Recurrence of prolactin-producing endometrial stromal sarcoma with sex-cord stromal component treated with progestin and aromatase inhibitor

Hormonal Therapy for Gynecological Cancers: How Far Has Science Progressed toward Clinical Applications?

Simple Summary

The most common therapies for severe and recurrent gynecological cancers are hormone therapy and chemotherapy, and responsiveness to therapy is a key component in prognosis and survivability. Hormone therapy has recently been demonstrated to be an excellent cancer treatment approach. Hormone treatment for gynecological cancers is taking drugs that decrease hormone levels or impede their biological activity, halting or slowing cancer progression. Hormone therapy works by suppressing the multiplication of cancer cells triggered by hormones. Hormonal therapy, such as progestogens or tamoxifen, is frequently recommended for patients with hormone-sensitive recurrent or metastatic gynecological cancers, but response rates and therapeutic effects are inconsistent. Therefore, we discuss the pathogenesis of gynecological malignancies from the hormonal landscape and the use of hormonal therapies toward clinical applications.

Abstract

In recent years, hormone therapy has been shown to be a remarkable treatment option for cancer. Hormone treatment for gynecological cancers involves the use of medications that reduce the level of hormones or inhibit their biological activity, thereby stopping or slowing cancer growth. Hormone treatment works by preventing hormones from causing cancer cells to multiply. Aromatase inhibitors, anti-estrogens, progestin, estrogen receptor (ER) antagonists, GnRH agonists, and progestogen are effectively used as therapeutics for vulvar cancer, cervical cancer, vaginal cancer, uterine cancer, and ovarian cancer. Hormone replacement therapy has a high success rate. In particular, progestogen and estrogen replacement are associated with a decreased incidence of gynecological cancers in women infected with human papillomavirus (HPV). The activation of estrogen via the transcriptional functionality of ERα may either be promoted or decreased by gene products of HPV. Hormonal treatment is frequently administered to patients with hormone-sensitive recurring or metastatic gynecologic malignancies, although response rates and therapeutic outcomes are inconsistent. Therefore, this review outlines the use of hormonal therapy for gynecological cancers and identifies the current knowledge gaps.

The Relevant Participation of Prolactin in the Genesis and Progression of Gynecological Cancers

Prolactin (PRL) is a hormone produced by the pituitary gland and multiple non-pituitary sites, vital in several physiological processes such as lactation, pregnancy, cell growth, and differentiation. However, PRL is nowadays known to have a strong implication in oncogenic processes, making it essential to delve into the mechanisms governing these actions. PRL and its receptor (PRLR) activate a series of effects such as survival, cellular proliferation, migration, invasion, metastasis, and resistance to treatment, being highly relevant in developing certain types of cancer. Because women produce high levels of PRL, its influence in gynecological cancers is herein reviewed. It is interesting that, other than the 23 kDa PRL, whose mechanism of action is endocrine, other variants of PRL have been observed to be produced by tumoral tissue, acting in a paracrine/autocrine manner. Because many components, including PRL, surround the microenvironment, it is interesting to understand the hormone's modulation in cancer cells. This work aims to review the most important findings regarding the PRL/PRLR axis in cervical, ovarian, and endometrial cancers and its molecular mechanisms to support carcinogenesis.

Italian consensus conference on management of uterine sarcomas on behalf of S.I.G.O. (Societa' italiana di Ginecologia E Ostetricia)

BACKGROUND

Uterine sarcomas are very rare tumours with different histotypes, molecular features and clinical outcomes; therefore, it is difficult to carry out prospective clinical trials, and this often results in heterogeneous management of patients in the clinical practice.

AIM

We planned to set up an Italian consensus conference on these diseases in order to provide recommendations on treatments and quality of care in our country.

