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Bendimya M, Al Jarroudi O, Brahmi SA, Afqir S. A Case Report of Uterine Müllerian Adenosarcoma With Sarcomatous Overgrowth. Cureus 2024; 16:e51806. [PMID: 38322085 PMCID: PMC10846754 DOI: 10.7759/cureus.51806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2024] [Indexed: 02/08/2024] Open
Abstract
Uterine adenosarcoma remains a highly aggressive tumor and is less described in the literature, with an unfavorable prognosis and an increased risk of local and distant recurrence. However, surgery, chemotherapy, and radiotherapy offer local control of the disease, and overall survival remains reduced. We report the case of a 79-year-old patient with stage IIIB uterine adenosarcoma, confirmed by immunohistochemistry and initially diagnosed with postmenopausal metrorrhagia. The patient was managed through a multimodal treatment by conducting a multidisciplinary consultation.
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Affiliation(s)
- Mohammed Bendimya
- Medical Oncology, Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, MAR
- Medical Oncology, Mohammed VI University Hospital Center, Oujda, MAR
| | | | - Sami Aziz Brahmi
- Medical Oncology, Mohammed VI University Hospital Center, Oujda, MAR
| | - Said Afqir
- Medical Oncology, Mohammed VI University Hospital Center, Oujda, MAR
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Li JY, Mutlu L, Tymon-Rosario J, Khadraoui W, Nagarkatti N, Hui P, Buza N, Lu L, Schwartz P, Menderes G. Clinicopathologic characteristics and oncologic outcomes in adenosarcoma of gynecologic sites. Gynecol Oncol Rep 2022; 39:100913. [PMID: 35005157 PMCID: PMC8715286 DOI: 10.1016/j.gore.2021.100913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 12/11/2021] [Accepted: 12/14/2021] [Indexed: 11/25/2022] Open
Abstract
Objective To examine clinicopathologic characteristics and oncologic outcomes of patients diagnosed with Mullerian adenosarcoma and to evaluate ovarian preservation as a practical management option in early-stage disease. Methods A retrospective review was performed of 31 patients treated for uterine, ovarian, or cervical adenosarcoma at our institution between 1/2000-3/2020. Recurrence-free survival (RFS) and overall survival (OS) were analyzed with Kaplan-Meier estimates, the log-rank test, and Cox proportional hazards regression. Results Median age was 51 years (IQR: 41-68). Primary sites included uterine corpus (n = 23, 74.2%), uterine cervix (n = 7, 22.6%), and ovary (n = 1, 3.2%). Surgical management primarily consisted of total hysterectomy +/- bilateral adnexectomy +/- lymph node dissection. Fifteen (48.1%) patients underwent lymph node dissection; no patients had positive nodes. Ovaries were preserved in 6 (19.4%). Twenty-two (71.0%) patients received no adjuvant therapy, 4 (12.9%) received chemotherapy, 1 (3.2%) received chemoradiation, and 3 (9.7%) received hormonal therapy. Sarcomatous overgrowth (p = 0.04), high grade histology (p = 0.002), and greater depth of myometrial invasion (p = 0.001) were associated with decreased RFS. None of the 6 patients with ovarian preservation had recurrences. At last follow up, 21 patients (67.7%) had no evidence of disease, 7 (22.6%) were deceased due to disease, and 3 (9.7%) were deceased due to non-cancerous reasons. Conclusions Uterine adenosarcoma appears to have a relatively good prognosis, especially in the absence of risk factors, such as sarcomatous overgrowth, high grade histology, and deep myometrial invasion. Ovarian preservation may be a feasible management option with non-inferior outcomes for premenopausal women with early-stage disease. Future studies including larger patient cohorts are needed for this rare disease.
