Practical issues related to uterine pathology: endometrial stromal tumors

Rare Pathology Case Report: Low-Grade Endometrial Stromal Sarcoma Forming Sex Cord- and Endometrioid Gland-Like Differentiation in Metastatic Foci

Low-grade endometrial stromal sarcomas (LGESSs) are indolent tumors with a slow progression rate that tend to recur locally. They represent up to 10% of all primary sarcomas of the uterus and endometrium and only 0.2% of all genital tract tumors. They are commonly present in a younger demographic compared to other uterine tumors, with patients' ages typically between 42 and 58 years old. Although the overall 5-year survival rate is excellent, it has a natural history of delayed metastases which may manifest even decades after the disease was first diagnosed. They typically present as poorly defined lesions infiltrating the myometrium, along with extensive engagement of surrounding vascular structures. LGESS may display variants of different morphologies such as smooth muscle, fibromyxoid, sex cord-like, and endometrioid-type gland differentiation. These variations can pose a diagnostic challenge. The occurrence of this differentiation in a metastatic focus rather than in the primary tumor is seldom recorded in the literature. We present a case of a 51-year-old lady with a history of LGESS who was treated with surgery and radiotherapy and then presented after 12 years with an inferior vena cava (IVC) mass, which was confirmed histologically to be metastatic LGESS. Immunohistochemistry studies reveal strong positivity for CD10, WT1, and PR. These markers were negative in the sex cord and endometrioid gland-like differentiation counterparts. The patient had her initial follow-up appointment after the IVC mass resection, and she was in good health with no complications. To the best of our knowledge, this case represents a unique instance of metastatic LGESS exhibiting both sex cord and endometrioid gland-like differentiation that has not been observed in the primary tumor.

Immunohistochemical Expression of Lymphoid Enhancer-binding Factor 1 in Low-grade Endometrial Stromal Tumors

Endometrial stromal tumors (ESTs) are uncommon uterine mesenchymal lesions. Nuclear expression of β-catenin, an indication of activated Wnt/β-catenin signaling pathway, was described in 50% to 92% of low-grade ESTs, including endometrial stromal nodule and low-grade endometrial stromal sarcoma. Activation of the Wnt/β-catenin signaling pathway leads to the translocation of β-catenin into the nucleus and interaction with the T-cell factor/lymphoid enhancer-binding factor-1 (LEF1) family of transcription factors to regulate cell proliferation, differentiation, migration, and survival. Immunohistochemical analysis of β-catenin and LEF1 was performed in 2 endometrial stromal nodules and 20 low-grade endometrial stromal sarcomas and demonstrated 90.9% and 81.8% positive rates for β-catenin and LEF1, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of β-catenin and LEF1 were 90.9% versus 81.8%, 81.0% versus 85.7%, 83.3% versus 85.7%, 89.5% versus 81.8%, respectively, in the diagnosis of low-grade ESTs. There is no statistical significance of the performance of β-catenin and LEF1 in all ESTs ( P = 0.664) or in primary or metastatic/recurrent settings ( P = 0.515 and 0.999, respectively). Only 3 smooth muscle tumors showed focal and weak positivity for LEF1. Our results indicate LEF1 can be a useful marker in aiding a diagnosis of low-grade EST and differentiating from smooth muscle tumors alone or in combination with β-catenin.

Low-grade endometrial stromal sarcoma, a rare uterine tumor: Case report

This case report describes a 45-year-old woman presenting with abnormal uterine bleeding and a cervical mass. Imaging and biopsy revealed low-grade endometrial stromal sarcoma (LGESS), emphasizing the importance of comprehensive evaluation for uterine masses. The report underscores the role of MRI and pathology in diagnosis, with immunohistochemical analysis helping confirmation. A multidisciplinary approach and vigilant follow-up are crucial for optimal management. The rarity of LGESS and its challenging diagnosis highlight the need for continued research to improve diagnostic and therapeutic strategies. Surgical intervention remains primary, but the optimal management approach is debated. This report indicates the necessity of a comprehensive approach to uterine mass evaluation and ongoing research for enhanced patient care.

