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Lewis D, Liang A, Mason T, Ferriss JS. Current Treatment Options: Uterine Sarcoma. Curr Treat Options Oncol 2024; 25:829-853. [PMID: 38819624 DOI: 10.1007/s11864-024-01214-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2024] [Indexed: 06/01/2024]
Abstract
OPINION STATEMENT The cornerstone of treatment for uterine sarcoma, regardless of histologic type, remains en bloc surgical resection with total hysterectomy. In the case of incidental diagnosis during another procedure, such as myomectomy, where a hysterectomy was not performed initially, completion hysterectomy or cervical remnant removal is recommended. The completion of additional surgical procedures, including bilateral salpingo-oophorectomy and lymphadenectomy, remains nuanced. Bilateral salpingo-oophorectomy remains controversial in the setting of most subtypes of uterine sarcoma, except in the case of hormone-receptor positivity, such as in low grade endometrial stromal sarcoma, where it is indicated as part of definitive surgical treatment. In the absence of apparent nodal involvement, we do not recommend performing universal lymphadenectomy for patients with sarcoma. We recommend systemic therapy for patients with extra-uterine or advanced stage disease, high-grade histology, and recurrence. The most active chemotherapy regimens for advanced, high-grade disease remain doxorubicin or gemcitabine and docetaxol combination therapy. A notable exception is low grade endometrial stromal sarcoma, where we recommend anti-hormonal therapy in the front-line setting. Radiation therapy is reserved for selected cases where it can aid in palliating symptoms.
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Affiliation(s)
- Dana Lewis
- Kelly Gynecologic Oncology Division, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Angela Liang
- Kelly Gynecologic Oncology Division, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Terri Mason
- Division of Gynecologic Pathology, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - James Stuart Ferriss
- Kelly Gynecologic Oncology Division, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287, USA.
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2
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Tian W, Wang C, Chu R, Ge H, Sun X, Li M. Injectable hydrogel nanoarchitectonics with near-infrared controlled drug delivery for in situ photothermal/endocrine synergistic endometriosis therapy. Biomater Res 2023; 27:100. [PMID: 37805518 PMCID: PMC10560439 DOI: 10.1186/s40824-023-00442-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/27/2023] [Indexed: 10/09/2023] Open
Abstract
BACKGROUND Endometriosis is a common gynecological disease in women of childbearing age. Commonly used treatment methods, such as endocrine and surgical therapies, display poor therapeutic effects with a high relapse probability. Thus, novel treatments for endometriosis are required. METHODS In our study, polydopamine (PDA), letrozole (LTZ), and agarose (AG) hydrogels were combined to construct an injectable hydrogel with near-infrared controlled drug delivery named LTZ-PDA@AG hydrogel for endometriosis treatment. The release of letrozole can be accurately controlled by the near-infrared light intensity, exposure duration, polydopamine concentration, and hydrogel composition. Meanwhile, we isolated endometrial stromal cells from endometrium in patients with endometriosis, and constructed the rats' model of endometriosis to verify the biological effects of LTZ-PDA@AG hydrogel. RESULTS Owing to the sufficiently deep penetration of near-infrared light, the LTZ-PDA@AG hydrogel displayed a high temperature increase for efficient photothermal therapy. In addition, high local temperatures can further enhance the diffusion and penetration of letrozole, thereby achieving excellent therapeutic effect in vivo. Importantly, the in vivo and vitro test demonstrated the capacity of the nanocomposite hydrogel for endocrine-photothermal synergistic therapy and the biocompatibility. CONCLUSION Our work proposes a novel concept for precision endometriosis therapy by photothermal-enhanced endocrine therapy for endometriosis, which is proposed for the first time for the treatment of endometriosis and demonstrates excellent potential for further clinical translation. TRIAL REGISTRATION Not applicable. LTZ-PDA@AG hydrogels were synthesized and displayed a high temperature increase for efficient photothermal therapy under NIR. The present study shows the capacity of the nanocomposite hydrogel for endocrine-photothermal synergistic therapy and the biocompatibility.
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Affiliation(s)
- Wei Tian
- Department of Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Chenyu Wang
- Department of Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Ran Chu
- Department of Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Haiyan Ge
- School of Chemistry and Pharmaceutical Engineering, Medical Science and Technology Innovation Center, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Xiao Sun
- School of Chemistry and Pharmaceutical Engineering, Medical Science and Technology Innovation Center, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China.
| | - Mingjiang Li
- Department of Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.
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3
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Mejbel HA, Harada S, Stevens TM, Huang X, Netto GJ, Mackinnon AC, Al Diffalha S. Spindle Cell Sarcoma of the Uterus Harboring MEIS1::NCOA1 Fusion Gene and Mimicking Endometrial Stromal Sarcoma. Int J Surg Pathol 2023; 31:227-232. [PMID: 35477326 DOI: 10.1177/10668969221098081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
MEIS1::NCOA1/2 sarcomas are a newly recognized group of exceedingly rare low-grade spindle cell sarcomas that often involve the genitourinary and gynecologic tracts. Due to its deceptively low-grade morphology and the non-specific immunoprofile, these neoplasms may pose a diagnostic challenge by histologically mimicking other entities such as endometrial stromal sarcoma, smooth muscle tumor, or uterine perivascular epithelioid cell tumor (PEComa). Histologically, MEIS1::NCOA1/2 sarcomas typically show spindle cell proliferation with hyperchromatic nuclei and a generalized cytologic uniformity, arranged in short fascicles and exhibiting alternating zones of hypo- and hypercellularity. Among the previously reported cases, molecular analysis revealed the MEIS1::NCOA2 fusion as the most commonly detected fusion gene, whereas the MEIS1::NCOA1 fusion gene has been reported in only a single case that involved kidney. Herein we report the first case of uterine sarcoma harboring the MEIS1::NCOA1 fusion gene that was initially misclassified as low-grade endometrial stromal sarcoma, demonstrating its clinicopathologic features, and highlighting the essential role of molecular pathology to arrive at the accurate diagnosis that may alter disease classification and inform therapy.
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Affiliation(s)
- Haider A Mejbel
- Division of Genomics Diagnostics and Bioinformatics, Molecular Genetics Pathology, 9968The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Shuko Harada
- Division of Genomics Diagnostics and Bioinformatics, Molecular Genetics Pathology, 9968The University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Pathology, Division of Anatomic Pathology, 9968The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Todd M Stevens
- O'Neal Comprehensive Cancer Center, 189178The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Xiao Huang
- O'Neal Comprehensive Cancer Center, 189178The University of Alabama at Birmingham, Birmingham, AL, USA
| | - George J Netto
- Division of Genomics Diagnostics and Bioinformatics, Molecular Genetics Pathology, 9968The University of Alabama at Birmingham, Birmingham, AL, USA.,O'Neal Comprehensive Cancer Center, 189178The University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Pathology, Division of Anatomic Pathology, 9968The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alexander C Mackinnon
- Division of Genomics Diagnostics and Bioinformatics, Molecular Genetics Pathology, 9968The University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Pathology, Division of Anatomic Pathology, 9968The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sameer Al Diffalha
- O'Neal Comprehensive Cancer Center, 189178The University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Pathology, Division of Anatomic Pathology, 9968The University of Alabama at Birmingham, Birmingham, AL, USA
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4
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New Insights into Hormonal Therapies in Uterine Sarcomas. Cancers (Basel) 2022; 14:cancers14040921. [PMID: 35205669 PMCID: PMC8870116 DOI: 10.3390/cancers14040921] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/02/2022] [Accepted: 02/08/2022] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Uterine sarcomas are rare mesenchymal malignant cancers, and surgery represents the mainstay of treatment for early-stage disease. In metastatic setting, uterine sarcomas’ treatment includes palliative surgery, a metastases resection, chemotherapy and targeted therapy. Hormonal therapies may also represent an effective option. Frequently, ER and PR are highly expressed in uterine sarcomas patients and they represent a favourable prognostic factor associated with improved overall survival. The scope of the present review is to report the existing evidence and future perspectives on hormonal therapy in uterine sarcomas, with a special focus on aromatase inhibitors, progestins and gonadotropin-releasing hormone analogues, in order to clarify their potential role in daily clinical practice. Abstract Uterine sarcoma (US) is a rare mesenchymal malignant cancer type, accounting for 3–7% of uterine malignancies. US prognosis is still poor due to high local and distant recurrence rates. As for molecular features, US may present variable oestrogen receptor (ER) and progesterone receptor (PR) expressions, mostly depending on histotype and grading. Surgery represents the mainstay of treatment for early-stage disease, while the role of adjuvant chemotherapy or local radiotherapy is still debated and defined on the basis of histotype, tumour grading and stage. In metastatic setting, uterine sarcomas’ treatment includes palliative surgery, a metastases resection, chemotherapy, hormonal therapy and targeted therapy. As for the chemotherapy regimen used, drugs that are considered most effective are doxorubicin (combined with ifosfamide or alone), gemcitabine combined with docetaxel and, more recently, trabectedin or pazopanib. Hormonal therapies, including aromatase inhibitors (AIs), progestins and gonadotropin-releasing hormone analogues (GnRH-a) may also represent an effective option, in particular for low-grade endometrial stromal sarcoma (LGESS), due to their favourable toxicity profile and patients’ compliance, while their role is still under investigation in uterine leiomyosarcoma (uLMS), high-grade endometrial stromal sarcoma (HGESS), undifferentiated uterine sarcoma (USS) and other rarer US. The present review aims to analyse the existing evidence and future perspectives on hormonal therapies in US, in order to clarify their potential role in daily clinical practice.
