Embryonal rhabdomyosarcoma (sarcoma botryoides) of the cervix presenting as a cervical polyp treated with fertility-sparing surgery and adjuvant chemotherapy

Sarcoma of the uterine cervix: experience of a single center

OBJECTIVES

To investigate the clinicopathological characteristics and prognosis of patients with primary sarcoma of the uterine cervix.

METHODS

We identified all patients with primary cervical sarcomas treated at our institution from 2002 to 2020 and analyzed the clinicopathological characteristics and prognosis.

RESULTS

34 patients were identified, 7 (20.6%) patients had leiomyosarcoma, 6 (17.6%) had carcinosarcoma, 5 (14.7%) had Ewing sarcoma, 4 (11.8%) had rhabdomyosarcoma, 4 (11.8%) had undifferentiated sarcoma, 2 (5.9%) had adenosarcoma, 2 (5.9%) had endometrial stromal sarcoma, 1 (2.9%) had dermatofibrosarcoma protuberans, 1 (2.9%) had alveolar soft tissue sarcoma and 2 (5.9%) had sarcoma not otherwise specified. The median age of the whole patients was 43.5 years (range, 13-63). The median age of patients with Ewing sarcoma or rhabdomyosarcoma was 22 years (range, 13-39) and 17 years (range, 13-36 years), respectively. The distribution by stage was: stage I in 21 (61.8%) patients, stage II in 4 (11.8%), stage III in 6 (17.6%) and stage IV in 3 (8.8%). Overall, 30 patients (88.2%) received surgical treatment. The median follow-up was 33.3 months (range 3.6-187.3 months). 11 patients died within 2 years after diagnosis, most of them were patients with carcinosarcoma or undifferentiated sarcoma (45.5%, 5/11). In the entire cohort, 2- and 5-year OS were 67.2% and 56.9%, respectively. 5-year OS was 25.0% for undifferentiated sarcoma, 50.0% for rhabdomyosarcoma, 50.0% for carcinosarcoma, 53.3% for Ewing sarcoma, 57.1% for leiomyosarcoma.

CONCLUSION

Cervical sarcomas are rare neoplasms with multiple histological subtypes and follow an aggressive course. Prognosis may be associated with tumor histology and stage.

Locally advanced cervical rhabdomyosarcoma in adults: A case report

BACKGROUND

Rhabdomyosarcoma is a soft tissue tumor of primitive mesenchymal cells origin, occurring predominantly in children and adolescents, but extremely rare in adults and the data regarding its treatment are sparse. Here, we would like to share our experience in the treatment of a locally advanced primary embryonal rhabdomyosarcoma of cervix in a 39-year-old female.

CASE SUMMARY

The patient was admitted with symptoms of intermenstrual bleeding and postcoital bleeding for six months. Physical examination revealed a friable, polyp-like mass (5 cm × 5 cm) in her cervix protruding into the vagina, while the uterus was mobile and normal-sized. Colposcopy-directed biopsy was performed, and a pathological diagnosis of embryonal rhabdomyosarcoma was made. Magnetic resonance imaging of the pelvis showed that the cervical volume was significantly increased, with a hypointense and hyperintense soft tissue mass on the right side, invading the cervical stroma; the mass was 5 cm × 5 cm with a clear boundary and confined to the cervix; there were no obvious findings indicating tumor invasion in the vaginal wall, parametrium, or pelvic wall; no enlarged lymph nodes were observed in the pelvic cavity. Based on our findings, the tumor was classified as stage IA according to the intergroup rhabdomyosarcoma studies criteria and IB3 stage according to The International Federation of Gynecology and Obstetrics 2018. The patient underwent two courses of neoadjuvant chemotherapy and a partial remission was achieved. Subsequently, she underwent laparoscopic radical hysterectomy, bilateral salpingo-oophrectomy and pelvic lymph node dissection and there were no risk factors revealed by postoperative pathological examination. Adjuvant chemotherapy was performed after surgery. The patient was disease-free until the last follow-up, 49 mo after completing the entire treatment.