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Affiliation(s)
- Jessie Y Li
- Yale University School of Medicine, New Haven, CT, USA
| | - Levent Mutlu
- Yale University School of Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, New Haven, CT, USA
| | - Joan Tymon-Rosario
- Yale University School of Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, New Haven, CT, USA
| | - Wafa Khadraoui
- Bridgeport Hospital, Department of Obstetrics and Gynecology, Bridgeport, CT, USA
| | - Nupur Nagarkatti
- Yale University School of Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, New Haven, CT, USA
| | - Pei Hui
- Yale University School of Medicine, Department of Pathology, New Haven, CT, USA
| | - Natalia Buza
- Yale University School of Medicine, Department of Pathology, New Haven, CT, USA
| | - Lingeng Lu
- Yale School of Public Health, Department of Chronic Disease Epidemiology, New Haven, CT, USA
| | - Peter Schwartz
- Yale University School of Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, New Haven, CT, USA
| | - Gulden Menderes
- Yale University School of Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, New Haven, CT, USA
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Role of lymphadenectomy for apparent early stage uterine sarcoma; a comprehensive analysis of the National Cancer Database. Surg Oncol 2021; 38:101589. [PMID: 33957499 DOI: 10.1016/j.suronc.2021.101589] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 03/28/2021] [Accepted: 04/18/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Investigate the role of lymphadenectomy for patients with apparent stage I uterine sarcoma. METHODS The National Cancer Database was accessed and patients without a history of another tumor diagnosed between 2004 and 2015 with an apparent early stage leiomyosarcoma, adenosarcoma, low-grade endometrial stromal and high-grade endometrial stromal/undifferentiated sarcoma who underwent hysterectomy with or without lymphadenectomy were identified. Overall survival was assessed after stratification by histology with the log-rank test while Cox models were constructed to control for confounders. RESULTS A total of 6412 patients with apparent early stage uterine sarcoma who underwent hysterectomy were identified; 2820 (44%) underwent lymphadenectomy. Rate of lymph node metastasis was 3.4% (42/1250) for patients with leiomyosarcoma, 2.3% (19/826) for those with adenosarcoma, 4.5% (21/463) for patients with low-grade endometrial stromal sarcoma and 7.9% (22/280) for those with high-grade endometrial stromal/undifferentiated sarcoma, p < 0.001. After controlling for confounders lymphadenectomy was not associated with better survival for patients with adenosarcoma (HR: 0.92, 95% CI: 0.73, 1.17), or low-grade endometrial stromal sarcoma (HR: 1.17, 95% CI: 0.73, 1.87). Patients with leiomyosarcoma who underwent lymphadenectomy had worse survival (HR: 1.15, 95% CI: 1.03, 1.28). Patients with high-grade endometrial stromal/undifferentiated sarcoma who underwent lymphadenectomy had better survival (HR: 0.66, 95% CI: 0.48, 0.89). CONCLUSIONS Incidence of lymph node metastasis in apparent early stage uterine sarcoma is rare while the performance of lymphadenectomy was not associated with a clear survival benefit for all histologic subtypes except high-grade endometrial stromal/undifferentiated sarcoma.
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Qu W, Liu Q, Jiao X, Zhang T, Wang B, Li N, Dong T, Cui B. Development and Validation of a Personalized Survival Prediction Model for Uterine Adenosarcoma: A Population-Based Deep Learning Study. Front Oncol 2021; 10:623818. [PMID: 33680946 PMCID: PMC7930479 DOI: 10.3389/fonc.2020.623818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/30/2020] [Indexed: 01/16/2023] Open
Abstract
Background The aim was to develop a personalized survival prediction deep learning model for adenosarcoma patients using the surveillance, epidemiology and end results (SEER) database. Methods A total of 797 uterine adenosarcoma patients were enrolled in this study. Duplicated and useless variables were excluded, and 15 variables were selected for further analyses, including age, grade, positive lymph nodes or not, marital status, race, tumor extension, stage, and surgery or not. We created our deep survival learning (DSL) model to manipulate the data, which was randomly split into a training set (n = 519, 65%), validation set (n = 143, 18%) and testing set (n = 143, 18%). The Cox proportional hazard (CPH) model was also included comparatively. Finally, personalized survival curves were plotted for randomly selected patients. Results The c-index for the CPH model was 0.726, and the Brier score was 0.17. For our deep survival learning model, we achieved a c-index of 0.774 and a Brier score of 0.14 in the external testing set. In addition, the limitations of the traditional staging system were revealed, and a personalized survival prediction system based on our risk scoring grouping was developed. Conclusions Our study developed a deep neural network model for adenosarcoma. The performance of this model was superior to that of the traditional Cox proportional hazard model. In addition, a personalized survival prediction system was developed based on our deep survival learning model, which provided more accurate prognostic information for adenosarcoma patients.
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Affiliation(s)
- Wenjie Qu
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qingqing Liu
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xinlin Jiao
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, China
| | - Teng Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, China
| | - Bingyu Wang
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ningfeng Li
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Taotao Dong
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, China
| | - Baoxia Cui
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, China
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[Interdisciplinary S2k guidelines on the diagnosis and treatment of uterine sarcomas-recommendations for surgical pathology]. DER PATHOLOGE 2021; 41:621-633. [PMID: 32940744 DOI: 10.1007/s00292-020-00826-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Uterine sarcomas represent a heterogeneous group of rare malignancies, derived from the myometrium, the endometrial stroma, and very rarely from the nonspecialized uterine soft tissue. The actual incidence is about 1.5 for Caucasian and 3.0 for Afro-American women. There is no grading system for leimoysarcoma defined by the WHO classification; however, if clinicians request, the FNCLCC grading can be specified in analogy to soft tissue sarcomas. Adenosarcomas must be distinguished from adenofibromas (the existence of which is questionable)-with the vast majority of these tumors being uterine adenosarcomas. Within adenosarcomas, deep myometrial invasion (>50%), sarcomatous overgrowth, and a high-grade heterologous component are associated with a higher recurrence rate and poor survival. The immunohistochemical panel represents a very helpful tool for distinguishing low-grade from high grade endometrial stromal sarcomas (ESS) and may be supplemented by molecular analyses. Steroid hormone receptor analysis should be performed for all ESS due to the possible therapeutic relevance. Undifferentiated uterine sarcomas represent a diagnosis of exclusion and have a very poor prognosis. Carcinosarcomas represent a special subtype of endometrial carcinomas and are in fact not uterine sarcomas. Uterine sarcomas may present substantial intratumoral heterogeneity and adequate embedding is mandatory. Lesions ≤2 cm in the largest dimension should be processed completely and larger tumors should be processed with one block per centimeter for the largest tumor dimension.