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5
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Altal OF, Al Sharie AH, Halalsheh OM, Tashtush N, Shaban S, Alfaqih M, Aleshawi A. Complete remission of advanced low-grade endometrial stromal sarcoma after aromatase inhibitor therapy: a case report. J Med Case Rep 2021; 15:262. [PMID: 33947445 PMCID: PMC8097811 DOI: 10.1186/s13256-021-02838-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 03/29/2021] [Indexed: 12/20/2022] Open
Abstract
Background Low-grade endometrial stromal sarcoma is a rare neoplastic growth in the uterine cavity, representing less than 1% of uterine tumors. Such tumors usually affect premenopausal and perimenopausal women, with a mean age of 46 years. Treatment generally starts with surgical resection of the tumor, followed by chemotherapy, radiotherapy, or hormonal therapy. Case presentation In the current report, we again present a case of low-grade endometrial stromal sarcoma in a 51-year-old Mediterranean woman presenting with abdominopelvic pain. Computed tomography scan revealed a primary uterine tumor measuring 17 × 9 × 9 cm metastasizing to the lungs, bladder, and ureteral orifice, along with lymphovascular involvement. The patient underwent total abdominal hysterectomy, omentectomy, and lymph node dissection. Estrogen deprivation was accomplished by bilateral salpingo-oophorectomy. Lifelong hormonal therapy consisting of letrozole 2.5 mg per day was prescribed, which demonstrated remarkable efficacy, resulting in a partial remission of lung metastasis within 8 months after surgery. Full remission was observed after 18 months of hormonal therapy, with no recurrence. Another scan was performed after 2.5 years, revealing complete remission with no recurrence. Conclusion We again report a case of complete remission of low-grade endometrial stromal sarcoma after surgical removal of the tumor along with first-line hormonal therapy without the use of chemotherapy or radiotherapy, emphasizing the role of hormonal therapy in the treatment of such tumors.
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Affiliation(s)
- Omar F Altal
- Department of Obstetrics & Gynecology, Faculty of Medicine, Jordan University of Science and Technology, King Abdullah University Hospital, P. O. Box: 3030, Irbid, 22110, Jordan.
| | - Ahmed H Al Sharie
- Faculty of Medicine, Jordan University of Science & Technology, Irbid, 22110, Jordan
| | - Omar M Halalsheh
- Department of General Surgery and Urology, Faculty of Medicine, Jordan University of Science & Technology, Irbid, 22110, Jordan
| | - Nour Tashtush
- Intern, King Abdullah University Hospital, Jordan University of Science & Technology, Irbid, 22110, Jordan
| | - Sarat Shaban
- Intern, King Abdullah University Hospital, Jordan University of Science & Technology, Irbid, 22110, Jordan
| | - Mahmoud Alfaqih
- Department of Physiology, Faculty of Medicine, Jordan University of Science & Technology, Irbid, Jordan
| | - Abdelwahab Aleshawi
- Intern, King Abdullah University Hospital, Jordan University of Science & Technology, Irbid, 22110, Jordan
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6
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Friedlander M, Benson C, O'Connell RL, Reed N, Clamp A, Lord R, Millan D, Nottley S, Amant F, Steer C, Anand A, Mileshkin L, Beale P, Banerjee S, Bradshaw N, Kelly C, Carty K, Divers L, Alexander L, Edmondson R. Phase 2 study of anastrozole in patients with estrogen receptor/progesterone receptor positive recurrent low-grade endometrial stromal sarcomas: The PARAGON trial (ANZGOG 0903). Gynecol Oncol 2021; 161:160-165. [PMID: 33608144 DOI: 10.1016/j.ygyno.2021.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/08/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Aromatase inhibitors are standard of care for low-grade endometrial stromal sarcomas (LGESS), based on very high response rates reported in retrospective studies. We evaluated the activity of anastrozole in recurrent/metastatic LGESS patients enrolled in PARAGON, a basket trial of anastrozole in estrogen receptor (ER±)/progesterone receptor (PR+) gynecological cancers. METHOD An investigator-initiated, single-arm, prospective open-label trial of anastrozole 1 mg/day in patients with ER ± PR + ve LGESS with measurable disease, treated until progressive disease or unacceptable toxicity. Primary endpoint was clinical benefit (complete/partial response + stable disease) rate (CBR) at 3 months. Secondary endpoints include progression-free survival (PFS), quality of life and toxicity. RESULTS 15 eligible patients were enrolled. CBR at 3 months was 73% (95% CI: 48-89.1%); unchanged at 6 months. Best response was 26.7%, including complete response in one (6.7%; 95% CI 1.2-29.8%), partial response in three (20%, 95% CI 7.1-45.2%) and stable disease in seven (46.7%). Four patients ceased treatment by 3 months due to progression. Median PFS was not reached (25th percentile: 2.9 months (95% CI: 1.2-NR)). PFS was 73.3%, 73.3% and 66% at 6, 12, and 18 months, respectively. Six patients remained on treatment for an average of 44.2 months (range 34.5-63.6) up until data cut. Toxicity was as expected, with 3 patients stopping due to adverse effects. CONCLUSION The 26.7% objective response rate with anastrozole is lower than reported in retrospective series, but the CBR was high and durable. The results underscore the importance of prospective trials in rare cancers.
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Affiliation(s)
- M Friedlander
- Royal Hospital for Women/Prince of Wales Hospital and Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.