CONCLUSION

Our experience suggests that neoadjuvant vincristine, dactinomycin, and cyclophosphamide chemotherapy followed by radical surgery and adjuvant chemotherapy might be reasonable therapeutic option for bulky cervical rhabdomyosarcoma in adults without fertility desire. Since large-scale studies on such rare conditions are rather impossible, further case reports and systematic reviews could help optimize the treatment of primary, bulky cervical rhabdomyosarcoma in adults.

Fertility-Sparing Management May Be Considered in Young Women with Uterine Sarcoma

Uterine sarcomas occur very rarely in young women. Hysterectomy, which is a standard treatment, may not be acceptable for those patients, especially nulliparous women. Fertility-sparing management may be an alternative. The aim of the study was to assess fertility-sparing management in patients with uterine sarcoma. Eleven patients were eligible for the study. Histopathologic types of the tumor included: adenosarcoma (n = 3), low-grade endometrial stromal sarcoma (n = 3), low-grade myofibroblastic sarcoma (n = 1), leiomyosarcoma (n = 1), leiomyosarcoma myxoides (n = 1), rhabdomyosarcoma (n = 1), high grade endometrial stromal sarcoma (n = 1). The mean age of the patients at the time of diagnosis was 27.4 years (range: 17–35) and the average follow-up 61 months (range: 12–158). Six patients received adjuvant treatment: megestrol (n = 5) and chemotherapy (n = 1). Recurrence was diagnosed in five cases. Median time to recurrence was 35 months (range: 8–90). Three patients conceived spontaneously following treatment and gave at least one live birth. In total, five full-term pregnancies were recorded and five healthy children were born. Fertility-sparing management may be considered in some patients with uterine sarcoma; however, it may not be appropriate in high-grade endometrial stromal sarcoma. Patients with adenosarcoma may have a low chance of childbearing.

Uterine cervix rhabdomyosarcoma: an uncommon entity in an adult patient

Embryonal rhabdomyosarcoma (ERMS) is a malignant neoplasm mostly affecting the genitourinary system of children and is rarely seen in adults. ERMS in uterine cervix is rare and can be misdiagnosed in adult as adenosarcoma or carcinosarcoma. The use of immunohistochemical staining is highly recommended to make sure that the correct diagnosis is reached. To the best of our knowledge, only seven cases of cervical ERMS in women above the age of 50 have been reported in English literature. Herein, we report a rare case of cervical ERMS in a 50-year-old woman that was initially misdiagnosed as an adenosarcoma.

Rhabdomyosarcoma of the cervix in teenagers - Is fertility preservation a feasible option?

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Embryonal rhabdomyosarcoma (RMS) of the cervix.

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Subtypes of embryonal RMS.

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Disease of adolescence.

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Fertility preservation.

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Lack of standard treatment.

Embryonal rhabdomyosarcoma (RMS) of the cervix is a rare entity, encountered mainly in the first two decades of life. The literature consists mainly of case reports and few small case series, and no standard treatment guidelines are available. As this is a disease of adolescence, fertility preservation in well selected cases is of paramount importance. We report 3 cases of cervical RMS, in adolescents highlighting the clinical presentation, diagnosis and management.

Fertility-sparing surgery for the management of young women with embryonal rhabdomyosarcoma of the cervix: A case series

OBJECTIVE

To report three cases of embryonal rhabdomyosarcoma (ERMS) of the cervix in young women successfully treated with fertility-sparing surgery and chemotherapy.

METHODS

Between January 2014 and December 2015, three cases of ERMS of the cervix were confirmed in young women at a single tertiary cancer center. All cases were managed by a pediatric oncologist and a gynecologic oncologist with a combination of surgery and chemotherapy. Fertility-sparing surgeries (cervical conization or robotic-assisted radical trachelectomy) were offered to patients depending on the tumor size.

RESULTS

All patients were nulliparous and aged 14, 20 and 21 years and all presented with abnormal uterine bleeding. The first patient was managed with radical trachelectomy followed by adjuvant chemotherapy. The second patient underwent primary hysteroscopic resection of the tumor followed by completion cervical conization and adjuvant chemotherapy. The third patient received neoadjuvant chemotherapy followed by loop electrosurgical excision procedure (LEEP) with positive residual margins. She then underwent completion radical trachelectomy. None of the patients experienced perioperative complications. None of the women received radiation. All patients are alive with no evidence of disease.