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Plentz TBDSF, Candido EC, Dias LF, Toledo MCS, Vale DB, Teixeira JC. Diagnosis, treatment and survival of uterine sarcoma: A retrospective cohort study of 122 cases. Mol Clin Oncol 2020; 13:81. [PMID: 33093955 DOI: 10.3892/mco.2020.2151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 08/11/2020] [Indexed: 12/24/2022] Open
Abstract
The present study aimed to assess the diagnosis, treatment and follow-up of uterine sarcoma cases. A retrospective cohort study with 122 women recruited between 2001 and 2016 was performed. The data regarding epidemiology, clinical presentation, treatment and follow-up were analyzed based on the following histological types: Carcinosarcoma, leiomyosarcoma, endometrial stromal sarcoma (ESS) and adenosarcoma. Statistical analysis included descriptive statistics, logistic regression and survival curves. The diagnosis of uterine sarcoma exhibited an increasing trend of +1.2 new cases every 2 years (P=0.044) and comprised 10% of all uterine cancer diagnoses. There were 47% carcinosarcomas, 22% leiomyosarcomas, 16% ESS and 14% adenosarcomas. The majority of the women was ≥60 years old (62%). Among the subjects, 77% were postmenopausal, 61% had a body mass index up to 29.9 kg/m2 and 71% presented with a comorbidity. Regression analysis exhibited an association between post menopause and the histological type associated with lower overall survival (OS), namely leiomyosarcoma or carcinosarcoma (odds ratio, 5.45, P<0.001). Stage I malignancy was present in 44% and Stage IV in 22%. The treatment included primary surgery in 78% of the cases, whereas 79% received adjuvant therapy. Only 55 cases achieved disease control and 20 relapsed (36%) with a 5-year OS rate of 33%. The OS was lower for carcinosarcoma and leiomyosarcoma (20%; P=0.003). In summary, the present study indicated that the number of uterine sarcoma cases had increased between 2001 and 2016. The majority of the women were >60 years old and diagnosed in advanced stages. The postmenopausal status was associated with histological types of poor prognosis. The OS was low and worse for patients with carcinosarcoma and leiomyosarcoma.
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Affiliation(s)
| | - Elaine Cristina Candido
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP), Campinas, 13083-881 São Paulo, Brazil
| | - Lais Flausino Dias
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP), Campinas, 13083-881 São Paulo, Brazil
| | | | - Diama Bhadra Vale
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP), Campinas, 13083-881 São Paulo, Brazil
| | - Julio Cesar Teixeira
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP), Campinas, 13083-881 São Paulo, Brazil
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Ban Y, Fischer JV, Maniar KP, Guo H, Zeng C, Li Y, Zhang Q, Wang X, Zhang W, Bulun SE, Wei JJ. Whole-Genome Sequencing and Target Validation Analysis of Müllerian Adenosarcoma: A Tumor With Complex but Specific Genetic Alterations. Front Oncol 2020; 10:538. [PMID: 32351899 PMCID: PMC7174971 DOI: 10.3389/fonc.2020.00538] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/25/2020] [Indexed: 12/16/2022] Open
Abstract
Mullerian adenosarcoma (MAS) is a biphasic tumor with malignant stroma. It is most commonly of endometrial origin but occasionally originates in the cervix, ovary, or other pelvic/peritoneal sites. The typical MAS is low grade with an indolent clinical course; however, tumors with sarcomatous overgrowth (SO) or a high-grade sarcoma tend to be aggressive. Tumor etiology is largely unknown. To better understand the global genome alterations and gene mutations in MAS, whole-genome sequencing (WGS) and target validation analysis were performed. MAS showed remarkable chromosome (chr) copy number variation (CNV), specifically, gains in chr 1q, 5p, 12p, 12q, and 17q and losses in chr 3p, 3q, 9p, and 11q. Gain of chr 12q13-15 was present in 50% of cases. The selected gene products in gain regions were upregulated as measured by immunohistochemistry. HMGA2 overexpression was significantly correlated with SO. While the structural variation (SV) rate was relatively low overall, a disproportionally high rate of break-ends at chr 7 was noted involving 6 in-frame rearrangement fusion genes. Among 40 frequently mutated genes detected by WGS and validated in 29 MAS by next generation sequencing (NGS), KMT2C, and BCOR were frequently seen in MAS both with and without SO, while MAGEC1 and KDM6B were strongly associated with SO. Overall, a higher rate of frequently mutated genes was found in MAS with SO (33%) than MAS without (11%). This study uncovers the complex and specific genetic alterations in this malignancy. The findings provide a tool for future investigation of these molecular changes in tumorigenesis and target therapies.