| | - C Benson
- The Royal Marsden NHS Foundation Trust, London, UK
| | - R L O'Connell
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - N Reed
- Beatson Oncology Centre, Gartnavel General Hospital, Glasgow, UK
| | - A Clamp
- The Christie NHS Foundation Trust and University of Manchester, Manchester, UK
| | - R Lord
- The Clatterbridge Cancer Centre, Liverpool and Wirral, UK
| | - D Millan
- Queen Elizabeth University Hospital, Glasgow, Scotland, UK
| | - S Nottley
- Queen Elizabeth University Hospital, Glasgow, Scotland, UK
| | - F Amant
- Division of Gynecologic Oncology, University Hospitals Gasthuisberg, Leuven, Belgium
| | - C Steer
- Border Medical Oncology, Albury-Wodonga Regional Cancer Centre, Albury, NSW, Australia
| | - A Anand
- Nottingham City Hospital, Nottingham, UK
| | - L Mileshkin
- Peter MacCallum Cancer Centre and The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - P Beale
- Chris O'Brien Lifehouse, Sydney, NSW, Australia
| | - S Banerjee
- The Royal Marsden NHS Foundation Trust, London, UK
| | - N Bradshaw
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - C Kelly
- Cancer Research UK Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, UK
| | - K Carty
- Cancer Research UK Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, UK
| | - L Divers
- Cancer Research UK Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, UK
| | - L Alexander
- Cancer Research UK Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, UK
| | - R Edmondson
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary''s Hospital, Manchester, UK; Department of Obstetrics and Gynaecology, Manchester Academic Health Science Centre, St Mary''s Hospital, Central Manchester NHS Foundation Trust; Manchester Academic Health Science Centre, Level 5, Research, Oxford Road, Manchester, UK; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary''s Hospital, Manchester, UK; Department of Obstetrics and Gynaecology, Manchester Academic Health Science Centre, St Mary''s Hospital, Central Manchester NHS Foundation Trust; Manchester Academic Health Science Centre, Level 5, Research, Oxford Road, Manchester, UK
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7
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Mercier NB, Roberts LF, Azordegan N, Altman AD. Extra-uterine endometrial stromal sarcoma of the left adnexa and distal ureter: A case report. Gynecol Oncol Rep 2021; 36:100702. [PMID: 33553557 PMCID: PMC7851353 DOI: 10.1016/j.gore.2021.100702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/02/2021] [Accepted: 01/10/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Nora-Beth Mercier
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lesley F Roberts
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nazila Azordegan
- Department of Pathology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alon D Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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8
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Fels Elliott DR, Pekmezci M, Geiersbach KB, Krings G, Rabban JT, Zaloudek C, Chen YY. Low-grade endometrial stromal sarcoma metastatic to the breast: Immunohistochemical and molecular characterization of an unusual mimic of mammary myofibroblastoma. HUMAN PATHOLOGY: CASE REPORTS 2020. [DOI: 10.1016/j.ehpc.2020.200447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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9
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Siddiqa AJ, Shrivastava NK, Ali Mohsin M, Abidi MH, Shaikh TA, El-Meligy MA. Preparation of letrozole dispersed pHEMA/AAm-g-LDPE drug release system: In-vitro release kinetics for the treatment of endometriosis. Colloids Surf B Biointerfaces 2019; 179:445-452. [DOI: 10.1016/j.colsurfb.2019.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 03/03/2019] [Accepted: 04/06/2019] [Indexed: 12/31/2022]
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10
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Park JY, Baek MH, Park Y, Kim YT, Nam JH. Investigation of hormone receptor expression and its prognostic value in endometrial stromal sarcoma. Virchows Arch 2018; 473:61-69. [DOI: 10.1007/s00428-018-2358-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 03/30/2018] [Accepted: 04/05/2018] [Indexed: 10/14/2022]
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11
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Deshmukh U, Black J, Perez-Irizarry J, Passarelli R, Levy K, Rostkowski A, Hui P, Rutherford TJ, Santin AD, Azodi M, Silasi DA, Ratner E, Litkouhi B, Schwartz PE. Adjuvant Hormonal Therapy for Low-Grade Endometrial Stromal Sarcoma. Reprod Sci 2018; 26:600-608. [DOI: 10.1177/1933719118778801] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Uma Deshmukh
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Jonathan Black
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Javier Perez-Irizarry
- Yale-New Haven Hospital-Smilow Cancer Center Tumor Registry, Yale University School of Medicine, New Haven, CT, USA
| | | | - Karen Levy
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Amanda Rostkowski
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Pei Hui
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Thomas J. Rutherford
- College of Medicine Obstetrics & Gynecology, University of South Florida, Tampa, FL, USA
| | - Alessandro D. Santin
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Masoud Azodi
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Dan-Arin Silasi
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Elena Ratner
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Babak Litkouhi
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Peter E. Schwartz
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
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12
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Nakamura K, Nakayama K, Ishikawa M, Ishikawa N, Katagiri H, Katagiri A, Ishibashi T, Sato E, Iida K, Sultana R, Kyo S. Letrozole as second-line hormonal treatment for recurrent low-grade endometrial stromal sarcoma: A case report and review of the literature. Oncol Lett 2016; 12:3856-3860. [PMID: 27895740 PMCID: PMC5104187 DOI: 10.3892/ol.2016.5186] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 08/03/2016] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Kohei Nakamura
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Izumo, Shimane 6938501, Japan
| | - Kentaro Nakayama
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Izumo, Shimane 6938501, Japan
| | - Masako Ishikawa
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Izumo, Shimane 6938501, Japan
| | - Noriyoshi Ishikawa
- Department of Organ Pathology, Shimane University School of Medicine, Izumo, Shimane 6938501, Japan
| | - Hiroshi Katagiri
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Izumo, Shimane 6938501, Japan
| | - Atsuko Katagiri
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Izumo, Shimane 6938501, Japan
| | - Tomoka Ishibashi
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Izumo, Shimane 6938501, Japan
| | - Emi Sato
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Izumo, Shimane 6938501, Japan
| | - Kohji Iida
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Izumo, Shimane 6938501, Japan
| | - Razia Sultana
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Izumo, Shimane 6938501, Japan
| | - Satoru Kyo
- Department of Obstetrics and Gynecology, Shimane University School of Medicine, Izumo, Shimane 6938501, Japan
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13
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Ray M, Singh S, Kumar S. Rare Case of Endometrial Stromal Sarcoma with Omental Metastasis in a 19-Year-Old Girl. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2016. [DOI: 10.1007/s40944-016-0054-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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14
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Low-Grade Endometrial Stromal Sarcoma with Intravenous and Intracardiac Extension: A Multidisciplinary Approach. Case Rep Obstet Gynecol 2016; 2016:3467849. [PMID: 27239357 PMCID: PMC4863127 DOI: 10.1155/2016/3467849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 04/14/2016] [Indexed: 11/30/2022] Open
Abstract
Background. A rare case of low-grade endometrial stromal sarcoma (LG-ESS) extending to inferior vena cava (IVC) and cardiac chambers. Case Report. A 40-year-old woman had IVC tumor, which was incidentally detected by abdominal ultrasonography during a routine medical checkup. CT scan revealed a tumor in IVC, right iliac and ovarian veins, which was derived from the uterus and extended into the right atrium and ventricle. The operation was performed, the heart and IVC were exposed, and cardiopulmonary bypass was initiated. A right atriotomy was performed, and the intracardiac mass was removed. Then the tumor in IVC and the right internal iliac vein were removed after longitudinal venotomies in the suprarenal and infrarenal vena cava, the right common iliac vein. Next the pelvis was explored. Tumors were found originating from the posterior wall of the uterus and continuing into both the right uterine and ovarian vein. The patient underwent total hysterectomy with bilateral salpingooophorectomy. Complete tumor resection was achieved. Histopathological analysis confirmed a diagnosis of LG-ESS. She showed no evidence of disease for 2 years and 3 months. Conclusions. Our case highlights the importance of a multidisciplinary approach in treating this rare cardiovascular pathological condition through preoperative assessment to final operation.
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Long-Term Outcome of Aromatase Inhibitor Therapy With Letrozole in Patients With Advanced Low-Grade Endometrial Stromal Sarcoma. Int J Gynecol Cancer 2015; 25:1645-51. [DOI: 10.1097/igc.0000000000000557] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BackgroundThere has been no consensus on the indications for the treatment of advanced low-grade endometrial stromal sarcoma (LGESS), and the possible effects of hormonal treatment including progestins and aromatase inhibitors have been reported. The aim of this study was to investigate the efficacy of aromatase inhibitor therapy with letrozole for patients with residual or recurrent LGESS.MethodsWe retrospectively reviewed the clinical response of patients with advanced LGESS who had been treated with letrozole. We also analyzed the adverse effects after the administration of letrozole. The expression levels of estrogen receptor and aromatase in the tumors were immunohistochemically examined.ResultsIn 5 patients who had been treated for unresectable LGESS lesions after initial or repeat surgical procedures, residual lesions in 3 patients and recurrence lesions in 2 patients were the indications for hormonal therapy with letrozole. The median duration of letrozole exposure at retrospective analysis was 53 (10–96) months. The clinical outcomes were classified as complete response in 2 patients, partial response in 1 patient, and stable disease in 2 patients. Myalgias, hot flashes, and arthralgias were not observed during the follow-up period in any patients. The median serum levels of estradiol were <5.0 (cutoff value, <0.5–11.8) pg/mL. The median age-matched bone mineral densities were 92% (79%–123%). The LGESS tissues in all 5 patients were positive for estrogen receptor and aromatase expression.ConclusionsLetrozole as well as progestins could be the first choice of treatment for patients with recurrent or residual LGESS, which is difficult to resect surgically because of its efficacy and minimal adverse effects.