RESULTS

Early-stage uterine sarcomas are managed by hysterectomy + bilateral salpingo-oophorectomy according to menopausal status and histology; lymphadenectomy is not indicated in patients without bulky nodes, and morcellation must be avoided. The postoperative management is represented by observation, even though chemotherapy can be considered in some high-risk patients. In early-stage low-grade endometrial stromal sarcoma and adenosarcomas without sarcomatous overgrowth, hormonal adjuvant treatment can be offered based on hormone receptor expression. In selected cases, external beam radiotherapy ± brachytherapy can be considered to increase local control only. Patients with advanced disease involving the abdomen can be offered primary chemotherapy (or hormonal therapy in the case of low-grade endometrial stromal sarcoma and adenosarcoma without sarcomatous overgrowth), even if potentially resectable in the absence of residual disease in order to test the chemosensitivity (or hormonosensitivity); debulking surgery can be considered in patients with clinical and radiological response. Chemotherapy is based on anthracyclines ± ifosfamide or dacarbazine. Palliative radiotherapy can be offered for symptom control, and stereotactic radiotherapy can be used for up to five isolated metastatic lesions.

CONCLUSIONS

Treatment of uterine sarcoma should be centralised at referral centres and managed in a multidisciplinary setting.

Uterine lesions with sex cord-like architectures: a systematic review

Background

Sex cord-like elements are rarely observed in uterine lesions, but these morphological patterns could appear in a variety of uterine tumors and non-tumorous lesions. In this review, we collected the literatures regarding the uterine tumorous and non-tumorous lesions containing sex cord-like elements and summarized these lesions in terms of clinicopathological, immunohistochemical, and molecular features in order to further understand these lesions and provide some new ideas for differential diagnosis.

Main body

This section provides a comprehensive overview of the clinicopathological, immunohistochemical, and molecular features of uterine lesions with sex cord-like architectures including uterine tumors resembling ovarian sex cord tumors, endometrial stromal tumors, adenomyosis, endometrial polyps, leiomyoma, epithelioid leiomyosarcoma, adenosarcoma, sertoliform endometrioid carcinoma, corded and hyalinized endometrioid carcinoma, mesonephric adenocarcinoma, and mesonephric-like adenocarcinoma. The differential diagnosis based on morphology, immunohistochemistry, and molecular alterations has also been discussed.

Conclusion

The sex cord-like areas in these lesions show heterogeneous but similar morphological features. Additionally, immunohistochemical staining plays a limited role in differential diagnosis. Furthermore, it is of significance for pathologists to better understand these lesions in order to avoid confusion and mistakes during pathological diagnosis, especially in a biopsy/curettage specimen.

Proteomic Biomarkers for the Detection of Endometrial Cancer

Endometrial cancer is the leading gynaecological malignancy in the western world and its incidence is rising in tandem with the global epidemic of obesity. Early diagnosis is key to improving survival, which at 5 years is less than 20% in advanced disease and over 90% in early-stage disease. As yet, there are no validated biological markers for its early detection. Advances in high-throughput technologies and machine learning techniques now offer unique and promising perspectives for biomarker discovery, especially through the integration of genomic, transcriptomic, proteomic, metabolomic and imaging data. Because the proteome closely mirrors the dynamic state of cells, tissues and organisms, proteomics has great potential to deliver clinically relevant biomarkers for cancer diagnosis. In this review, we present the current progress in endometrial cancer diagnostic biomarker discovery using proteomics. We describe the various mass spectrometry-based approaches and highlight the challenges inherent in biomarker discovery studies. We suggest novel strategies for endometrial cancer detection exploiting biologically important protein biomarkers and set the scene for future directions in endometrial cancer biomarker research.

Uterine tumor resembling ovarian sex cord tumor: a clinicopathological and immunohistochemical analysis of two cases and a literature review

A uterine tumor resembling an ovarian sex cord tumor (UTROSCT) is a rare type of neoplasm that is almost thoroughly differentiated towards ovarian sex cord elements. Because of abnormal uterine bleeding, a 64-year-old postmenopausal woman received total abdominal hysterectomy with bilateral salpingo-oophorectomy. Under a microscope, the tumor cells showed an anastomosing fascicular and trabecular pattern with a reticular architecture. Immunohistochemistry showed that the tumor cells were positive for calretinin, Wilm’s tumor-1, and vimentin. A 33-year-old woman who suffered from menorrhagia, and was treated for bilateral salpingectomy, total abdominal hysterectomy, and bilateral ovarian biopsy, was also studied. Using histology, the patient was diagnosed with UTROSCT as shown by CD99, smooth muscle actin, calretinin, vimentin, and desmin expression. As a type of rare uterine tumor, UTROSCT can be diagnosed based on morphological and immunohistochemical conditions. Generally, these tumors are benign, but can easily relapse through incomplete resection. Hysterectomy should be performed after completion of family planning.

