications, poor quality of life, and unsatisfactory survival rates. 5-Fluorouracil [5-FU] or 5-FU- and cisplatin-based chemotherapy concurrent with irradiation followed by tailored surgery represents an attractive therapeutic option for advanced disease, planned to avoid such ultra-radical surgical procedures and, hopefully, to improve patient outcome. Chemotherapy has also been used in neoadjuvant setting, with contrasting and generally unsatisfactory results, and in palliative treatment of patients with distant metastases. Surgery is the primary treatment also for vulvar malignancies other than squamous cell carcinoma, whereas the clinical usefulness of adjuvant irradiation or chemotherapy is still to be defined. Primary chemoradiation can be also used for advanced carcinoma of the Bartholin gland or for advanced adenocarcinoma associated with extramammary Paget's disease. The drugs used for chemotherapy of metastatic melanomas or sarcomas of the vulva are the same employed for the melanomas or sarcomas developed in other sites.

Rapid growth of myxoid leiomyosarcoma of the vulva during pregnancy: a case report

Smooth muscle tumors arising in the vulva are rare. Leiomyosarcoma is the most common variant of vulvar sarcoma, and very few cases have been reported during pregnancy. A 36-year-old woman presented with a progressively enlarging vulvar mass during pregnancy, diagnosed as a Bartholin's gland cyst. The lesion was resected at 38 weeks of gestation during cesarean section and diagnosis of myxoid leiomyosarcoma of the vulva was made. Six weeks later the patients were referred to our center and submitted to wide vulvar excision with groin lymph node dissection that revealed the presence of a small residual focus of leiomyosarcoma. At 30 months of follow-up the patient was well without any sign of recurrent disease. Leiomyosarcoma should be included in the differential diagnosis of vulvar masses; progressively enlarging vulvar lesion should be biopsied even during pregnancy. Leiomyosarcoma should be considered in the differential diagnosis of vulvar mass.

Bartholin's gland carcinoma, malignant melanoma and other rare tumours of the vulva

Non-squamous cancers of the vulva encompass an exciting and broad group of tumours, including Bartholin's gland carcinoma, malignant melanoma, Paget's disease, sarcomas and lymphoma. These tumours range from innocuous lesions treatable with simple local excision, such as basal-cell carcinoma, to cancers with very poor prognosis, such as Merkel-cell tumours. All of these tumours are thoroughly reviewed, with emphasis on presenting symptoms, pathological diagnosis and optimal management approaches. The literature supporting these recommendations is reviewed. Of the utmost importance in the management of these tumours is a thorough review of the pathological diagnosis by a specialist pathologist and a gynaecological oncologist. Establishing the correct diagnosis is essential to reaching appropriate treatment decisions. Frequently this will necessitate a second opinion by a referral centre.

Epithelioid sarcoma of the uterine cervix

BACKGROUND

Epithelioid sarcoma is a rare, yet aggressive soft tissue neoplasm that has not previously been reported to originate in the cervix.

CASE

A 29-year-old woman was seen in consultation at our institution after having been diagnosed with a poorly differentiated carcinoma of the cervix, which was treated with radiation and chemotherapy. Examination of the original biopsy material with additional studies led to a diagnosis of epithelioid sarcoma of the cervix.

CONCLUSION

Epithelioid sarcoma can occur in the cervix and should be included in the differential diagnosis of cervical neoplasms. Additional cases are needed to develop optimum treatment strategies and predict prognosis.