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Laurelli G, Falcone F, Scaffa C, Messalli EM, Del Giudice M, Losito S, Greggi S. Fertility-sparing management of low-grade endometrial stromal sarcoma: analysis of an institutional series and review of the literature. Eur J Obstet Gynecol Reprod Biol 2015; 195:61-66. [PMID: 26476800 DOI: 10.1016/j.ejogrb.2015.09.041] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 09/20/2015] [Accepted: 09/28/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Low-grade endometrial stromal sarcoma (LG-ESS) is a rare malignancy, often occurring before menopause. There is no consensus regarding its optimal management. Total hysterectomy and bilateral salpingo-oophorectomy precludes future fertility and may thus be undesirable by women wishing to maintain their reproductive potential. However, experience of fertility-sparing management in LG-ESS is very limited. In this paper, the disease outcome is presented in six young women with LG-ESS conservatively treated by combined hysteroscopic resection and hormonal therapy. STUDY DESIGN From October 2009 to February 2013, at the Gynecologic Oncology Department of the National Cancer Institute of Naples, six women, with early-stage LG-ESS aged 18-40 years who desired childbearing and/or retaining their fertility, were enrolled into a pilot study of fertility-sparing management. Diagnosis of LG-ESS was made on specimens from hysteroscopic resection performed on a presumed benign lesion. All patients were planned to be treated with adjuvant megestrol acetate for two years. Hormonal therapy was started within 6 weeks from the hysteroscopic resection, with orally megestrol acetate at 40mg daily, increasing gradually according to patient's tolerance to the recommended total dose of 160mg daily. RESULTS All patients were submitted to hysteroscopic resection in a one-step procedure. Five patients started megestrol acetate within 6 weeks from the hysteroscopic resection (one patient did not start hormonal therapy because of early pregnancy after the hysteroscopic resection). Hormonal therapy was well tolerated; one patient stopped megestrol acetate after 12 months because of self-supporting strong desire to conceive; the other four patients regularly completed the hormonal therapy. To date, all patients show no evidence of disease. CONCLUSIONS Although fertility-sparing management is not the current standard of care for young women with early-stage LG-ESS, our preliminary data are promising. Larger series with a longer follow-up are needed to further assess safety and efficacy of combined hysteroscopic resection and hormonal therapy.
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Affiliation(s)
- Giuseppe Laurelli
- Gynecologic Oncology Surgery, Istituto Nazionale Tumori "Fondazione G. Pascale" IRCCS, Naples, Italy
| | - Francesca Falcone
- Department of Woman, Child, and General and Specialized Surgery, Seconda Università degli Studi di Napoli, Naples, Italy
| | - Cono Scaffa
- Gynecologic Oncology Surgery, Istituto Nazionale Tumori "Fondazione G. Pascale" IRCCS, Naples, Italy
| | - Enrico M Messalli
- Department of Woman, Child, and General and Specialized Surgery, Seconda Università degli Studi di Napoli, Naples, Italy
| | - Maurizio Del Giudice
- Anesthesiology and Intensive Care, Istituto Nazionale Tumori "Fondazione G. Pascale" IRCCS, Naples, Italy
| | - Simona Losito
- Surgical Pathology, Istituto Nazionale Tumori "Fondazione G. Pascale" IRCCS, Naples, Italy
| | - Stefano Greggi
- Gynecologic Oncology Surgery, Istituto Nazionale Tumori "Fondazione G. Pascale" IRCCS, Naples, Italy.
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Ryu H, Choi YS, Song IC, Yun HJ, Jo DY, Kim S, Lee HJ. 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. Oncol Lett 2015; 10:3310-3314. [PMID: 26722331 DOI: 10.3892/ol.2015.3674] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Accepted: 08/17/2015] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Hyewon Ryu
- Division of Hematology-Oncology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon 301-721, Republic of Korea
| | - Yoon-Seok Choi
- Division of Hematology-Oncology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon 301-721, Republic of Korea
| | - Ik-Chan Song
- Division of Hematology-Oncology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon 301-721, Republic of Korea
| | - Hwan-Jung Yun
- Division of Hematology-Oncology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon 301-721, Republic of Korea
| | - Deog-Yeon Jo
- Division of Hematology-Oncology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon 301-721, Republic of Korea
| | - Samyong Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon 301-721, Republic of Korea
| | - Hyo Jin Lee
- Division of Hematology-Oncology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon 301-721, Republic of Korea
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Thanopoulou E, Aleksic A, Thway K, Khabra K, Judson I. Hormonal treatments in metastatic endometrial stromal sarcomas: the 10-year experience of the sarcoma unit of Royal Marsden Hospital. Clin Sarcoma Res 2015; 5:8. [PMID: 25810898 PMCID: PMC4373094 DOI: 10.1186/s13569-015-0024-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 02/23/2015] [Indexed: 11/27/2022] Open
Abstract
Background Hormonal manipulation is sometimes recommended in the treatment of metastatic endometrial stromal sarcoma, but there are few data assessing the efficacy of endocrine therapies in this subtype of uterine sarcomas. Methods We performed a retrospective electronic medical record review of patients with metastatic ESS treated with a hormonal agent at Royal Marsden Hospital between 1999 and 2011. We assessed progression-free survival (PFS), objective response and toxicity profile among patients with measurable disease. Results Thirteen patients with metastatic ESS were treated with hormonal therapies. Hormone receptor status (estrogen and progesterone receptors) was assessed in 9 out of 13 patients and in all of them it was moderately to strongly positive. Aromatase inhibitors (AIs) were prescribed as first endocrine line in 11/13 patients and progestins in the remainder, while in 2nd line treatment AIs were prescribed in 7/10 patients, followed by progestins and GnRH analogues. Median PFS for 1stline was 4.0 years (95% CI: 2.4 – 5.5 years) with 5-year progression-free rate of 30.8% (95% CI: 5.7 – 55.9%), both of which reflect the indolent natural history of ESS. Best objective response was partial response (PR) in 6/13 patients (46.2%; 95% CI: 19.2 – 74.9) and clinical benefit rate (defined as complete response + PR + stable disease ≥6 months) was 92.4% (95% CI: 64.0 – 99.8%; 12/13 patients). Median PFS for 2nd line was 3.0 years (95% CI: 2.0 – 4.1 years) with 2-year progression-free rate of 88.9% (95% CI: 68.3 – 100.0). Conclusions In this cohort of metastatic ESS patients, 1st line endocrine treatment achieved objective response in 46.2% of them and clinical benefit in 92.4%. Tamoxifen and hormone replacement therapy should not be prescribed in patients with ESS due to their detrimental effects. Until more solid data are available, a reasonable recommendation would be that 1st line treatment with an endocrine treatment, preferably with an AI. Moreover, in view of the positive outcomes of our patients that received 2nd/3rdline endocrine treatments, all available hormonal options should be used in sequence in the management of ESS.
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Affiliation(s)
- Eirini Thanopoulou
- Sarcoma Unit, Royal Marsden NHS Foundation Trust, Chelsea, London SW3 6JJ UK
| | - Aleksandar Aleksic
- Sarcoma Unit, Royal Marsden NHS Foundation Trust, Chelsea, London SW3 6JJ UK
| | - Khin Thway
- Sarcoma Unit, Royal Marsden NHS Foundation Trust, Chelsea, London SW3 6JJ UK
| | - Komel Khabra
- Sarcoma Unit, Royal Marsden NHS Foundation Trust, Chelsea, London SW3 6JJ UK
| | - Ian Judson
- Sarcoma Unit, Royal Marsden NHS Foundation Trust, Chelsea, London SW3 6JJ UK
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Reversion of Hormone Treatment Resistance with the Addition of an mTOR Inhibitor in Endometrial Stromal Sarcoma. Case Rep Med 2014; 2014:612496. [PMID: 25104960 PMCID: PMC4109292 DOI: 10.1155/2014/612496] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 06/30/2014] [Indexed: 01/08/2023] Open
Abstract
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.