Pitfalls of Frozen Section in Gynecological Pathology: A Case of Endometrial Tumor With Sex Cord–Like Elements

Endometrial stromal tumor with sex cord–like elements (ESTSCLE) is a rare entity that shares similar histological features with uterine tumors resembling ovarian sex cord tumors (UTROSCT). Differentiating the 2 entities involves ample sampling of the tissue to distinguish the percentage of sex cord components within the tissue, genetic studies, and immunohistochemical staining. Frozen section provides limited information for exclusion of either tumor; and the tumor is rare enough that the diagnosis may not be considered with the limited sampling; therefore, deferral of diagnosis to permanent sections may be appropriate.

Letrozole as second-line hormonal treatment for recurrent low-grade endometrial stromal sarcoma: A case report and review of the literature

Low-grade endometrial stromal sarcoma (LGESS) is a rare malignancy. The tumor is reportedly responsive to hormonal therapy, most commonly with medroxyprogesterone acetate (MPA), but the effectiveness of aromatase inhibitors for recurrent LGESS remains unclear. The present study reports a case of stage IC LGESS presenting with abnormal uterine bleeding, and also provides a review of the literature. Following a total abdominal hysterectomy and bilateral salpingo-oophorectomy, MPA therapy was initiated; treatment was successful, but discontinued 19 months later due to disruptive side effects. A further 2 months later, the patient presented with recurrent disease and received chemotherapy. MPA treatment was restarted with a partial response. A second recurrence, 4 years later, presented with lung and para-aortic lymph node metastases. The patient responded to treatment with the aromatase inhibitor letrozole. The patient has since exhibited stable disease and remained free of symptoms for 7 years. This case suggests that aromatase-inhibitor treatment may be effective for recurrent LGESS as a second-line treatment.

Long-term treatment of residual or recurrent low-grade endometrial stromal sarcoma with aromatase inhibitors: A report of two cases and a review of the literature

Endometrial stromal sarcoma (ESS) occurs rarely and accounts for only 0.2% of all uterine malignancies. ESS usually expresses estrogen and progesterone receptors, and is regarded as hormone-sensitive. Due to the rarity of these tumors, there are only few case series on the use of aromatase inhibitors in the treatment of low-grade ESS. The present study reports the cases of two patients with residual or recurrent low-grade ESS who experienced long-term disease-free survival following treatment with letrozole. The study also reviews the literature with regard to the data on aromatase inhibitors used in patients with low-grade ESS. In total, 30 patients with recurrent or residual low-grade ESS who were treated with aromatase inhibitors were identified, including the present cases. Among the 30 patients, the overall response rate of advanced low-grade ESS to aromatase inhibitors was 77.4% (complete response, 25.8%; partial response, 51.6%) and the disease control rate was 90.3%. The response rate of first-line treatment was similar to that of second-line therapy or higher (84.6 vs. 72.2%; P=0.453). Duration of aromatase inhibitor treatment ranged from 1.5 to 168 months (median, 26.5 months). The aromatase inhibitors showed minimal adverse effects. In conclusion, aromatase inhibitors, particularly third-generation drugs, are a well-tolerated class of medications that are effective in the treatment of advanced low-grade ESS, with a favorable toxicity profile.

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.