A rare case report of low-grade endometrial sarcoma: A surgical tale from Himalayas

INTRODUCTION

In the context of female genital tract malignancy, uterine sarcoma is considered the rarest form of the disease. Despite the inert nature of low-grade endometrial sarcoma, they must be meticulously diagnosed on time, with an exact grading of the severity and staging of the disease, which further guides the treatment modality and prognosis.

CASE SUMMARY

A married Asian female without any significant past medical and surgical history complained of abdominal distension and discomfort, which was progressive in nature, for which a radiological assessment was made that showed features suggestive of endometrial sarcoma. Total abdominal hysterectomy with sapingoopherectomy was done without any perioperative complications. Histology further confirmed the diagnosis. Post-operatively, the patient had an unremarkable hospital stay and was discharged home.

DISCUSSION

Endometrial stromal sarcoma is one of the rare malignant entities presenting usually in late adult females, but sometimes it can present at an earlier age as well. Abdominal masses in females, although usually overlooked as benign, can sometimes be associated with a malignant picture. Low-grade endometrial sarcomas have been seen to masquerade other minor benign cases, such as leiomyoma. Despite the rarity of such malignant conditions, diagnosis and management are rather straightforward, and post-operative patient prognosis has been found to be rewarding.

CONCLUSION

Among the uterine sarcoma cases, endometrial sarcoma comes under the malignant disease of the least occurrence. Compared to other malignant conditions, these patients present with minor symptoms like discomfort, which may go unchecked. The major factor that should be noted is the on-time diagnosis and appropriate choice of treatment modality. Overall, despite a minute prevalence and difficult diagnosis, the prognosis of the patient is rather good.

Rare case of high-grade endometrial stromal sarcoma metastasising to inferior vena cava and right atrium

Endometrial stromal sarcomas (ESSs) are a rare form of uterine malignancy representing <10% of all uterine sarcomas and <1% of all primary malignant tumours of the uterus. Invasion of the vascular system by low-grade ESS has been reported in the literature. Here we report the first case of a high-grade ESS invading the pelvic and gonadal vein and extending through the inferior vena cava to the right atrium, the diagnostic challenges and multidisciplinary management of the case.

Expression of immune checkpoint regulators, programmed death-ligand 1 (PD-L1/PD-1), cytotoxic T lymphocyte antigen 4 (CTLA-4), and indolaimine-2, 3-deoxygenase (IDO) in uterine mesenchymal tumors

BACKGROUND

Immune checkpoints including programmed death-ligand 1/programmed death-1/ (PD-L1/PD-1), cytotoxic T lymphocyte antigen 4 (CTLA-4), and indolaimine-2, 3-deoxygenase (IDO) have recently emerged as effective candidates for treatment against a range of human malignancies. We have investigated their expression in the uterine mesenchymal tumors.

METHODS

Sixty-eight mesenchymal tumors were categorized into 6 diagnostic groups. We assessed PD-L1, PD-1, CTLA-4, and IDO expression on paraffin embedded tissue blocks of the uterine tumors using the respective antibodies. Immunohistochemical (IHC) stains were classified as positive when the reactions were present in at least 1% of the cell membranes for PD-L1/PD-1 or in cytoplasm for CTLA-4 and IDO, regardless of intensity. Student's t-test and McNemar's chi-square tests were carried out to analyze the results.

RESULTS

The mesenchymal neoplasms had expressed the immune checkpoints in the tumor and/or the lymphoid cells at the rate of 49% and 54% respectively. The tumor cells were positive in 10 (18%, PD-L1), 0 (0%, PD-1), 18 (32%, CTLA-4), and 13 (23%, IDO) cases while the infiltrating lymphoid cells were positive in 10 (18%, PD-L1), 23 (40%, PD-1), 18 (32%, CTLA-4), and 13 (23%, IDO) cases. Overall, comparison of paired tumor vs lymphoid cells resulted in p-values of ≤ 0.04.

CONCLUSIONS

Nearly 50% of the uterine tumors express at least one of the immune checkpoints in tumor and/or the infiltrating lymphoid cells. However, expression of the proteins in the two cellular components are mutually exclusive. Namely, when tumor cells express an immune checkpoint, the infiltrating lymphoid cells do not, and vice versa. Since the leiomyosarcomas are reportedly resistant to the immunotherapy when PD-L1 is expressed in the tumor cells, it can be posited that presence of the IHC positive lymphoid cells may be a better indicator of response to the treatment.