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Thanopoulou E, Judson I. Hormonal therapy in gynecological sarcomas. Expert Rev Anticancer Ther 2014; 12:885-94. [DOI: 10.1586/era.12.74] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Bai H, Yang J, Cao D, Huang H, Xiang Y, Wu M, Cui Q, Chen J, Lang J, Shen K. Ovary and uterus-sparing procedures for low-grade endometrial stromal sarcoma: a retrospective study of 153 cases. Gynecol Oncol 2014; 132:654-60. [PMID: 24412112 DOI: 10.1016/j.ygyno.2013.12.032] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 12/09/2013] [Accepted: 12/23/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To discuss the optimal treatment options for low grade endometrial stromal sarcoma (LG-ESS). METHODS Medical records of consecutive patients with LG-ESS in our institute were collected. The pertinent data, including clinicopathological characteristics, treatment and prognostic information were evaluated. RESULTS A total of 153 cases of LG-ESS were included. The 5-year relapse free survival (RFS), overall survival (OS) and survival after relapse (SAR) rates were 66.1%, 95.8% and 82.9%, respectively. Ovary-sparing procedures, positive resection-margins, and myomectomy were the independent adverse factors for relapse (P<0.0001, =0.0041, and =0.0075, respectively). Post-menopause, cervical involvement, and positive lymphovascular space involvement were significantly associated with survival (P<0.0001, =0.0020, and =0.0163, respectively). Distance recurrence and macroscopically residual tumors negatively affected SAR (P=0.0137 and =0.0004, respectively). No benefit was found for lymphadenectomy in terms of both RFS and OS (P=0.1187 and =0.5138, respectively). Initial ovary-sparing procedures and myomectomy had no impact on OS (P=0.0810 and =0.8845, respectively). Adjuvant treatment had a slightly beneficial effect both on OS and SAR. CONCLUSION Hysterectomy with bilateral salpingo-oophorectomy and complete resection of the macroscopic lesion should be treated as the initial and salvage mainstay treatments for LG-ESS patients. Ovary-sparing procedures could be considered for young women without cervical involvement; however, long-term follow-up should be mandatory. Myomectomy should only be conserved for young patients with a strong desire for future fertility, with fully informed consent; hysterectomy was recommended after the completion of pregnancy and delivery. However, the roles of lymphadenectomy and adjuvant treatment deserve further investigation.
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Affiliation(s)
- Huimin Bai
- Department of Obstetrics and Gynecology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, China
| | - Jiaxin Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, China
| | - Dongyan Cao
- Department of Obstetrics and Gynecology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, China
| | - Huifang Huang
- Department of Obstetrics and Gynecology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, China
| | - Yang Xiang
- Department of Obstetrics and Gynecology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, China
| | - Ming Wu
- Department of Obstetrics and Gynecology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, China
| | - Quancai Cui
- Department of Pathology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, China
| | - Jie Chen
- Department of Pathology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, China
| | - Jinghe Lang
- Department of Obstetrics and Gynecology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, China
| | - Keng Shen
- Department of Obstetrics and Gynecology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, China.
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Positron emission tomography imaging of oestrogen receptor-expression in endometrial stromal sarcoma supports oestrogen receptor-targeted therapy: Case report and review of the literature. Eur J Cancer 2013; 49:3850-5. [DOI: 10.1016/j.ejca.2013.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 08/08/2013] [Indexed: 11/18/2022]
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Sardinha R, Hernández T, Fraile S, Tresserra F, Vidal A, Gómez MC, Astudillo A, Hernández N, Saenz de Santamaría J, Ordi J, Gonçalves L, Ramos R, Balañá C, de Álava E. Endometrial stromal tumors: immunohistochemical and molecular analysis of potential targets of tyrosine kinase inhibitors. Clin Sarcoma Res 2013; 3:3. [PMID: 23497641 PMCID: PMC3599876 DOI: 10.1186/2045-3329-3-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 03/04/2013] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Ruth Sardinha
- Pathology Department, Hospital Espírito Santo E.P.E, Évora, Portugal
| | - Teresa Hernández
- Centro de Investigación del Cáncer-IBMCC USAL-CSIC, Salamanca, Spain
| | - Susana Fraile
- Centro de Investigación del Cáncer-IBMCC USAL-CSIC, Salamanca, Spain
| | - Francesc Tresserra
- Pathology Department, USP-Institut Universitari Dexeus, Barcelona, Spain
| | - August Vidal
- Pathology Department, Hospital de Bellvitge, Barcelona, Spain
| | - Maria Carmén Gómez
- Pathology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Aurora Astudillo
- Pathology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Nieves Hernández
- Anatomical Pathology Department, Hospital Universitario de la Laguna, Canarias, Spain
| | | | - Jaume Ordi
- Pathology Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Luis Gonçalves
- Pathology Department, Hospital do Espírito Santo E.P.E, Évora, Portugal
| | - Rafael Ramos
- Pathology Department, Hospital Son Espases, Palma de Mallorca, Spain
| | - Carmen Balañá
- Medical Oncology Service, Catalan Institute of Oncology - Hospital Germans Trias i Pujol, Badalona, Spain
| | - Enrique de Álava
- Centro de Investigación del Cáncer-IBMCC USAL-CSIC, Salamanca, Spain
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Abstract
Endometrial stromal tumor is a rare mesenchymal uterine tumor. We report the case of a patient with endometrial stromal sarcoma and concomitant bilateral endometrioid adenocarcinoma of the ovary in the context of pelvic endometriosis. The patient underwent a complete cytoreduction including total hysterectomy and bilateral adnexectomy, pelvic lymphadenectomy, appendicectomy, infracolic omentectomy, and pelvic peritonectomy. This is the first report to our knowledge that describes a synchronous endometrial stromal sarcoma and bilateral endometrioid adenocarcinoma of the ovary.
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Uterine Sarcoma and Aromatase Inhibitors: Tom Baker Cancer Centre Experience and Review of the Literature. Int J Gynecol Cancer 2012; 22:1006-12. [DOI: 10.1097/igc.0b013e31825b7de8] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ObjectivesUterine 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 MethodsWe 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.ResultsFour 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.ConclusionsAromatase 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.
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Hensley ML. Role of chemotherapy and biomolecular therapy in the treatment of uterine sarcomas. Best Pract Res Clin Obstet Gynaecol 2011; 25:773-82. [DOI: 10.1016/j.bpobgyn.2011.06.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 06/02/2011] [Indexed: 10/17/2022]
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Recurrent endometrial stromal sarcoma: treatment with a progestin and gonadotropin releasing hormone agonist. Sarcoma 2010; 2010:353679. [PMID: 20613993 PMCID: PMC2896615 DOI: 10.1155/2010/353679] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2009] [Revised: 03/24/2010] [Accepted: 04/08/2010] [Indexed: 11/17/2022] Open
Abstract
Endometrial stromal sarcoma (ESS) formerly classified as low-grade endometrial stromal sarcoma is a rare uterine malignancy with a good prognosis despite a tendency to recur. Primary surgical management for ESS includes total abdominal hysterectomy and bilateral salpingo-oophorectomy. Patients with ESS have long disease-free survival rates when treated with primary surgical therapy, but nearly fifty percent of these patients will recur. We present the case of a patient with recurrent ESS who had an excellent response to combined therapy with megestrol and leuprolide.