Endometrial stromal tumors: immunohistochemical and molecular analysis of potential targets of tyrosine kinase inhibitors

BACKGROUND

The systemic treatment of malignant endometrial stromal tumors (EST) is not well established. A few reports describe objective responses to imatinib, which suggest a novel therapeutic strategy for these tumors. Due to these facts, we aimed to perform a retrospective analysis of possible molecular targets of tyrosine kinase inhibitors (TKI) in EST: KIT, PDGFRA and EGFR.

METHODS

52 endometrial stromal sarcomas and 13 undifferentiated endometrial sarcomas were examined and reviewed. Mutational analysis were performed for exons 9, 11, 13, and 17 of the KIT gene, exons 12 and 18 of the PDGFRA gene and exons 18, 19, 20 and 21 of the EGFR gene. The incidence and distribution of the KIT, PDGFRA, and EGFR expression were examined by immunohistochemistry, and EGFR amplification was assessed by fluorescence in situ hybridization.

RESULTS

No mutations in KIT, PDGFRA and EGFR genes were detected. Overexpression of KIT, PDGFRA, EGFR, was detected in 2 (3%), 23 (35.4%), 7 (10.8%) cases respectively, whereas amplification of EGFR gene was not found.

CONCLUSIONS

Absence of significant expression, amplification and activating mutations on these tyrosine kinase receptors suggest that it is unlikely that EST can benefit from therapies such as TKI on the systemic setting.

Uterine Sarcoma and Aromatase Inhibitors: Tom Baker Cancer Centre Experience and Review of the Literature

Objectives

Uterine sarcomas are a rare group of mesenchymal tumors with a poor prognosis and aggressive biology. Standard treatment involves surgical staging. The role of further adjuvant treatment is unclear. The goals of this study were to determine the response rates to treatment of patients with uterine sarcomas and to review the currently available literature on the use of aromatase inhibitors (AIs).

Materials and Methods

We performed a retrospective analysis on all patients with uterine sarcoma treated with an AI between 2000 and 2010 at the Tom Baker Cancer Centre in Calgary, Alberta.

Results

Four patients with endometrial stromal sarcoma and 3 patients with leiomyosarcoma received treatment with an AI. A literature search resulted in 10 case reports and 4 retrospective studies of patients with endometrial stromal sarcoma and 1 case report and 2 retrospective studies of patients with leiomyosarcoma. On the basis of the available literature, combined with the current findings, the overall response rate of endometrial stromal sarcoma to AIs is 67% (complete response of 7% and partial response of 60%), and the partial response rate of leiomyosarcoma to AIs is 11%, with no reported complete responses.

Conclusions

Aromatase inhibitors are a well-tolerated class of medications that are effective in the treatment of endometrial stromal sarcomas. These medications may also have a role to help stabilize disease progression in the treatment of leiomyosarcoma. More large, prospective, multicentered trials will be needed to clarify this issue.

Case reports of sarcoma patients with optimized lectin-oriented mistletoe extract therapy

BACKGROUND

Mistletoe (Viscum album L) extracts (ME) are widespread as immunomodulatory therapeutic agents in alternative tumor treatment. Assessing the often-controversial clinical results is rather difficult since the effects of ME on the immune system cannot be equally reproduced. Mistletoe lectins (ML) are the only mistletoe ingredients also found in vivo that are capable of having a positive effect on the immune balance of patients with tumors. Other components have only been tested in vitro, and the removal of mistletoe lectins ML from the extract can put an end to the immunological efficacy of ME. Preclinical investigations in the tumor models (using nude mice xenotransplanted with human leiomyosarcoma and interleukin-12-deficient C57BL6 mice) show that without immunological reactions, ME induce less antitumor efficacy. ML, functioning as ligands for pattern recognition receptors of the natural immune system, are docked to ganglioside molecules (CD75) of monocytes and granulocytes, thereby stimulating the natural antitumor mechanisms.

OBJECTIVES

The aim of this article is to present and discuss several favorable clinical responses of patients who had sarcoma and who were treated with immunologically effective ME preparations. COURSE OF THERAPY AND RESULTS: In accordance with the bell-shaped dose-response relationship of ML, the patients with sarcoma were treated with ME preparations, standardized for the active sugar-binding lectin contents. Thus, an optimal dose of 0.75-1.0 ng/kg ML was given twice a week subcutaneously. In this report, the clinical progress of 6 patients with sarcoma showed remissions of tumor symptoms.