CONCLUSION

Fertility-sparing surgery and chemotherapy in well-selected patients with ERMS of the cervix result in low complication rates and excellent oncologic outcomes. This treatment option may be considered in young patients who wish to preserve fertility by avoiding hysterectomy. A collaborative effort between pediatric oncologists and gynecologic oncologists is imperative to facilitate innovative approaches to these rare tumors in young adults.

Botryoid Rhabdomyosarcoma of the Cervix: Case report with review of the literature

Botryoid rhabdomyosarcoma is an aggressive malignancy that arises from embryonal rhabdomyoblasts. It is commonly seen in the genital tract of female infants and young children. Due to the young age of affected patients, this malignancy poses a management challenge as the preservation of hormonal, sexual and reproductive function is essential. There is currently no consensus regarding management. However, treatment strategies for these tumours have evolved from radical exenterative surgeries to more conservative management options. We report a case of botryoid rhabdomyosarcoma in an adolescent girl presenting to Kasturba Hospital, in Manipal, India, in August 2007 with botryoid rhabdomyosarcoma of the cervix. She was treated with surgery and adjuvant chemotherapy. The patient remained healthy until eight months after the surgery. After acquiring a varicella zoster virus infection, she died due to septic shock and multiple organ failure. Awareness of such an uncommon lesion and its clinical implications is important to avoid misdiagnosis.

Embryonal rhabdomyosarcoma of the cervix presenting as a cervical polyp in a 16-year-old adolescent: a case report

INTRODUCTION

Embryonal rhabdomyosarcoma of the female genital tract is rare in the cervix. It has been mainly discussed in the context of individual case studies. It tends to occur in children and young women. Treatment ranges from radical surgery to conservative surgery, followed by chemotherapy.

CASE PRESENTATION

A 16-year-old Moroccan adolescent girl presented to our center with a protruding mass from her vaginal introitus, as a polyp of 6cm. An examination revealed a polyp within her vagina, thought to be arising from her cervix and a polypectomy was performed. Microscopic findings are consistent with an embryonal rhabdomyosarcoma (botryoide type). A computed tomography of her thorax, abdomen and pelvis were performed and residual disease was found as a mass located at her cervix, which measured approximately 4.5cm in its widest dimensions, without evidence of metastatic disease. Due to the fact that she is young, after discussions in a multidisciplinary meeting, she was subsequently treated with four cycles of multi-agent chemotherapy. Two cycles of chemotherapy and radiotherapy were administered due to the lack of response, but she presented vaginal bleeding with persistence of the same mass in computed tomography. Hence a total interadnexal hysterectomy was made. A histologic examination found residual embryonal rhabdomyosarcoma (botryoide type) located in all her cervix and she is currently under chemotherapy.

CONCLUSIONS

The presence of a cervical polyp in an adolescent is a gynecologic oddity and must necessarily be examined histologically because it might be a rhabdomyosarcoma. This is extremely important because diagnosis at an early stage of the disease is a highly favorable prognostic factor that allows "fertility-sparing surgery" for these young patients.

Embryonal rhabdomyosarcoma (botryoid type) of the uterine corpus and cervix in adult women: report of a case series and review of the literature