Description of a Novel ERBB4 -rearranged Uterine Sarcoma

High-grade endometrial stromal sarcoma (HGESS) is an uncommon tumor accounting for <1% of all uterine malignancies. Currently this designation is largely reserved for neoplasms harboring YWHAE-NUTM2A/B and ZC3H7B-BCOR translocations. Here, we report a novel CIQTNF1-ERBB4 translocation in a uterine neoplasm arising in a 49-yr-old woman with morphology suggestive of HGESS. Histologic examination of the 5 cm polypoid uterine corpus mass showed a neoplasm composed of a monotonous population of cells with moderately atypical ovoid to spindle shaped nuclei with easily identifiable mitotic activity and prominent vasculature with focal intravascular extension. Immunohistochemistry showed variable positivity with desmin, estrogen receptor, progesterone receptor, AE1/3 and cyclin D1, and molecular testing showed a translocation between CIQTNF1 on chromosome 17 and ERBB4 on chromosome 2. This represents the first report of this translocation in a uterine neoplasm and adds to the growing list of translocations identified in uterine sarcomas. Although the morphology is suggestive of HGESS, this neoplasm is currently best termed an ERBB4 -rearranged uterine sarcoma until additional cases are reported to more fully characterize these neoplasms.

Advances in the Preoperative Identification of Uterine Sarcoma

Simple Summary

As a lethal malignant tumor, uterine sarcomas lack specific diagnostic criteria due to their similar presentation with uterine fibroids, clinicians are prone to make the wrong diagnosis or adopt incorrect treatment methods, which leads to rapid tumor progression and increased metastatic propensity. In recent years, with the improvement of medical level and awareness of uterine sarcoma, more and more studies have proposed new methods for preoperative differentiation of uterine sarcoma and uterine fibroids. This review outlines the up-to-date knowledge about preoperative differentiation of uterine sarcoma and uterine fibroids, including laboratory tests, imaging examinations, radiomics and machine learning-related methods, preoperative biopsy, integrated model and other relevant emerging technologies, and provides recommendations for future research.

Abstract

Uterine sarcomas are rare malignant tumors of the uterus with a high degree of malignancy. Their clinical manifestations, imaging examination findings, and laboratory test results overlap with those of uterine fibroids. No reliable diagnostic criteria can distinguish uterine sarcomas from other uterine tumors, and the final diagnosis is usually only made after surgery based on histopathological evaluation. Conservative or minimally invasive treatment of patients with uterine sarcomas misdiagnosed preoperatively as uterine fibroids will shorten patient survival. Herein, we will summarize recent advances in the preoperative diagnosis of uterine sarcomas, including epidemiology and clinical manifestations, laboratory tests, imaging examinations, radiomics and machine learning-related methods, preoperative biopsy, integrated model and other relevant emerging technologies.

Discrepancies in pathological diagnosis of endometrial stromal sarcoma: a multi-institutional retrospective study from the Japanese Clinical Oncology Group

Endometrial stromal sarcoma (ESS) is a rare uterine malignancy that requires accurate pathological diagnosis for proper treatment. This study aimed to clarify the discrepancies in the pathological diagnosis of ESS and obtain practical clues to improve diagnostic accuracy. Between 2002 and 2015, 148 patients with low-grade ESS (LGESS), high-grade ESS (HGESS), undifferentiated endometrial sarcoma (UES), or undifferentiated uterine sarcoma (UUS) diagnosed at 31 institutions were included. We performed immunohistochemistry, real-time polymerase chain reaction for JAZF1-SUZ12 and YWHAE-NUTM2A/B, and break-apart fluorescent in situ hybridization for JAZF1, PHF1, and YWHAE. Central pathology review (CPR) was performed by six pathologists. After CPR, LGESS, HGESS, UES/UUS, and other diagnoses were confirmed in 72, 25, 16, and 31 cases, respectively. Diagnostic discrepancies were observed in 19.6% (18/92) of LGESS and 34% (18/53) of HGESS or UUS/UES. Adenosarcomas, endometrial carcinomas, carcinosarcomas, and leiomyosarcomas were common diagnostic pitfalls. JAZF1-SUZ12 transcript, PHF1 split signal, and YWHAE-NUTM2A/B transcript were mutually exclusively detected in 23 LGESS, 3 LGESS, and 1 LGESS plus 3 HGESS, respectively. JAZF1-SUZ12 and YWHAE-NUTM2A/B transcripts were detected only in cases with CPR diagnosis of LGESS or HGESS. The CPR diagnosis of LGESS, HGESS, and UUS was a significant prognosticator, and patients with LGESS depicted a favorable prognosis, while those with UUS showed the worst prognosis. Pathological diagnosis of ESS is often challenging and certain tumors should be carefully considered. The accurate pathological diagnosis with the aid of molecular testing is essential for prognostic prediction and treatment selection.