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Affiliation(s)
- Yanli Ban
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Jinan, China
| | - Jean V. Fischer
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Kruti P. Maniar
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Haiyang Guo
- Department of Biology, Princess Margaret Cancer Centre, Ontario Cancer Institute, Toronto, ON, Canada
| | - Chang Zeng
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Yinuo Li
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Qing Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Jinan, China
| | - Xinkun Wang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Wei Zhang
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Serdar E. Bulun
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jian-Jun Wei
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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Conservative management of uterine adenosarcoma: lessons learned from 20 years of follow-up. Arch Gynecol Obstet 2019; 300:1383-1389. [PMID: 31584132 PMCID: PMC6814630 DOI: 10.1007/s00404-019-05306-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/14/2019] [Indexed: 11/24/2022]
Abstract
Purpose Uterine adenosarcomas (UAs) account for 5–8% of cases of uterine sarcomas. Treatment includes total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO). Fertility preservation is an emerging concept in gynaecology oncology and is particularly relevant in UA, where cases are diagnosed as young as 15-year-old. This manuscript demonstrates a case of UA which was treated conservatively, achieved successful livebirths and underwent completion hysterectomy after two decades of follow-up. Method This was a retrospective case note review. Results An 18-year-old nulliparous woman presented with abnormal vaginal bleeding. Ultrasound identified an endometrial polyp, which was histologically diagnosed as low-grade adenosarcoma. She was advised to undergo TAH and BSO, but instead decided to preserve her fertility and opted for conservative management. She was monitored with pelvic ultrasound, hysteroscopy and endometrial biopsy bi-annually, with annual pelvic magnetic resonance imaging for 10 years which was uneventful. 11 years post-operatively she conceived following in-vitro fertilization (IVF) but suffered a miscarriage at 16 weeks likely due to cervical incompetence. She subsequently conceived with twins. She delivered spontaneously preterm at 28 weeks. Both children are alive and well. After 20 years of follow-up, she underwent a laparoscopic hysterectomy with no evidence of recurrence. She remains disease free. Conclusion Whilst radical completion surgery should be advised in UA, this case, in addition to all published conservatively managed cases of UA, demonstrates that conservative management is possible in appropriately selected women. Intensive monitoring post-operatively is essential owing to the risk of recurrence; however, this may pose deleterious side effects which require consideration.
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Abstract
OBJECTIVE This study aimed to identify the hormonal receptor status in uterine adenosarcoma (AS) and uterine AS with sarcomatous overgrowth (AS + SO), including those with high-grade histologic features (nuclear pleomorphism, atypical mitoses, necrosis), with or without heterologous elements. Estrogen receptor (ER) status, including estrogen receptor α (ERα), estrogen receptor β (ERβ), and G protein-coupled estrogen receptor (GPER), and progesterone receptor (PgR) status were examined. METHODS From August 2001 to November 2013, 11 patients with histologic diagnosis of uterine AS were identified. Tumor tissue sections were stained for ERα, ERβ, GPER, and PgR and examined both for percentage of overall cells stained and for intensity of staining. Descriptive statistics were calculated using clinicopathologic data abstracted from the medical record. RESULTS Eight cases of AS and 3 cases of AS with high-grade features were identified. Seven of 8 tumor samples of AS showed strong or moderate intensity immunostaining for ERα; all AS + SO tumor samples showed minimal to no immunoreactivity for ERα. There was a significant decrease in ERα H scores in high-grade tumors when compared with AS (P = 0.01). Lower PgR H scores were observed in high-grade tumors compared with those in AS (P = 0.04). Estrogen receptor β immunostaining was variable, and GPER immunostaining was absent in the majority of tumor samples. CONCLUSIONS Higher expression of ERα and PgR was observed in AS when compared with those with AS + SO and high-grade features. Both tumor subtypes showed similar levels of ERβ and GPER expression, although significant differences in ERβ and GPER expression were not detected. In contrast to our previous findings in uterine carcinosarcoma, ERs ERβ and GPER do not seem to play a significant role in AS in this study.
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Abstract
INTRODUCTION Uterine adenosarcoma is a rare tumor with both epithelial and stromal components. Standard treatment is total abdominal hysterectomy and bilateral salpingo-oophorectomy. There is no defined role for adjuvant or neoadjuvant chemotherapy or radiation. There is a misconception that this is an indolent, low-grade sarcoma. In fact, at least 50% of patients will develop disease recurrence. Establishing prognostic factors is of paramount importance. Areas covered: This article reviews the current literature regarding adenosarcoma prognostic factors from case reports, case series, and retrospective series. An extensive review of the literature was undertaken via PubMed and Medline searches, relevant articles are included in this review. Expert commentary: The most important prognostic factors of uterine adenosarcoma are age, presence of sarcomatous overgrowth, presence of myometrial invasion, presence of lymphovascular invasion, and lymph node involvement. These factors can be used to accurately prognosticate for uterine adenosarcoma patients. Patients at low risk of disease recurrence can be identified. These patients require observation alone. Patients at high risk of disease recurrence can be identified and are candidates for aggressive therapy with adjuvant chemotherapy to reduce the risk of disease recurrence.