In its classical form, embryonal rhabdomyosarcoma (ERMS, botryoid type) is a vaginal neoplasm occurring in infants and young girls and is often not considered in the differential diagnosis of uterine corpus and cervical spindle cell tumors in adult women. Clinicopathologic and immunohistochemical features of 25 cases of ERMS in women 20 years of age or older were analyzed. Patient age ranged from 20 to 89 years (mean, 44.4 y; median, 46 y), with 8 patients aged 20 to 39 years, 14 patients aged 40 to 59 years, and 3 patients older than 60 years of age. Tumors originated in the cervix in 20 cases and in the uterine corpus in 5. They were characterized by an edematous hypocellular spindle cell proliferation, typically with cellular condensation beneath epithelial surfaces (cambium layer), in which tightly packed hypercellular foci were scattered. Neoplastic cells had hyperchromatic nuclei and minimal cytoplasm, usually with delicate cytoplasmic processes. Occasionally, elongated or globular cells with eosinophilic cytoplasm (rhabdomyoblasts) were evident, but cytoplasmic cross-striations were only rarely identified. Apoptotic bodies and mitotic figures were usually identified in the hypercellular foci. Hemorrhage was common, often making recognition of the hypercellular foci difficult. Desmin and myogenin were coexpressed in 22 of 23 (95.6%) tumors evaluated. Proliferative activity, as assessed by Ki-67 expression, was notably elevated in all tumors evaluated, typically concentrated in the hypercellular foci. Estrogen and progesterone receptors were expressed focally in only 3 of 12 (25%) and 1 of 8 (12.5%) tumors evaluated, respectively. Follow-up was available in 7 cases. Five patients were alive without evidence of disease with follow-up of 3 to 8 years, and 1 patient was alive with disease at 5 months. One patient died at 5 months with pulmonary nodules, but it was not determined whether this was due to metastatic ERMS or the patient's known ductal breast carcinoma. ERMS has a broader clinical profile than classically expected and should be considered in the differential diagnosis of a uterine corpus or cervical spindle cell tumor, regardless of patient age. Recognition can be rendered difficult by the hypocellular background, which can suggest a benign polyp or low-grade tumor, and hemorrhage, which can obscure the characteristic hypercellular foci. Identification of hypercellular foci in which mitotic activity and apoptotic bodies are found, desmin and myogenin are coexpressed, proliferative activity is notably elevated, and hormone receptor expression is usually absent is very useful for establishing the diagnosis.

18-Year-Old Woman with an Embryonal Rhabdomyosarcoma of the Uterus in Statu Nascendi

Background: We report a case of an 18-year-old woman with an embryonal rhabdomyosarcoma in statu nascendi. Case: A fist-sized embryonal rhabdomyosarcoma of the uterus filling the vaginal vault was diagnosed in an adolescent with virgo intacta suffering from therapy resistant vaginal discharge, bleeding and bulging mass for six months. Further imaging revealed one suspicious pelvine lymph node. Excision of the tumour including the intracervical stalk was performed and followed by systemic multiagent chemotherapy. PET-CT scan presented a complete response after the third cycle. Histological complete response was shown by laparoscopic dissection of regional pelvic lymph nodes and curettage. Conclusion: Uterine Rhabdomyosarcoma should be considered as differential diagnosis of therapy resistant vaginal flour and bleeding in young women. Fertility-sparing therapy is possible in selected exceptional cases.

Rhabdomyosarcoma of the cervix in adult women and younger patients

OBJECTIVES

Cervical rhabdomyosarcoma is extremely rare, and there is a paucity of literature on the subject. The purpose of this study was to describe the clinical and pathologic features of cervical rhabdomyosarcoma.

METHODS

We retrospectively reviewed all patients with cervical rhabdomyosarcoma who presented to our institution from 1980 to 2010. We reviewed pathologic, demographic, and clinical information.

RESULTS

During the study period, 11 females presented with cervical rhabdomyosarcoma. The median age at presentation was 18.4 years, and 6 patients were <19 years old at diagnosis. Vaginal bleeding was the most common presenting symptom, and a vaginal mass was often a co-presenting symptom. Eight patients (73%) presented with stage IB disease, and 8 (73%) presented with the embryonal (botryoid) histologic subtype. Nine patients (82%) received multimodal therapy consisting of surgery with chemotherapy, radiation therapy, or both. All patients were without evidence of disease after completion of primary therapy, but 3 patients experienced local recurrence. At a median follow-up of 23 months, 6 patients (55%) were without evidence of disease, 1 (9%) was alive with disease, 1 (9%) had died of disease, and 3 (27%) had died of other causes. Three patients (27%) had other primary malignancies in addition to rhabdomyosarcoma-1 had a Sertoli-Leydig tumor, 1 had a Sertoli-Leydig tumor and a pinealoblastoma, and 1 had thyroid cancer and a parotid adenocarcinoma.