Pulmonary Metastasizing Low-Grade Endometrial Stromal Sarcoma: Case Report and Review of Diagnostic Pitfalls

Pulmonary manifestations of benign metastasizing leiomyoma (BML) usually include multiple well-defined, round, bilateral nodules. Low-grade endometrial stromal sarcoma (LG-ESS) is a rare uterine tumor. A 70-year-old woman visited the clinic complaining of acute cough and dyspnea in April 2017. Chest computed tomography (CT) revealed pneumothorax and multiple pulmonary nodules. She had a history of hysterectomy for uterine leiomyoma 23 years ago. Biopsy revealed that the pulmonary masses were consistent with BML. However, the patient had two subsequent episodes of acute, recurrent respiratory distress, accompanied by massive pleural effusions and hydropneumothorax over the next two years. A chest CT performed for acute dyspnea revealed large and multiple hydropneumothoraces. The size and distribution of pulmonary masses were aggravated along with cystic changes and bilateral pleural effusions. Given this aggressive feature, additional immunohistochemical findings and gynecologic pathologist review confirmed the correct diagnosis to be LG-ESS. After initiating anti-estrogen therapy, the patient achieved a partial response, without recurrence of symptoms, for 28 months. Metastatic LG-ESS responds well to anti-hormonal therapy. If the clinical pattern of a disease is different than expected, the possibility of a correction in the diagnosis should be considered.

SATB2 Expression in Uterine Sarcoma: A Multicenter Retrospective Study

Uterine sarcomas represent a clinical challenge because of their difficult diagnosis and the poor prognosis of certain subtypes. The aim of this study was to evaluate the expression of the special AT-rich sequence-binding protein 2 (SATB2) in endometrial stromal sarcoma (ESS) and other types of uterine sarcoma by immunohistochemistry. We studied the expression of SATB2 on 71 full tissue sections of endometrial stromal nodule, low-grade ESS, uterine leiomyomas and leiomyosarcoma, undifferentiated uterine sarcoma, adenosarcoma, and carcinosarcoma samples. Nuclear SATB2 expression was then evaluated in an extended sample set using a tissue microarray, including 78 additional uterine tumor samples. Overall, with a cut-off of ≥10% of tumor cell staining as positive, the nuclear SATB2 score was negative in all endometrial stromal nodule samples (n=10) and positive in 83% of low-grade ESS samples (n=29/35), 40% of undifferentiated uterine sarcoma (n=4/10), 13% of leiomyosarcoma (n=2/16), 14% of adenosarcoma (n=3/22), and 8% carcinosarcoma (n=2/25) samples. Furthermore, in ESS patients, direct comparison of nuclear SATB2 scores with clinicopathologic parameters and other reported biomarkers such as progesterone receptor and estrogen receptor showed that nuclear SATB2 was associated with PR expression and a decreased risk of disease-specific death (odds ratio=0.06, 95% confidence interval=0.04-0.81, P=0.04). Our data suggest that SATB2 could be a marker with relative sensitivity (83%) for distinguishing between endometrial stromal nodule and ESS with potential prognostic value.

Metastatic endometrial stromal sarcoma: A rare cause of right-sided intracardiac mass

The endometrial stromal sarcoma (EES) is a rare uterine malignancy and its intracardiac metastasis are exceedingly rare. We report a case of a 53-year-old female patient diagnosed with a metastatic tumor of a ESS in the right side of the heart, who underwent successful surgical resection and initiated chemotherapy with docetaxel and gemcitabine. At a 9-month follow-up, the patient was in New York Heart Association-Class I, without any further complications.

