Primary epithelioid sarcoma of the vulva in pregnancy

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.

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.

Prognostic significance of c-KIT in vulvar cancer: bringing this molecular marker from bench to bedside

Background

Vulvar carcinomas are rare tumors, and there is limited data regarding molecular alterations. To our knowledge there are no published studies on c-KIT and squamous cell carcinomas of the vulva (VSCC). Although there are a significant number of other tumor types which express c-KIT, there remains controversy as to its relationship to patient outcome. Thus, we wished to investigate such controversial findings to determine the prognostic importance of c-KIT by evaluating its protein and mRNA expression in VSCCs, correlating these findings with clinicopathological features and Human Papillomavirus (HPV) infection.

Methods

c-KIT expression was scored by immunohistochemistry (IHC) as positive or negative in 139 formalin-fixed paraffin-embedded (FFPE) cases of vulvar carcinomas arrayed in a tissue microarray (TMA) using the DAKO® A4502 rabbit polyclonal c-KIT antibody (diluted 1:100). c-KIT mRNA was evaluated by qRT-PCR in 34 frozen samples from AC Camargo Hospital Biobank (17 tumoral and 17 non-tumoral samples) using TaqMan probes–Applied Biosystems [Hs00174029_m1]. HPV genotyping was assessed in 103 samples using Linear Array® HPV Genotyping Test kit (Roche Molecular Diagnostics, Basel, Switzerland). All results obtained were correlated with clinical and pathological data of the patients.

Results

c-KIT protein was positive by immunohistochemistry in 70.5% of the cases and this was associated with a higher global survival (p = 0.007), a higher recurrence-free survival (p < 0.0001), an absence of associated lesions (p = 0.001), lymph node metastasis (p = 0.0053), and HPV infection (p = 0.034). Furthermore, c-KIT mRNA quantitation revealed higher levels of transcripts in normal samples compared to tumor samples (p = 0,0009).

Conclusions

Our findings indicate that those vulvar tumors staining positively for c-KIT present better prognosis. Thus, positivity of c-KIT as evaluated by IHC may be a good predictor for use of more conservative surgery techniques and lymph node dissection in vulvar cancer. So part of the essence of our study is to see the possibility of translating our current results from the bench to the bedside. This will help provide patients a more appropriate, less mutilating treatment, in order to keep the maximum physical and psychic quality as possible to these women.