CONCLUSIONS

With multimodal therapy, cervical rhabdomyosarcoma appears to be associated with a good prognosis. Favorable prognostic factors such as early stage at diagnosis and a favorable histologic subtype may contribute to the excellent observed survival.

Embryonal rhabdomyosarcoma of the uterine cervix: a report of 14 cases and a discussion of its unusual clinicopathological associations

Embryonal rhabdomyosarcoma of the uterine cervix is an uncommon presentation of the most common soft-tissue sarcoma in the first decades of life. Unlike embryonal rhabdomyosarcoma in other anatomic sites, in which 70-80% of cases present before 9 years of age, the average age in our series of 14 cervical cases was 12.4 years (median, 13 years), with an age range of 9 months to 32 years at diagnosis. Of the 14 cases, 12 presented as a polyp at the cervical os; two patients had an infiltrative mass in the cervix without a botryoid polyp. The polyps measured 1.5-5 cm and all had the histopathological pattern of the sarcoma botryoides variant of embryonal rhabdomyosarcoma, with condensations of primitive and differentiated rhabdomyoblasts beneath the surface epithelium and around endocervical glands. Nodules of benign-appearing cartilage were present in the stroma of six cases (43%). One of the embyronal rhabdomyosarcomas from the youngest patient, 9 months old, also had a distinctive microscopic focus of immature tubular profiles in a primitive stroma; these tubules expressed epithelial and neuroendocrine markers. Two patients had a pleuropulmonary blastoma, one diagnosed 9 years before the embryonal rhabdomyosarcoma of the cervix and the other recognized synchronously. This latter 9-year old had a DICER1 germline mutation. One patient presented with hirsutism and had a Sertoli-Leydig cell tumor, an incidentally detected cervical embryonal rhabdomyosarcoma, and nodular hyperplasia of the thyroid. Although a pleuropulmonary blastoma was not documented in the latter patient, ovarian sex-cord stromal tumors and nodular hyperplasia of the thyroid are manifestations of the pleuropulmonary blastoma family tumor and dysplasia syndrome (OMIM 601200). Embryonal rhabdomyosarcoma of the cervix must be distinguished from other rare entities, including adenosarcoma, malignant mixed Mullerian tumor and low-grade stromal sarcoma, as the former has a better prognosis; 12 of our 14 patients remain disease-free following conservative surgery and chemotherapy. Our study suggests that cervical embryonal rhabdomyosarcoma may be another pathological manifestation in the spectrum of extrapulmonary pathology in the setting of pleuropulmonary blastoma.

Embryonal rhabdomyosarcoma: adjuvant and ex vivo assay-directed chemotherapy

The aim of this retrospective study was to evaluate differences in treatment of embryonal rhabdomyosarcoma (RMS) of the uterus in 2 premenopausal women. We discuss adjuvant chemotherapy and use of ChemoFx Assay (Precision Therapeutics, Pittsburgh, PA) to guide choice of active chemotherapeutic agents. Two premenopausal patients were identified with a pathologic diagnosis of embryonal RMS of the uterus. Both met inclusion criteria for the study. A 21-year-old woman underwent a staging abdominal hysterectomy for a variant of embryonal RMS. Vincristine, actinomycin D, and cyclophosphamide were given adjunctively for a complete response. A 20-year-old woman underwent a diagnostic dilation and curettage revealing embryonal RMS. Initial treatment included an abdominal hysterectomy and nodal sampling. Presentation to a subsequent gynecologic oncologist 7 months later revealed recurrence. Carboplatin, doxorubicin, and paclitaxel provided a partial response. After a second surgical resection, ChemoFx Assay identified ifosfamide and mitomycin C as active agents and resulted in a complete response. Recommended treatment includes surgery and chemotherapy with possible radiation therapy if deemed necessary. The benefit of adding neoadjuvant or adjuvant chemotherapy and radiation therapy allows for a conservative surgical approach and improved survival. Choosing active chemotherapy agents can be aided by ChemoFx Assay. The chemotherapy most commonly used for treatment of embryonal RMS is a combination of vincristine, actinomycin D, and cyclophosphamide.