Genomic Profiling Aids Classification of Diagnostically Challenging Uterine Mesenchymal Tumors With Myomelanocytic Differentiation

Although diagnosis of high-grade uterine mesenchymal tumors (UMTs) exhibiting classic morphologic features is straightforward, diagnosis is more challenging in tumors in which prototypical features are poorly developed, focal, and/or coexist with features seen in other neoplasms. Here, we sought to define the repertoire of somatic genetic alterations in diagnostically challenging UMTs with myomelanocytic differentiation, including some reported as perivascular epithelioid cell tumors (PEComas). In 17 samples from 15 women, the tumors were histologically heterogenous. Immunohistochemical expression of at least 1 melanocytic marker (HMB45, Melan-A, or MiTF) was identified in all tumors, and of myogenic markers (desmin or smooth muscle actin) in most tumors. Targeted massively parallel sequencing revealed several genetic alterations, most commonly in TP53 (41% mutation, 12% deletion), TSC2 (29% mutation, 6% deletion), RB1 (18% deletion), ATRX (24% mutation), MED12 (12% mutation), BRCA2 (12% deletion), CDKN2A (6% deletion) as well as FGFR3, NTRK1, and ERBB3 amplification (each 6%). Gene rearrangements (JAZF1-SUZ12; DNAJB6-PLAG1; and SFPQ-TFE3) were identified in 3 tumors. Integrating histopathologic, immunohistochemical, and genetic findings, tumors from 4 patients were consistent with malignant PEComa (1 TFE3-rearranged); 6 were classified as leiomyosarcomas; 3 showed overlapping features of PEComa and other sarcoma types (leiomyosarcoma or low-grade endometrial stromal sarcoma); and 2 were classified as sarcoma, not otherwise specified. Our findings suggest that diagnostically challenging UMTs with myomelanocytic differentiation represent a heterogenous group of neoplasms which harbor a diverse repertoire of somatic genetic alterations; these genetic alterations can aid classification.

Cytologic features of undifferentiated and dedifferentiated carcinomas of the endometrium

BACKGROUND

Undifferentiated carcinoma (UC) is a rare, aggressive subtype of endometrial carcinoma. Dedifferentiated carcinomas (DCs) are UCs associated with a component of well differentiated endometrioid carcinoma. The authors sought to describe the morphologic features of UCs and DCs in cytologic specimens.

METHODS

Cytologic specimens from 23 women (aged 46-86 years; median age, 59 years) were reviewed, including cervicovaginal specimens (n = 7), peritoneal washings (n = 5), touch preparations of core biopsies from various sites (n = 5), fine-needle biopsies of lymph nodes (n = 3), ascitic fluid (n = 1), pleural fluid (n = 1), and intrauterine fluid (n = 1).

RESULTS

There were 10 UCs (43%) and 13 DCs (57%). Tumor cells were arranged as single cells (9 UCs, 90%; 12 DCs, 92%) and 3-dimensional groups (8 UCs, 80%; 11 DCs, 85%). Most cases showed high nuclear-to-cytoplasmic ratios. Nuclear molding was observed in 3 UCs (30%) and in 5 DCs (38%). Nuclear chromatin was often coarsely granular 6 UCs, 60%; 9 DCs, 69%). Nucleoli were inconspicuous in some cases (6 UCs, 60%; 8 DCs, 62%) but were appreciable in others. Necrosis was observed in 5 UCs (50%) and in 5 DCs (38%). Most cases exhibited clean backgrounds, and a few showed acute inflammation. Comparison of the cytologic features of UCs and DCs did not reveal any statistically significant differences.

CONCLUSIONS

UCs and DCs have a spectrum of cytomorphologic appearances that are not pathognomonic, but the presence of some of these (relatively uniform population of predominantly singly dispersed cells with high nuclear-to-cytoplasmic ratios and variably conspicuous nucleoli) should prompt consideration of UC and DC in the differential diagnosis.

Endometrial stromal sarcoma: A review of rare mesenchymal uterine neoplasm

OBJECTIVE

This review aims to analyze the pathological aspects, diagnosis and treatment of rare mesenchymal uterine tumors.