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Shoji K, Oda K, Nakagawa S, Kawana K, Yasugi T, Ikeda Y, Takazawa Y, Kozuma S, Taketani Y. Aromatase inhibitor anastrozole as a second-line hormonal treatment to a recurrent low-grade endometrial stromal sarcoma: a case report. Med Oncol 2010; 28:771-4. [PMID: 20354812 DOI: 10.1007/s12032-010-9511-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Accepted: 03/17/2010] [Indexed: 11/29/2022]
Abstract
Low-grade endometrial stromal sarcoma (ESS) is a rare neoplasm and is generally an indolent tumor with estrogen and progesterone receptors. Objective responses by hormonal treatment with progestin or aromatase inhibitor have been reported, however, long-term management of this disease could be difficult if it becomes refractory to one of these hormonal therapies. A 34-year-old woman was diagnosed with stage I low-grade ESS at the time of hysterectomy for presumed uterine fibroma. Five years later, she recurred with multiple tumors in the lower abdomen. After an optimal surgery, she was free from progression for 6 years with progestin treatment (medroxyprogesterone acetate: MPA, 200-600 mg daily). Thereafter, she recurred twice during the MPA treatment and received debulking surgery each time. MPA was discontinued at age of 53, because another recurrent tumor grew up to 13 cm in diameter. Aromatase inhibitor anastrozole was then given at a daily dose of 1 mg with partial response (the tumor size decreased to 7 cm in diameter) for a duration of 9 months. After complete resection of the recurrent tumor, she remains progression-free for 16 months. Anastrozole was effective to recurrent low-grade ESS even after being refractory to progestin therapy. Aromatase inhibitor treatment may be a useful option as a second-line hormonal treatment to low-grade ESS.
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Affiliation(s)
- Keiko Shoji
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo, 113-8655, Japan
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Malouf GG, Duclos J, Rey A, Duvillard P, Lazar V, Haie-Meder C, Balleyguier C, Morice P, Lhommé C, Pautier P. Impact of adjuvant treatment modalities on the management of patients with stages I-II endometrial stromal sarcoma. Ann Oncol 2010; 21:2102-2106. [PMID: 20305035 DOI: 10.1093/annonc/mdq064] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To explore whether adjuvant treatment options may impact on the prognosis in localized endometrial stromal sarcomas (ESSs; stages I and II). The historical options usually discussed in addition to hysterectomy and bilateral salpingoophorectomy (BSO) are active surveillance, pelvic radiotherapy, chemotherapy and hormonal therapy, alone or in combination. PATIENTS AND METHODS Among 84 consecutive patients treated for ESS at a single referral center, 54 with localized stage disease were identified. Recurrence-free survival and overall survival were estimated and patterns of recurrences described. Univariate and multivariate analyses were carried out. RESULTS With a median follow-up of 58 months, only one patient had died. None of the 23 patients who had received adjuvant therapy relapsed compared with 13 of 31 patients who had not received any adjuvant therapy. Adjuvant treatments were hormonal therapy (n = 10) and brachytherapy with/without pelvic radiotherapy (n = 13). Almost the majority of relapses were local (92%) and extra-pelvic metastasis was observed in nearly half of the patients (46%). In the multivariate analysis, the major determinants of relapse-free survival were adjuvant treatment, myometrial invasion (P = 0.005) and no BSO (P = 0.005). CONCLUSIONS In this series, adjuvant treatment of localized ESSs was associated with the absence of recurrence.
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Affiliation(s)
| | | | - A Rey
- Department of Biostatistics
| | | | - V Lazar
- Department of Platform of Genomics
| | | | | | - P Morice
- Department of Surgery, Institut Gustave-Roussy, Villejuif, France
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30
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Nakayama K, Ishikawa M, Nagai Y, Yaegashi N, Aoki Y, Miyazaki K. Prolonged long-term survival of low-grade endometrial stromal sarcoma patients with lung metastasis following treatment with medroxyprogesterone acetate. Int J Clin Oncol 2010; 15:179-83. [DOI: 10.1007/s10147-010-0040-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 10/23/2009] [Indexed: 11/25/2022]
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Treatment of Recurrent Endometrial Stromal Sarcoma with Letrozole: A Case Report and Literature Review. Discov Oncol 2010; 1:112-5. [DOI: 10.1007/s12672-010-0007-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2009] [Accepted: 01/07/2010] [Indexed: 12/23/2022] Open
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Abstract
Mesenchymal tumors of the female genital tract include various benign and malignant neoplasms. Mesenchymal tumors may arise from the stroma or associated elements of the organ of origin, such as connective tissue, vascular or neural structures, or others. Malignant mesenchymal tumors of the female genital tract represent a rare group of gynecologic cancers. They are generally aggressive tumors, with a propensity for local and distant recurrence. The mainstay of treatment usually involves surgical excision of the primary tumor. Malignant mesenchymal tumors of the female genital tract are generally refractory to systemic chemotherapy and radiation therapy. This review highlights the treatment options for the most common types of mesenchymal tumors of the female genital tract.
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Affiliation(s)
- Marcela G Del Carmen
- Division of Gynecologic Oncology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Yawkey 9E, Boston, MA 02114, USA.
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Tzakas E, Liu S, Todd RW, Redman CW. Hormonal therapy with letrozole prior to surgical management of recurrent metastatic low-grade endometrial stromal sarcoma (LGESS). J OBSTET GYNAECOL 2009; 29:778-9. [DOI: 10.3109/01443610903165552] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kim JY, Hong SY, Sung HJ, Oh HK, Koh SB. A case of multiple metastatic low-grade endometrial stromal sarcoma arising from an ovarian endometriotic lesion. J Gynecol Oncol 2009; 20:122-5. [PMID: 19590725 DOI: 10.3802/jgo.2009.20.2.122] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Revised: 01/09/2009] [Accepted: 02/13/2009] [Indexed: 11/30/2022] Open
Abstract
The development of endometrial stromal sarcomas (ESSs) in foci of endometriosis is extremely rare, and few cases have been reported in the literature to date, particularly with regard to multiple extrauterine ESS. Here we report a case of endometrial stromal sarcoma with multiple metastasis that arose from an ovarian endometriotic lesion. The literature is also briefly reviewed.
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Affiliation(s)
- Joo Yeon Kim
- Department of Obstetrics and Gynecology, School of Medicine, Catholic University of Daegu, Daegu, Korea
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Zagouri F, Dimopoulos AM, Fotiou S, Kouloulias V, Papadimitriou CA. Treatment of early uterine sarcomas: disentangling adjuvant modalities. World J Surg Oncol 2009; 7:38. [PMID: 19356236 PMCID: PMC2674046 DOI: 10.1186/1477-7819-7-38] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Accepted: 04/08/2009] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Flora Zagouri
- Department of Clinical Therapeutics, Alexandra Hospital, University of Athens, School of Medicine, Athens, Greece.
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Dahhan T, Fons G, Buist MR, Ten Kate FJW, van der Velden J. The efficacy of hormonal treatment for residual or recurrent low-grade endometrial stromal sarcoma. A retrospective study. Eur J Obstet Gynecol Reprod Biol 2009; 144:80-4. [PMID: 19269732 DOI: 10.1016/j.ejogrb.2009.02.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2008] [Revised: 12/22/2008] [Accepted: 02/02/2009] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Taghride Dahhan
- Department of Gynecologic Oncology, Academic Medical Centre, Amsterdam, The Netherlands
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Thomas MB, Keeney GL, Podratz KC, Dowdy SC. Endometrial Stromal Sarcoma: Treatment and Patterns of Recurrence. Int J Gynecol Cancer 2009; 19:253-6. [PMID: 19396004 DOI: 10.1111/igc.0b013e3181999c5f] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Our objective was to investigate recurrence patterns and conduct an outcome analysis of patients with endometrial stromal sarcoma (ESS).A retrospective review yielded 30 patients with ESS (20 low-grade, 10 high-grade) who underwent primary surgical resection from 1982 to 2005. Median follow-up was 42 months.All patients underwent hysterectomy, whereas pelvic (P) and paraaortic (PA) lymphadenectomy were performed in 12 and 7 patients, respectively. A median of 26 pelvic lymph nodes and 9 PA lymph nodes were removed. Pelvic or PA lymphatic disease was noted in 25% and 29% of patients, respectively. Extrauterine disease was identified in 11 (45%) of 24 patients undergoing exploratory laparotomy; 6 had no residual disease after cytoreductive surgery. None of these 6 patients experienced abdominal failure, but 1 had a hematological recurrence. Thrombotic complications were noted in 13% of patients. The 5-year overall survival was 65%. Overall survival was influenced by grade (79% vs 40%, P = 0.03) and extrauterine disease (77% vs 32%, P = 0.01). No patient who underwent a systematic lymphadenectomy had a lymphatic recurrence, irrespective of nodal status. There were 7 (23%) hematological recurrences; 2 in surgical stage I ESS. Two patients with low-grade ESS remain without evidence of disease 130 and 210 months after secondary cytoreduction. In contrast, no patient with high-grade ESS survived a recurrence.There is high prevalence of extrauterine and nodal disease in ESS. Patients are at high risk for thrombotic complications. If aggressively staged, the predominant failure risk for stage I patients is hematogenous, suggesting the need for improved systemic treatments.