Pediatric radical abdominal trachelectomy for anaplastic embryonal rhabdomyosarcoma of the uterine cervix: an alternative to radical hysterectomy

Rhabdomyosarcoma arising in the female genital tract carries 5-year survival in excess of 80%, but lifelong infertility may be a consequence of local control strategies. We present the technique and outcome for a fertility-sparing, radical abdominal trachelectomy in a 12-year-old girl with anaplastic, embryonal rhabdomyosarcoma involving the uterine cervix. The patient had presented to our center after the piecemeal resection of a uterine cervical mass; because of concern about microscopic residual disease, we classified her as group II-A according to the Intergroup Rhabdomyosarcoma Study system. Staging studies excluded the presence of distant disease. The patient received 4 cycles of multiagent chemotherapy and then underwent radical abdominal trachelectomy, with removal of the uterine cervix, parametria, vaginal cuff, and regional lymph nodes. Microscopically, the specimen showed treatment effect and no residual tumor. Regional nodes were negative. Radical abdominal trachelectomy, which has not been previously reported for rhabdomyosarcoma, has appeared to secure local disease control in this case while preserving the patient's future fertility potential. In properly selected cases of rhabdomyosarcoma of the uterine cervix, where involvement of the uterus proper is not present, radical abdominal trachelectomy may be an attractive fertility-sparing alternative to radical hysterectomy.

Robotic radical hysterectomy and pelvic lymphadenectomy for uterine rhabdomyosarcoma

Mullerian rhabdomyosarcoma (RMS) is a rare malignancy most commonly diagnosed in childhood and adolescence. RMS of the female genital tract is often difficult to diagnose. Treatment includes chemotherapy with adjuvant surgery and/or radiation therapy reserved for persistent disease. We report a case of an 18-year-old African-American female who presented with severe menometrorrhagia, and was diagnosed with embryonal rhabdomyosarcoma of the uterus. After vincristine, dactinomycin, and cyclophosphamide failed to eradicate the central tumor, she underwent a robotic radical hysterectomy and pelvic lymphadenectomy. Mullerian rhabdomyosarcoma was once managed with multimodality therapy that often included ultraradical surgery including total pelvic exenteration. Surgical procedures that were exclusively performed via large abdominal incisions can now be completed with minimally invasive techniques. Robotic surgery can be safely and successfully applied to radical hysterectomy and lymphadenectomy for uterine rhabdomyosarcoma.

Clinicopathologic features of rhabdomyosarcoma of gynecologic origin in adults

Rhabdomyosarcoma (RMS) is the most common soft tissue tumor found in children. Up to 20% of RMS tumors in children originate in the genital tract making this the second most common site. RMS of gynecologic origin in adults is much less common. The purpose of this study was to describe the clinical and pathologic features of RMS of the adult female genital tract. We reviewed the histologic slides of women 16 years of age and older and included them in our study if they contained the classic histologic features of RMS as described by the 2002 World Health Organization classification of tumors. Rhabdomyoblastic components present in other established malignancies were not studied. We identified 15 patients, with a median age of 48 years (range, 16 to 69). Eleven (73%) of the tumors were of embryonal histology (cervix, 8; uterus, 2; and ovary, 1). Of the remaining 4 tumors, 2 were of alveolar (vulva) and 2 of pleomorphic (uterus, 1; fallopian tube, 1) histologic subtype. The majority (79%) of these patients presented with locoregional disease and had surgery as their primary intervention (73%). The median progression-free survival (PFS) and disease-specific survival was 9 months [95% confidence interval (CI), 1-24] and 21 months (95% CI, 14-28), respectively. The 5-year disease-specific survival was only 29%. There was a significant difference in PFS between cases of embryonal compared to cases with nonembryonal histology (19 vs. 3 mo, respectively) (P=0.04). Adult RMS of gynecologic origin presents with locoregional disease and most are morphologically similar to pediatric RMS; however, adult RMS behaves more aggressively, with worse overall survival. It is unclear whether these divergent outcomes are the result of differences in clinical management or because these tumors are biologically distinct.