CONCLUSIONS

It seems that this disease is beneficially influenced by optimized lectin-oriented ME therapy since patients with sarcoma may react especially well to the improved balance of natural immunological mechanisms. These case reports require further clinical studies with patients with sarcoma.

A case of uterine tumour resembling ovarian sex cord tumour responding to second-line, single agent anastrazole

Uterine tumour resembling ovarian sex cord tumour (UTROSCT) are a histological variant of endometrial stromal sarcomas (ESS). There is no established medical management of metastatic UTROSCT or ESS, although there is evidence supporting the use of hormonal therapy. Given the success of aromatase inhibitors in breast cancer, their potential role in ESS and UTROSCT is of current interest. We report the first case of response to second-line, single agent anastrazole in a patient with metastatic UTROSCT.

HE4 as a biomarker for ovarian and endometrial cancer management

Ovarian and endometrial cancer will be diagnosed in over 63,000 women in 2009, resulting in 22,000 deaths in the USA. Histologic screening, such as pap smears for detection of cervical cancer, is not feasible for these diseases given difficulty with access to the tissue. Thus, a serum- screening test using a biomarker or panel of biomarkers would be useful to aid in cancer diagnosis, detection of recurrence and as a means to monitor response to therapy. In this review, we focus on the human epididymis protein (HE)4 gene, which appears to have potential as a biomarker for both of these diseases. The structure and methods of detection of HE4 are discussed. Preliminary data show that HE4 may have more potential than cancer antigen 125 in discriminating benign from cancerous ovarian masses, and has the strongest correlation with endometrial cancer of all markers tested to date. Utilizing risk stratification, a panel of biomarkers including HE4 may ultimately be useful for detecting ovarian and endometrial cancer at an early stage in patients at high risk.

Case report: Recurrence of a uterine tumor resembling ovarian sex-cord tumor

BACKGROUND

Uterine tumors resembling ovarian sex-cord tumors are very rare uterine neoplasias that generally behave in a benign manner. We report the case of a uterine tumor resembling an ovarian sex-cord tumor that recurred after hysterectomy.

CASE

A 35-year-old nulliparous woman presented with abdominal discomfort, galactorrhea and abnormal vaginal bleeding. Ultrasound examination showed a heterogeneous uterine tumor composed of cystic and solid parts. Because of the patient's desire to preserve fertility, tumor resection was scheduled. Frozen sections suggested malignancy and led to abdominal hysterectomy. The final histological diagnosis was uterine tumor resembling ovarian sex-cord tumor. Three years into follow-up, metastasis occurred.

CONCLUSION

Although uterine tumors resembling ovarian sex-cord tumors generally behave in a benign manner, they may in rare cases metastasize.

Treatment of early uterine sarcomas: disentangling adjuvant modalities

Uterine sarcomas are a rare group of neoplasms with aggressive clinical course and poor prognosis. They are classified into four main histological subtypes in order of decreasing incidence: carcinosarcomas, leiomyosarcomas, endometrial stromal sarcomas and "other" sarcomas. The pathological subtype demands a tailored approach. Surgical resection is regarded as the mainstay of treatment. Total abdominal hysterectomy and bilateral salpingo-oophorectomy represents the standard treatment of uterine sarcomas. Pelvic and para-aortic lymph node dissection in carcinosarcomas is recommended, given their high incidence of lymph node metastases, and may have a role in endometrial stromal sarcomas. Adjuvant radiation therapy has historically been of little survival value, but it appears to improve local control and may delay recurrence. Regarding adjuvant chemotherapy, there is little evidence in the literature supporting its use except for carcinosarcomas. However, more trials are needed to address these issues, especially, their sequential application. Patients with uterine sarcomas should be referred to large academic centers for participation in clinical trials.