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Affiliation(s)
- M Bijoy Thomas
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN 55905, USA
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38
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Koivisto-Korander R, Butzow R, Koivisto AM, Leminen A. Clinical outcome and prognostic factors in 100 cases of uterine sarcoma: Experience in Helsinki University Central Hospital 1990–2001. Gynecol Oncol 2008; 111:74-81. [DOI: 10.1016/j.ygyno.2008.06.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2008] [Revised: 06/02/2008] [Accepted: 06/03/2008] [Indexed: 10/21/2022]
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Low-grade endometrial stromal sarcoma with inferior vena cava tumor thrombus and intracardiac extension: radical resection may improve recurrence free survival. Surg Oncol 2008; 18:57-64. [PMID: 18708288 DOI: 10.1016/j.suronc.2008.07.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Revised: 06/15/2008] [Accepted: 07/03/2008] [Indexed: 11/23/2022]
Abstract
BACKGROUND Endometrial stromal sarcoma (ESS) represents 0.2% of all uterine malignancies. Based on the mitotic activity, a distinction is made between low and high-grade ESS. Although the overall five-year survival rate for low-grade ESS exceeds 80%, about 50% of the patients show tumor recurrence, mostly after a long latency period. Tumor invasion of the great vessels is extremely rare. We describe a patient with advanced low-grade ESS with tumor invasion of the infrarenal aorta and the inferior vena cava. The patient presented with a large tumor thrombus extending from the inferior vena cava into the right atrium. METHODS Review of literature and identification of 19 patients, including our own case report, with advanced low-grade ESS with invasion of the great vessels and formation of an inferior vena cava tumor thrombus. RESULTS All 19 patients presented with an abdominal tumor mass and a tumor thrombus protruding into the inferior vena cava. The tumor thrombus extended into the right heart cavities in nine patients reaching the right atrium in four, the right ventricle in three and the pulmonary artery in two patients. There were 5 patients with an advanced primary tumor and 14 patients with an advanced recurrent tumor. Seven patients presented with synchronous metastatic disease and six patients with a pelvic tumor infiltrating the bladder, the rectosigmoid colon or the infrarenal aorta. Mean age at surgery was 45.9+/-12.3 years (median 47, range 25-65 years). Tumor thrombectomy was accomplished by cavatomy or by right atriotomy after installation of a cardiopulmonary bypass. There was no peri-operative mortality and a very low morbidity. Radical tumor resections were achieved in 10 patients. The follow-up for these 10 patients was 2+/-1.3 years (median 2, range 0.3-4.5 years). Nine patients remained recurrence free whereas one patient suffered an asymptomatic local recurrence. CONCLUSIONS Low-grade ESS is a rare angioinvasive tumor with a high recurrence rate. Resection of an inferior vena cava tumor thrombus, even with extension into the right heart cavities, can be performed safely. Extensive radical surgery is therefore justified in the treatment of advanced tumor manifestations of a low-grade ESS potentially improving recurrence free survival.
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40
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Long-term disease-free survival after hormonal therapy of a patient with recurrent low grade endometrial stromal sarcoma: a case report. Arch Gynecol Obstet 2008; 279:57-60. [DOI: 10.1007/s00404-008-0631-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Accepted: 03/11/2008] [Indexed: 11/26/2022]
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41
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Li N, Wu LY, Zhang HT, An JS, Li XG, Ma SK. Treatment options in stage I endometrial stromal sarcoma: A retrospective analysis of 53 cases. Gynecol Oncol 2008; 108:306-11. [DOI: 10.1016/j.ygyno.2007.10.023] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2007] [Revised: 10/19/2007] [Accepted: 10/19/2007] [Indexed: 10/22/2022]
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42
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Kim WY, Lee JW, Choi CH, Kang H, Kim TJ, Kim BG, Lee JH, Bae DS. Low-grade endometrial stromal sarcoma: a single center's experience with 22 cases. Int J Gynecol Cancer 2007; 18:1084-9. [PMID: 18179547 DOI: 10.1111/j.1525-1438.2007.01159.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The aim of this retrospective study was to evaluate the clinical behavior and management outcome of low-grade endometrial stromal sarcoma (LGESS). From September 1994, to March 2007, 22 patients with histologically proven stage I LGESS were included in this study. Clinicopathologic variables, recurrence, and management outcomes were reviewed retrospectively. The median age of the 22 patients was 43 years. The most common presenting symptom was abnormal vaginal bleeding. All patients underwent a hysterectomy and had stage I disease. Six patients had adjuvant therapy after the hysterectomy. The median follow-up period was 77 months (range 12-202 months). Ten patients had disease recurrence. The median disease-free survival period was 111 months (range 6-182 months). The pelvis (eight cases) was the most common site of recurrence followed by the lung (four cases) and the liver (one case). Recurrent disease was treated with surgery (one case), surgery plus chemotherapy (five cases), chemotherapy (two cases), and surgery plus radiotherapy (two cases). Two patients died after 25 and 54 months after disease recurrence. Treatment with a bilateral salpingo-oophorectomy or adjuvant chemoradiation did not affect the disease-free interval. LGESS is usually a slow-growing neoplasm with an indolent clinical course. Surgery is the primary treatment for recurrent endometrial stromal sarcoma when feasible. Adjuvant treatment (radiotherapy, chemotherapy, or both) had no effect on the prognosis of patients with stage I disease.
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Affiliation(s)
- W Y Kim
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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43
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Sandberg A. The cytogenetics and molecular biology of endometrial stromal sarcoma. Cytogenet Genome Res 2007; 118:182-9. [DOI: 10.1159/000108299] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2007] [Accepted: 02/04/2007] [Indexed: 12/12/2022] Open
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44
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Amant F, De Knijf A, Van Calster B, Leunen K, Neven P, Berteloot P, Vergote I, Van Huffel S, Moerman P. Clinical study investigating the role of lymphadenectomy, surgical castration and adjuvant hormonal treatment in endometrial stromal sarcoma. Br J Cancer 2007; 97:1194-9. [PMID: 17895898 PMCID: PMC2360466 DOI: 10.1038/sj.bjc.6603986] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The objective of this study is to assess the therapeutic importance of surgical castration, adjuvant hormonal treatment and lymphadenectomy in endometrial stromal sarcoma (ESS). A retrospective and multicentric search was performed. Clinicopathologic data were retrieved from cases that were confirmed to be ESS after central pathology review. The protocol was approved by the Ethical Committee. ESS was confirmed histopathologically in 34 women, but follow-up data were available in only 31 women. Surgical treatment (n=31) included hysterectomy with or without bilateral salpingo-oophorectomy (BSO) in 23 out of 31 (74%) and 8 out of 31 (26%) cases, respectively. Debulking surgery was performed in 6 out of 31 cases (19%). Stage distribution was as follows: 22 stage I, 4 stage III and 5 stage IV. Women with stage I disease recurred in 4 out of 22 (18%) cases. Among stage I women undergoing hormonal treatment with or without BSO, 3 out of 15 (20%) and 1 out of 7 (14%) relapsed, respectively. Among stages III–IV women receiving adjuvant hormonal treatment or not, 1 out of 5 (20%) and 3 out of 4 (75%) relapsed, respectively (differences=55.0%, 95% CI=−6.8–81.2%). Kaplan–Meier curves show comparable recurrence rates for stage I disease without adjuvant hormonal treatment when compared to stages III–IV disease treated with surgery and adjuvant hormonal treatment. Furthermore, women taking hormones at diagnosis have a better outcome when compared to women not taking hormonal treatment. Three out of 31 (9%) patients had a systematic lymphadenectomy whereas 3 out of 31 (9%) had a lymph node sampling. In one case, obvious nodal disease was encountered at presentation. Isolated retroperitoneal recurrence occurred in 1 out of 31 (3%) of all cases and in 1 out of 8 (13%) recurrences. This single woman later also developed lung and abdominal metastases. Leaving lymph nodes in situ does not appear to alter the clinical outcome of ESS. Although numbers are low, the retrospective data suggest that the need for surgical castration (BSO) in premenopausal women with early-stage disease should be discussed with the patient on an individual basis. The data support the current practice in some centres to administer adjuvant hormonal treatment.