METHODS

On August 2019, a systematic review of the literature was done on Pubmed, MEDLINE, Scopus, and Google Scholar search engines. The systematic review was carried out in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes statement (PRISMA). The following words and key phrases have been searched: "endometrial stromal sarcoma", "low-grade endometrial stromal sarcoma", "high-grade endometrial stromal sarcoma", "uterine sarcoma", "mesenchymal uterine tumors" and "uterine stromal sarcoma". Across these platforms and research studies, five main aspects were analyzed: the biological characteristics of the neoplasms, the number of cases, the different therapeutic approaches used, the follow-up and the oncological outcomes.

RESULTS

Of the 94 studies initially identified, 55 were chosen selecting articles focusing on endometrial stromal sarcoma. Of these fifty-five studies, 46 were retrospective in design, 7 were reviews and 2 randomized phases III trials.

CONCLUSION

Endometrial stromal sarcomas are rare mesenchymal uterine neoplasms and surgery represents the standard treatment. For uterus-limited disease, the remove en bloc with an intact resection of the tumor (without the use of morcellation) is strongly recommended. For advanced-stage disease, the standard surgical treatment is adequate cytoreduction with metastatectomy. Pelvic and para-aortic lymphadenectomy is not recommended in patients with Low-grade Endometrial Stromal Sarcoma (ESS), while is not clear whether cytoreduction of advanced tumors improves patient survival in High-grade ESS. Administration of adjuvant radiotherapy or chemotherapy is not routinely used and its role is still debated.

Uterine Tumor Resembling Ovarian Sex Cord Tumor (UTROSCT): A Morphologic and Molecular Study of 26 Cases Confirms Recurrent NCOA1-3 Rearrangement

Uterine tumor resembling ovarian sex cord tumor (UTROSCT) is a rare mesenchymal neoplasm, of uncertain biological potential, that was recently reported to exhibit recurrent gene fusions involving NCOA2-3. The purpose of this study was to, using a larger sample size, better characterize the histopathologic and molecular diversity of UTROSCT. Twenty-six cases of UTROSCT from 5 institutions were selected for further study. Fluorescence in situ hybridization for NCOA1, NCOA2, NCOA3, ESR1 and GREB1, and targeted RNA sequencing was performed on 17 and 8 UTROSCTs, respectively. Eight cases underwent massively parallel sequencing to detect single nucleotide variants (SNV), copy number variations, and structural variants using a targeted hybrid-capture based assay. NCOA1-3 rearrangement was identified in 81.8% (18/22) of cases. The most common fusion was ESR1-NCOA3, occurring in 40.9% (9/22). GREB1-NCOA1 (n=4), ESR1-NCOA2 (n=3), and GREB1-NCOA2 (n=1) rearrangements were also identified. No recurrent SNVs were identified and no tumor had SNVs in FOXL2, DICER1, STK11, or AKT1, which can be seen in ovarian sex cord-stromal tumors. Copy number variations were infrequent. Clinical follow-up was available for 11 cases with a mean follow-up interval of 94.4 (range, 1 to 319) months. Only one case had a recurrence 66 months after the initial diagnosis and this was the single case with a GREB1-NCOA2 fusion. This study reports the morphologic spectrum of UTROSCT and confirms the recently reported recurrent NCOA2-3 gene fusions, in addition to identifying novel rearrangements involving NCOA1 in these tumors.

A Comprehensive Review of Biomarker Use in the Gynecologic Tract Including Differential Diagnoses and Diagnostic Pitfalls

Morphologic (ie, hematoxylin and eosin) evaluation of the Mullerian tract remains the gold standard for diagnostic evaluation; nevertheless, ancillary/biomarker studies are increasingly utilized in daily practice to assist in the subclassification of gynecologic lesions and tumors. The most frequently utilized "biomarker" technique is immunohistochemistry; however, in situ hybridization (chromogenic and fluorescence), chromosomal evaluation, and molecular analysis can also be utilized to aid in diagnosis. This review focuses on the use of immunohistochemistry in the Mullerian tract, and discusses common antibody panels, sensitivity and specificity of specific antibodies, and points out potential diagnostic pitfalls when using such antibodies.