The efficacy of hormonal treatment for residual or recurrent low-grade endometrial stromal sarcoma. A retrospective study

OBJECTIVE

Low-grade endometrial stromal sarcoma (EES) is a rare tumour with a high recurrence rate but a very good prognosis. Responses to hormonal treatment of these recurrences have been published in case reports. The aim of this study was to determine the objective response rate and response duration of hormonal treatment for recurrent or residual low-grade ESS in a consecutive series of patients.

STUDY DESIGN

Thirteen consecutive patients with residual or recurrent disease were retrieved from the files. Eleven patients with measurable disease were treated with hormones and form the basis of this study. The following data were collected: age, date of primary diagnosis, type of primary treatment, the presence and localization of residual or recurrent disease, type of treatment, response, duration of response and survival.

RESULTS

After hormonal treatment 9 (82%) patients showed an objective response (4 complete response; 5 partial response), one showed stable disease (26+ months) and one progressive disease. Response duration was from 4+ to 252+ months (median 48+ months).

CONCLUSION

Hormonal treatment for measurable residual or recurrent low-grade ESS has a high response rate and should be considered as the treatment of choice for patients in which recurrent disease cannot easily be resected.

Development of multimarker panel for early detection of endometrial cancer. High diagnostic power of prolactin

OBJECTIVE

Endometrial carcinoma is the most common gynecologic cancer. Although the prognosis for endometrial cancer is generally good, cancers identified at late stages are associated with high levels of morbidity and mortality. Therefore, prevention and early detection may further reduce the burden of this challenging disease.

METHODS

A panel of 64 serum biomarkers was analyzed in sera of patients with stages I-III endometrial cancer and age-matched healthy women, utilizing a multiplex xMAP bead-based immunoassay. For multivariate analysis, four different statistical classification methods were used: logistic regression (LR), separating hyperplane (SHP), k nearest neighbors (KNN), and classification tree (CART). For each of these classifiers, a diagnostic model was created based on the cross-validation set consisting of sera from 115 patients with endometrial cancer and 135 healthy women.

RESULTS

Our data have demonstrated that patients with endometrial cancer have significantly different expression patterns of several serum biomarkers as compared to healthy controls. Prolactin was the strongest discriminative biomarker for endometrial cancer providing 98.3% sensitivity and 98.0% specificity alone. Our results have revealed that serum concentration of cancer antigens, including CA 125, CA 15-3, and CEA are higher in patients with Stage III endometrial cancer as compared to those with Stage I. In addition, we have shown that the expression of CA 125, AFP, and ACTH is elevated in women with tumor grade 3 vs. grade 1. Furthermore, five-biomarker panel (prolactin, GH, Eotaxin, E-selectin, and TSH) identified in this study was able to discriminate endometrial cancer from ovarian and breast cancers with high sensitivity and specificity.

CONCLUSIONS

The ability of prolactin to accurately discriminate between cancer and control groups indicates that this biomarker could potentially be used for development of blood-based test for the early detection of endometrial cancer in high-risk populations. Combining the information on multiple serum markers using flexible statistical methods allows for achieving high cancer selectivity.

Hormonal therapy of endometrial stromal sarcoma

PURPOSE OF REVIEW

Low-grade endometrial stromal sarcomas are steroid receptor positive tumors with slow tumor progression and high recurrence rates, which lack established treatment protocols. We present an update on hormonal therapy options.

RECENT FINDINGS

In the past, hormonal therapy consisted of progestins for advanced/recurrent/metastatic low-grade endometrial stromal sarcomas. Aromatase inhibitors and gonadotropin-releasing hormone analogues have become new effective alternatives for first and second line treatment. The high recurrence rates after short disease free intervals in low-grade endometrial stromal sarcoma patients were partly due to inadvertent growth stimulation during estrogen-containing hormone replacement therapy and tamoxifen treatment, which - according to current knowledge - are contraindicated. Recently, hormonal therapy has been introduced for the prevention of recurrences. Aromatase inhibitors are becoming the treatment of choice, since progestins are poorly tolerated due to side effects. The effective duration of preventive hormonal therapy is still undetermined.