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Affiliation(s)
- Michael J Nathenson
- a Center for bone and soft tissue sarcomas , Dana-Farber Cancer Institute , Boston , MA , USA
| | - Anthony P Conley
- b Department of Sarcoma Medical Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
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The Importance of Lymphovascular Invasion in Uterine Adenosarcomas: Analysis of Clinical, Prognostic, and Treatment Outcomes. Int J Gynecol Cancer 2018; 28:1297-1310. [DOI: 10.1097/igc.0000000000001306] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ObjectiveThis retrospective study examined the clinicopathologic features of adenosarcoma patients to determine potential prognostic factors and retrospectively evaluated overall survival (OS), disease-free survival (DFS), and local recurrence-free survival (LRFS) after primary treatment of adenosarcoma including surgery, radiation, and chemotherapy.MethodsOne hundred sixty-five patients with adenosarcoma were identified from the MD Anderson Cancer Center tumor registry between 1982 and 2014. Clinical data were collected retrospectively. Pathologic characteristics were examined by sarcoma pathologists. We used the Kaplan-Meier method to estimate OS, DFS, and LRFS. The log-rank test was performed to test the difference in survival between groups. Multivariate regression analyses of survival data were conducted using the Cox proportional hazards model.ResultsMedian OS and DFS for all patients were 8.5 and 4.7 years, respectively. Pathologic characteristics that influence OS and DFS were sarcomatous overgrowth (SO), myometrial invasion (MI), lymphovascular invasion (LVI), tumor size, number of mitosis, estrogen receptor, progesterone receptor, International Federation of Gynecology and Obstetrics (FIGO) stage, age, and resection status. Median OS for adenosarcoma patients with SO was 5.2 versus 14.5 years for patients without SO (P < 0.0001). Median OS for adenosarcoma patients with MI was 5.8 years versus not reached for patients without MI (P = 0.0005). Median OS for adenosarcoma patients with LVI was 1.0 versus 8.9 years for patients without LVI (P = 0.0021). On Cox analysis for OS and DFS and LRFS, only SO, MI, LVI, age, resection status, and FIGO stage remained significant. There was no difference in OS or LRFS for adjuvant radiation versus no adjuvant radiation (P = 0.17, P = 0.076).ConclusionsThis study highlights the importance of LVI as a prognostic factor and confirms the prognostic significance of SO, MI, age, resection status, and FIGO stage for adenosarcoma. Furthermore, this study suggests that there is no additional benefit to adjuvant radiation. The standard-of-care treatment for adenosarcoma should remain total abdominal hysterectomy bilateral salpingo-oophorectomy +/− lymphadenectomy and no adjuvant radiation.
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Treatment of Recurrent or Metastatic Uterine Adenosarcoma. Sarcoma 2017; 2017:4680273. [PMID: 29445312 PMCID: PMC5763139 DOI: 10.1155/2017/4680273] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 11/07/2017] [Indexed: 11/17/2022] Open
Abstract
Purpose This study retrospectively evaluated overall survival (OS) by treatment of recurrent or metastatic uterine adenosarcoma including surgery, radiation, chemotherapy, and hormonal therapy and evaluated OS and progression-free survival (PFS) after 1st line systemic chemotherapy. Methods 78 patients with recurrent or metastatic adenosarcoma comprised the study population. The Kaplan-Meier method was used to estimate OS and PFS. The log-rank test was performed to test the difference in survival between groups. Results Median OS from diagnosis of recurrent or metastatic disease was 1.8 yrs. OS was influenced by pathology on recurrence, p=0.035. Median OS differed by surgery for 1st recurrence 26.3 months versus 15.1 months. OS was not influenced by chemotherapy, p=0.58, palliative radiation, p=0.58, or hormonal therapy, p=0.15. The response rate (CR + PR) per RECIST 1.1 for chemotherapy was 31.2% for doxorubicin-based regimens and 14.3% for gemcitabine/docetaxel. OS since 1st line chemotherapy was not significantly different among chemotherapy regimens. However, the median PFS was superior for doxorubicin/ifosfamide (15.4 months) compared to gemcitabine/docetaxel (5.0 months), platinum-based regimens (5.7 mo), or other doxorubicin-based regimens (6.5 months). Conclusion These results suggest that surgery is an important treatment modality for recurrent or metastatic uterine adenosarcoma, and the most effective chemotherapeutics are doxorubicin/ifosfamide and gemcitabine/docetaxel.
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Abstract
Adenosarcomas are rare malignancies of the female genital tract, accounting for approximately 5 % of uterine sarcomas. Occasionally, adenosarcoma occurs in the ovaries or in extra-uterine tissue, which may be related to endometriosis. These tumors are characterized by benign epithelial elements and a malignant mesenchymal component. Pathologic diagnosis is dependent on the identification of the characteristic morphologic features. The most common immunohistochemical markers for adenosarcoma are CD10 and WT1, but these are not specific. The most frequent presenting symptom is abnormal uterine bleeding. The majority of patients present with stage I disease, with a 5-year overall survival of 60 to 80 %. Survival is influenced by the presence of myometrial invasion, sarcomatous overgrowth, lymphovascular invasion, necrosis, and the presence of heterologous elements including rhabdomyoblastic differentiation. Patients with sarcomatous overgrowth have significantly increased risk of recurrence 23 versus 77 % and decreased 5-year overall survival 50 to 60 %. Standard of care treatment is total hysterectomy with bilateral salpingo-oophorectomy without lymphadenectomy, as the incidence of lymph node metastasis is rare. Retrospective data does not support the use of adjuvant pelvic radiotherapy in uterine adenosarcomas as no survival benefit is seen. Insufficient data exists to recommend routinely neoadjuvant or adjuvant chemotherapy for uterine adenosarcomas. Limited evidence exists for the role of hormonal therapy in uterine adenosarcomas. The PIK3/AKT/PTEN pathway is mutated in ∼70 % of adenosarcomas, and this may represent a possible therapeutic target. This article reviews the current state of knowledge concerning uterine adenosarcoma and discusses the management of this rare tumor.