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Affiliation(s)
- F Amant
- Division of Gynecological Oncology, Leuven Cancer Institute (LKI), Department of Obstetrics and Gynecology, UZ Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium.
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45
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Abstract
The female genital tract is hormonally responsive, and consequently some tumors, which arise within in it, may be treated at least in part, with hormonal manipulation. The range of responses in clinical trials and case reports will be reviewed. Many of these diseases are too rare for clinical trial testing, and in some cases evidence is anecdotal at best. Recurrences of ovarian cancer have been treated with tamoxifen and megesterol acetate with variable response rates from 0 to 56%. The favorable toxicity profile of aromatase inhibitors led to trials of these agents for the treatment of relapsed epithelial ovarian cancer. These agents have proved tolerable with minor response rates but a significant disease stabilization rate, which may be prolonged in a minority of cases. It is unclear if these responses may be predicted by estrogen receptor expression or aromatase expression. Anastrazole has also been tried in combination with an EGFR receptor-inhibitor, again showing minor responses but possibly an increase in TTT in some patients. Granulosa cell tumors of the ovary are rare, hormonally sensitive tumors, with reported responses to a variety of hormonal manipulations, including aromatase inhibition. In addition, combined endocrine blockade, including aromatase inhibition, has been tried with reports of success. Endometrial cancers, particularly type I lesions, are often treated with hormonal manipulation, most commonly with progestins, but also with antiestrogens such as tamoxifen. A trial of aromatase inhibition in the treatment of recurrent endometrial cancer showed minimal responses. Endometrial stromal sarcoma, an uncommon uterine malignancy, has shown response to hormonal treatments, with multiple case reports of efficacy of aromatase inhibition. Despite the rarity of some of these tumor types, rare tumor study groups, such as within the Gynecologic Oncology Group, should make an effort to prospectively define the utility of these treatments.
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Affiliation(s)
- Carolyn Krasner
- Gillette Center for Women's Oncology, Massachusetts General Hospital, USA
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Abstract
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.
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Affiliation(s)
- Olaf Reich
- Department of Obstetrics and Gynaecology, Medical University of Graz, Graz, Austria.
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Bréchot JM, Kamboucher M, Brauner M, Destable MD, Duperron F, Morère JF. [Pulmonary metastases from endometrial stromal sarcoma may benefit from hormone therapy]. Rev Mal Respir 2007; 24:69-72. [PMID: 17268368 DOI: 10.1016/s0761-8425(07)91014-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Low grade endometrial stromal sarcoma (ESS) often expresses oestrogen (ER) and progesterone (PR) receptors, even in metastatic disease. These receptors may also be hormone dependent. CASE REPORT Two years after the institution of oestrogen replacement therapy (HRT) a woman of 56 presented with haemoptysis which led to the discovery of multiple pulmonary nodules. Twelve years previously the patient had had a hysterectomy for a low grade endometrial stromal sarcoma, ER and PR positive. Surgical resection of the nodules on the right side confirmed the diagnosis of metastatic endometrial stromal sarcoma. The metastases expressed oestrogen and progesterone receptors. Three months after the withdrawal of HRT and treatment with an aromatase inhibitor (letrozole) the contralateral metastases had disappeared and this complete response was maintained for more than 2 years of follow-up. CONCLUSION Care should be taken in the institution of HRT in a woman with a history of low grade ESS. Hormonal treatment with aromatase inhibitors may be considered in cases where ER and PR are expressed by the primary tumour and metastases, with possible benefits even in metastatic disease.
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Affiliation(s)
- J M Bréchot
- Service d'Oncologie Médicale, Hôpital Avicenne, AP-HP, Bobigny, France.
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Leath CA, Huh WK, Hyde J, Cohn DE, Resnick KE, Taylor NP, Powell MA, Mutch DG, Bradley WH, Geller MA, Argenta PA, Gold MA. A multi-institutional review of outcomes of endometrial stromal sarcoma. Gynecol Oncol 2007; 105:630-4. [PMID: 17320937 DOI: 10.1016/j.ygyno.2007.01.031] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2006] [Revised: 01/06/2007] [Accepted: 01/17/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To compare the clinical behavior and outcomes of low- and high-grade endometrial stromal sarcomas (LGESS and HGESS), respectively. METHODS Patients with endometrial stromal sarcoma from five different institutions were identified and reviewed for clinicopathologic variables, surgical management and outcomes. Statistical calculations including Chi-square, t-test and survival using the Kaplan-Meier method with the log rank test were performed. RESULTS One hundred and five patients were identified with 72 having LGESS, 31 with HGESS and 2 having unclassified tumors. The mean age was 50 years for patients with LGESS and 64 years for those with HGESS (p<0.0001). In patients with LGESS, 68% (49 patients) had disease confined to the uterine corpus or cervix compared to 39% (12 patients) in HGESS (p=0.002). The median overall survival was 53 months for HGESS and had not yet been reached in LGESS with 87.8% alive at 80 months (p<0.0001). In HGESS patients with extrauterine disease, the presence of residual disease greater than 2 cm had a significant effect on median survival. Median survival was 52 months for those who underwent optimal cytoreduction versus 2 months for those with suboptimal residual disease (p=0.007). The impact of cytoreduction was not seen in LGESS patients with extrauterine disease with 82.1% alive at 78 months. CONCLUSIONS Low-grade and high-grade endometrial stromal sarcomas represent two distinct clinical entities and should be treated as such. Survival in patients with high-grade tumors appears to be related to amount of residual disease at the completion of initial surgery and would suggest the need for aggressive cytoreduction. The role of surgical staging and optimal adjuvant therapy remains unclear.
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Affiliation(s)
- Charles A Leath
- Department of Obstetrics, Division of Gynecologic Oncology, The University of Alabama at Birmingham, Birmingham, AL, USA.
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Reich O, Singer C, Hudelist G, Regauer S. Estrogen sulfotransferase expression in endometrial stromal sarcomas: An immunohistochemical study. Pathol Res Pract 2007; 203:85-7. [PMID: 17197118 DOI: 10.1016/j.prp.2006.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2006] [Revised: 10/19/2006] [Accepted: 10/25/2006] [Indexed: 11/23/2022]
Abstract
Levels and activity of the enzyme estrogen sulfotransferase (EST) have been reported to play an important role in the regulation of in situ estrogen levels in human breast, prostate, and endometrial cancer. To better understand growth progression in endometrial stromal sarcomas (ESS), estrogen-dependent tumors, we analyzed the expression of EST in a series of 29 ESS. Archival formalin-fixed, paraffin-embedded material was analyzed immunohistochemically with a monoclonal antibody to EST using the peroxidase-antiperoxidase method. A score was calculated based on the percentage of positive tumor cells and staining intensity. EST staining was identified in 5 of 29 (18%) ESS and was scored as weakly positive, while 24 of 29 (82%) ESS were negative for EST. We demonstrate that a subset of ESS express EST, which may allow them to inactivate intratumoral estrogens. ESS without EST expression may have increased levels of biologically active estrogen, which explains the tumor progression of this entity and these patients may be at increased risk for recurrences and metastases.
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Affiliation(s)
- Olaf Reich
- Department of Obstetrics and Gynecology, University of Graz, Graz, Austria.
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50
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Baker P, Oliva E. Endometrial stromal tumours of the uterus: a practical approach using conventional morphology and ancillary techniques. J Clin Pathol 2007; 60:235-43. [PMID: 17347285 PMCID: PMC1860562 DOI: 10.1136/jcp.2005.031203] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2006] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- Patricia Baker
- Pathology Department, Health Sciences Centre, Winnipeg, Manitoba, Canada
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