SUMMARY

Hormonal therapy with progestins, aromatase inhibitors and gonadotropin-releasing hormone analogues has become an effective treatment alternative to radiation and chemotherapy for low-grade endometrial stromal sarcoma patients. Preventive hormonal therapy is of particular interest in the setting of concomitant endometriosis.

Endometrial stromal tumours of the uterus: a practical approach using conventional morphology and ancillary techniques

Endometrial stromal tumours (ESTs) are diagnosed in most instances by light microscopy. Often, the greatest challenge is to distinguish between the different subtypes of these tumours. Furthermore, a handful of new or relatively new entities have been described in the literature, which may cause problems in the differential diagnosis; highly cellular leiomyoma is the most common. In addition, new antibodies have been developed to help in the distinction of ESTs from their mimics, as there are prognostic and therapeutic implications. A practical approach is provided for the diagnosis of ESTs on the basis of systematic assessment of histological and immunohistochemical parameters, and recent developments related to these tumours are highlighted.

Harm or benefit of hormonal treatment in metastatic low-grade endometrial stromal sarcoma: single center experience with 10 cases and review of the literature

Endometrial stromal sarcoma (ESS) is a rare disease with probably less than 700 new cases in the US or EU per year. ESS usually expresses steroidal receptors and is regarded to be hormone-sensitive. A higher risk in women receiving estrogen replacement therapy (ERT) or tamoxifen has been suspected, and remissions following treatment with progestins have been reported in case studies. Aromatase inhibitors represent an interesting new treatment option. Due to the rarity of the tumor, only few case series and no prospective studies are published. We therefore conducted a retrospective study to evaluate the influence of hormonal treatment to ESS.

METHODS

Our institutional sarcoma data bank was screened for cases of ESS since 1999. All corresponding files and radiographs were reviewed retrospectively.

RESULTS

Ten patients with low-grade ESS were identified. Diagnosis was established before or by hysterectomy in 6 patients, by local recurrence after previous hysterectomy for nonmalignant disease in 3 patients or by pulmonary metastases with no primary tumor found so far in 1 patient. 5/10 patients were on ERT and 3/10 on tamoxifen at the time of diagnosis of metastatic disease. Treatment strategies consisted of stopping ERT and tamoxifen, respectively, or initiation of the progestin MPA or letrozole. Three patients achieved stable disease after stopping ERT. 2/3 patients responded to MPA as first-line treatment (1 CR; 50+ months, 1 PR; 9 months). 4/5 patients responded to letrozole as first-line therapy (3 PR;3+, 9+ and 10+ months) or second-line treatment after MPA (1 PR; 37+ months). 9/10 patients are alive 33 to 255 months after hysterectomy. Survival since diagnosis of metastatic disease is 4 to 164 months.

CONCLUSIONS

Patients with a previous history of low-grade ESS should not be treated with estrogens or tamoxifen. If nevertheless present, withdrawal of ERT or tamoxifen is strongly advised, resulting in disease stabilization in some cases. MPA and letrozole, in particular, are highly effective and lead to sustained disease control in most cases.

Recurrent endometrial stromal tumors with smooth-muscle differentiation and a protracted clinical course

BACKGROUND

A 24-year-old white female gravida 1, para 0010, presented with heavy vaginal bleeding and abdominal cramps of 2 weeks' duration. Medical history was remarkable for spontaneous abortion 5 years previously. She had no significant family history or other gynecological problems. Physical examination revealed tissue fragments and blood clots oozing from the cervical os, and her uterus was diffusely enlarged.

INVESTIGATIONS

Physical examination, ultrasound, uterine dilation and curettage, immunohistochemistry and human androgen receptor gene clonality analysis, uterine sonohistogram, MRI and exploratory laparotomy.

DIAGNOSIS

Intrauterine dissemination of endometrial stromal tumors with smooth-muscle differentiation.

MANAGEMENT

Partial wedge resection of the anterior uterine wall via abdominal myomectomy and total abdominal hysterectomy.