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Affiliation(s)
- Michael J Nathenson
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA.
| | - Vinod Ravi
- Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 450, Houston, TX, 77030, USA
| | - Nicole Fleming
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 450, Houston, TX, 77030, USA
| | - Wei-Lien Wang
- Department of Pathology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 450, Houston, TX, 77030, USA
| | - Anthony Conley
- Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 450, Houston, TX, 77030, USA
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Lee YJ, Kim DY, Suh DS, Kim JH, Kim YM, Kim YT, Nam JH. Feasibility of uterine preservation in the management of early-stage uterine adenosarcomas: a single institute experience. World J Surg Oncol 2017; 15:87. [PMID: 28424089 PMCID: PMC5395796 DOI: 10.1186/s12957-017-1137-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 03/22/2017] [Indexed: 12/01/2022] Open
Abstract
Background We aimed to evaluate the efficacy and the safety of uterine preservation in patients with early-stage uterine adenosarcoma who want to preserve future fertility. Methods We performed a retrospective review of patients with stage I uterine adenosarcoma diagnosed and treated at a single institute from 1998 through 2014. Results Among the total of 31 patients, uterine preservation surgery was performed in 7 of the nulliparas. Of the 7 patients receiving uterine preservation surgery, 3 showed no evidence of disease (NED), 2 had persistent disease confined to the uterus, and 2 were alive with disease (AWD) after recurrence. One patient with an NED status had a vaginal delivery at term. In the uterine preservation group, 1 patient had sarcomatous overgrowth at the time of diagnosis and experienced disease recurrence. In the hysterectomy group, 3 of 24 patients had tumor recurrence. Of the five patients with tumor recurrence, four (80%) had sarcomatous overgrowth at diagnosis and it was significantly associated with recurrence by univariate analysis (OR 13.3, p = 0.027). Conclusions Uterine preservation represents a possible treatment option for young female patients who want to maintain fertility. However, a detailed explanation of the risk of recurrence is necessary, especially in patients with sarcomatous overgrowth, which seems to be associated with a higher risk of recurrence. Trial registration Retrospectively registered.
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Affiliation(s)
- Young-Jae Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, South Korea
| | - Dae-Yeon Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, South Korea.
| | - Dae-Shik Suh
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, South Korea
| | - Jong-Hyeok Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, South Korea
| | - Yong-Man Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, South Korea
| | - Young-Tak Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, South Korea
| | - Joo-Hyun Nam
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, South Korea
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15
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Machida H, Nathenson MJ, Takiuchi T, Adams CL, Garcia-Sayre J, Matsuo K. Significance of lymph node metastasis on survival of women with uterine adenosarcoma. Gynecol Oncol 2017; 144:524-530. [PMID: 28109626 DOI: 10.1016/j.ygyno.2017.01.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 01/04/2017] [Accepted: 01/10/2017] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Uterine adenosarcoma (UAS) is a rare gynecologic malignancy and the significance of lymph node metastasis on survival has not been well studied. METHODS A retrospective study was performed utilizing the Surveillance, Epidemiology, End Results Program to examine UAS (n=994), endometrial stromal sarcoma (ESS, n=2910), and uterine leiomyosarcoma (LMS, n=5506) diagnosed between 1973 and 2013. The impact of lymph node metastasis on cause-specific survival (CSS) was cross-compared by multivariable analysis. Systematic literature review was conducted to examine the impact of nodal metastasis on progression-free survival (PFS) in UAS. RESULTS UAS had the lowest incidence of lymph node metastasis among the sarcoma subtypes examined (UAS 2.9%, LMS 3.4%, and ESS 6.6%, P<0.001). Lymph node metastasis was independently associated with decreased CSS in all three tumor types (all, P<0.01); however, magnitudes of statistical significance of lymph node metastasis for CSS were similar across the three tumor types: adjusted-hazard ratio (aHR) for UAS 2.34, ESS 2.43, and LMS 2.10. Systematic literature review identified 230 unique cases of surgically treated UAS. On multivariable analysis, lymph node metastasis (aHR 4.72) had the greatest degree of significance for PFS compared to other tumor factors including sarcomatous overgrowth (aHR 2.88), heterologous elements (aHR 2.08), and deep myometrial invasion (aHR 1.51). Large tumor, deep myometrial invasion, and sarcomatous overgrowth were associated with increased risk of lymph node metastasis (all, P<0.05). CONCLUSION While uterine adenosarcoma had a low incidence of lymph node metastasis, the impact of lymph node metastasis on survival was comparable to ESS or LMS.
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Affiliation(s)
- Hiroko Machida
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA 90089, USA
| | - Michael J Nathenson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA
| | - Tsuyoshi Takiuchi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA 90089, USA
| | - Crystal L Adams
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA 90089, USA
| | - Jocelyn Garcia-Sayre
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA 90089, USA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA 90089, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA 90089, USA.
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16
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Özgü E, Narin MA, Yalçın HR, Taşçı T, Güngör T, Çavuşoğlu D, Meydanlı MM, Tulunay G. Uterine adenosarcomas: A dual-institution experience. J OBSTET GYNAECOL 2016; 37:93-96. [PMID: 27923317 DOI: 10.1080/01443615.2016.1228619] [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: 10/20/2022]
Abstract
There has been limited literature about treatment and follow-up strategies of uterine adenosarcomas because of their rare nature. For this study we retrospectively investigated the medical database of the two major womens' health hospitals in Turkey. A total of 15 patients were identified from the hospital's database. Median follow-up was 86.43 months for all patients. Seven out of 15 patients had recurrences during their follow-up. Among these 7 patients, 4 of them had stage IA disease. Median Disease Free Survival (DFS) and Overall Survival (OS) were calculated as 41.47 and 57.21 months, respectively. According to our study, polypoid tumours confined to the uterus with superficial myometrial invasion can be treated without comprehensive surgical staging. We believe that, publishing all the data in an organised manner even though they are small in size, gives us an opportunity to design meta-analysis for the development of more appropriate treatment strategies.
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Affiliation(s)
- Emre Özgü
- a Department of Gynaecologic Oncology , Zekai Tahir Burak Women Health Education and Research Hospital , Ankara , Turkey
| | - Mehmet Ali Narin
- b Department of Gynaecologic Oncology , Etlik Zübeyde Hanım Women Health Education and Research Hospital , Ankara , Turkey
| | - Hakan Raşit Yalçın
- a Department of Gynaecologic Oncology , Zekai Tahir Burak Women Health Education and Research Hospital , Ankara , Turkey
| | - Tolga Taşçı
- b Department of Gynaecologic Oncology , Etlik Zübeyde Hanım Women Health Education and Research Hospital , Ankara , Turkey
| | - Tayfun Güngör
- a Department of Gynaecologic Oncology , Zekai Tahir Burak Women Health Education and Research Hospital , Ankara , Turkey.,c Depertment of Obstetrics and Gynaecology , Hitit University Faculty of Medcine , Çorum , Turkey
| | - Deniz Çavuşoğlu
- d Department of Pathology , Etlik Zübeyde Hanım Women Health Education and Research Hospital , Ankara , Turkey
| | - Mehmet Mutlu Meydanlı
- a Department of Gynaecologic Oncology , Zekai Tahir Burak Women Health Education and Research Hospital , Ankara , Turkey
| | - Gökhan Tulunay
- b Department of Gynaecologic Oncology , Etlik Zübeyde Hanım Women Health Education and Research Hospital , Ankara , Turkey
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17
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Hong SB, Kim MJ, Kwon JY, Choi SJ, Kim EY, Lim J. A Case of Solitary Brain Metastasis from Uterine Mullerian Adenosarcoma with Sarcomatous Overgrowth. Brain Tumor Res Treat 2016; 4:138-141. [PMID: 27867926 PMCID: PMC5114186 DOI: 10.14791/btrt.2016.4.2.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 08/29/2016] [Accepted: 09/12/2016] [Indexed: 11/24/2022] Open
Abstract
Uterine adenosarcoma (AS) are rare tumors and have more favorable outcomes than the aggressive uterine carcinosarcomas. Uterine adenosarcoma with sarcomatous overgrowth (ASSO) is a variant form of AS and exhibits aggressive growth of tumor and the prognosis is relatively poor compared with typical AS. Usually patterns of metastasis have been known to behave like endometrial carcinoma and spread through the lymphatics. Brain metastasis from uterine AS is extremely rare. Herein, we report a case of successfully surgically removed solitary brain metastasis without any extracranial recurrence from uterine ASSO after 4 years of primary treatment.
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Affiliation(s)
- Suk Bo Hong
- Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Min Jung Kim
- Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Ji Yeon Kwon
- Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Seok Jin Choi
- Department of Pathology, Inha University College of Medicine, Incheon, Korea
| | - Eun Young Kim
- Department of Neurosurgery, Inha University College of Medicine, Incheon, Korea
| | - Joohan Lim
- Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
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Podduturi V, Pinto KR. Mullerian adenosarcoma of the cervix with heterologous elements and sarcomatous overgrowth. Proc (Bayl Univ Med Cent) 2016; 29:65-7. [PMID: 26722175 DOI: 10.1080/08998280.2016.11929364] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Cervical adenosarcomas are exceedingly infrequent tumors that occur most often in women of reproductive age. Adenosarcomas comprise benign epithelial elements and malignant stromal elements. The malignant stromal elements can either be homologous, such as fibroblasts or smooth muscle, or heterologous, like cartilage, striated muscle, or bone. We report a case of adenosarcoma of the cervix with heterologous elements and sarcomatous overgrowth in a 38-year-old woman.
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Affiliation(s)
- Varsha Podduturi
- Department of Pathology, Baylor University Medical Center at Dallas
| | - Karen R Pinto
- Department of Pathology, Baylor University Medical Center at Dallas
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19
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Is open surgery the solution to avoid morcellation of uterine sarcomas? A systematic literature review on the effect of tumor morcellation and surgical techniques. Arch Gynecol Obstet 2015; 292:499-506. [DOI: 10.1007/s00404-015-3664-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 02/12/2015] [Indexed: 12/27/2022]
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20
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Howitt BE, Sholl LM, Dal Cin P, Jia Y, Yuan L, MacConaill L, Lindeman N, Kuo F, Garcia E, Nucci MR, Quade BJ. Targeted genomic analysis of Müllerian adenosarcoma. J Pathol 2014; 235:37-49. [PMID: 25231023 DOI: 10.1002/path.4442] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 08/04/2014] [Accepted: 09/09/2014] [Indexed: 12/30/2022]
Abstract
Müllerian adenosarcoma (MA) is a rare mixed mesenchymal tumour of the female genital tract, composed of malignant stroma and benign-appearing epithelium. Sarcomatous overgrowth (SO) is the only established histological variable associated with higher stage and shorter survival. Specific molecular or immunohistochemistry (IHC) tools for the diagnosis of MA are lacking. Our goal was to study genomic mutations and copy number variations (CNVs) in MA to understand better its pathobiology, and develop specific diagnostic and prognostic tools. DNA was extracted from 20 samples of MA from 18 subjects (12 without SO and 6 with SO), including two in which areas of both typical MA histology and SO were independently tested. Samples were analysed using a targeted next-generation sequencing assay interrogating exonic sequences of 275 cancer genes for mutations and CNVs as well as 91 introns across 30 genes for cancer-associated rearrangements. The mean number of mutations in MA with SO (mean 9.7; range 3-14) did not differ significantly from that in MA without SO (mean 9.6; range 5-16). MA with SO had significantly higher mean numbers of gene-level CNVs (24.6) compared to MA without SO (5; p = 0.0002). The most frequent amplification involved MDM2 and CDK4 (5/18; 28%), accompanied by focal CDK4 and MDM2 and diffuse HMGA2 expression using immunohistochemistry. MYBL1 amplification was seen in 4/18 (22%), predominantly in SO. Alterations in PIK3CA/AKT/PTEN pathway members were seen in 13/18 (72%). Notably, TP53 mutations were uncommon, present in only two cases with SO. Three out of 18 (17%) had mutations in ATRX, all associated with SO. No chromosomal rearrangements were identified. We have identified a number of recurrent genomic alterations in MA, including some associated with SO. Although further investigation of these findings is needed, confirmation of one or more may lead to new mechanistic insights and novel markers for this often difficult-to-diagnose tumour.
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Affiliation(s)
- Brooke E Howitt
- Women's and Perinatal Pathology Division, Department of Pathology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
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21
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Seagle BLL, Falter KJ, Lee SJ, Frimer M, Samuelson R, Shahabi S. Mullerian adenosarcoma of the cervix: Report of two large tumors with sarcomatous overgrowth or heterologous elements. GYNECOLOGIC ONCOLOGY CASE REPORTS 2014; 9:7-10. [PMID: 25426405 PMCID: PMC4241484 DOI: 10.1016/j.gynor.2014.04.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 04/29/2014] [Indexed: 11/30/2022]
Abstract
Two cases of large cervical mullerian adenosarcoma with sarcomatous overgrowth or heterologous elements and contrasting survival outcomes are reported. When the diagnosis of mullerian adenosarcoma is uncertain or suspected, review of pathology by a national expert may be considered. Rhabdomyoblastic differentiation of mullerian adenosarcoma may be a more aggressive histologic type.
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Affiliation(s)
- Brandon-Luke L Seagle
- Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Gynecologic Oncology, Western Connecticut Health Network, Danbury Hospital, 24 Hospital Avenue, Danbury, CT 06810, USA
| | - Keith J Falter
- Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Gynecologic Oncology, Western Connecticut Health Network, Danbury Hospital, 24 Hospital Avenue, Danbury, CT 06810, USA
| | - Stephen J Lee
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Marina Frimer
- Department of Obstetrics and Gynecology and Women's Health, Division of Gynecologic Oncology, Albert Einstein College of Medicine, Montefiore Medical Center, 1300 Morris Park Avenue, Belfer Educational Center, Room 501, Bronx, NY 10461, USA
| | - Robert Samuelson
- Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Gynecologic Oncology, Western Connecticut Health Network, Danbury Hospital, 24 Hospital Avenue, Danbury, CT 06810, USA
| | - Shohreh Shahabi
- Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Gynecologic Oncology, Western Connecticut Health Network, Danbury Hospital, 24 Hospital Avenue, Danbury, CT 06810, USA
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