Treatment of uterine high-grade endometrial stromal sarcoma with apatinib combined with chemotherapy: A case report

RATIONALE

The standard treatment for uterine high-grade endometrial stromal sarcoma (HGESS) is chemotherapy after surgery. However, the traditional combination chemotherapy has certain limitation, for example, the cancer cells will quickly become resistant to the chemotherapy drugs. Apatinib is a small-molecule antiangiogenic agent which has shown promising therapeutic effect against diverse tumor, but it still remains unknown whether apatinib has an antitumor effect in patients with endometrial stromal sarcoma (ESS). Here, we report a case of pulmonary metastasis from uterine HGESS successfully treated with apatinib combined with chemotherapy. We also review relevant literature discussing treatment of ESS.

PATIENTS CONCERNS

A 54-years-old Chinese woman complained of intermittent pain in the waist and abdomen for 4 months. The patient was diagnosed as uterine fibroids before operation. The surgeon performed a total hysterectomy with bilateral salpingo-oophorectomy, resection of peritoneal disseminated lesions, and the pathological examination revealed a HGESS.

DIAGNOSIS

Uterine HGESS stage IV with lung metastases.

INTERVENTIONS

The patient underwent surgery, chemotherapy, chemotherapy combined with apatinib, apatinib maintenance therapy, and radioactive particle implantation for lung metastasis.

OUTCOMES

The patient experienced the above interventions and achieved good results. And continue oral apatinib (500 mg daily) as maintenance therapy. It has been 16 months since the initial diagnosis, and the patient is still in follow-up.

LESSONS

Apatinib combined with chemotherapy and apatinib monotherapy as maintenance therapy could be a new therapeutic strategy for ESS.

Beyond Smooth Muscle-Other Mesenchymal Neoplasms of the Uterus

Mesenchymal tumors of the uterus comprise a heterogeneous group of neoplasms of varied biologic potential. In addition to being host to several anatomically unique entities, the uterus may contain mesenchymal neoplasms typically found elsewhere in the body. Although smooth muscle neoplasms are common, other mesenchymal neoplasms in this location are relatively rare. Many of these neoplasms exhibit morphologic overlap. In addition to a careful histomorphologic review, definitive classification frequently depends on the judicious application of ancillary immunohistochemical and molecular testing. The intent of this review is to offer a basic approach to the classification of primary uterine mesenchymal neoplasms.

Extra-uterine low grade endometrioid stromal sarcoma arising from ovarian endometriosis: a case report and review of the literature

Background

Endometrial stromal sarcoma (ESS) is a rare neoplasm accounting for only 0.2% of female genital tract tumors. The primary extra-uterine location of ESS is an extremely uncommon occurrence.

Case presentation

We present a case of a 64-year-old woman presenting with abdominopelvic and bilateral ovarian tumors with misleading clinical presentation and diagnostic challenge. The histopathological examination of the resected specimens disclosed the diagnosis of primary extra-uterine ESS arising from ovarian endometriosis. Adjuvant therapy with an aromatase inhibitor drug was prescribed for the patient, and she is still alive with no evidence of disease 7 months after surgery.

Conclusion

The awareness of the potential extra-uterine location of ESS should lead to correct diagnosis as this tumor has histopathological features and clinical behavior similar to its uterine counterpart.

A Case of High-grade Endometrial Stromal Sarcoma: A Poignant Allegory

Endometrial stromal sarcomas (ESS) are rare tumors of endometrial stromal origin that account for approximately 1% of all uterine malignant neoplasms and are responsible for a significant proportion of mortality due to uterine malignancies. There are immense case reports on low-grade ESS, but there is a paucity of data on high-grade ones, probably, because these cases generally present in advanced stages and have a high case fatality rate. Moreover, there have been several refinements in the classification of these tumors. We, herein, provide an update on this topic and discuss the poignant outcome of a case of high-grade ESS.

Treatment of low-grade endometrial stromal sarcoma in a nulligravid woman

A 32 year-old nulligravid woman with a uterine mass underwent exploratory laparotomy with myomectomy. Final pathology revealed a low-grade endometrial stromal sarcoma (ESS) with positive margins. She subsequently underwent definitive robotic hysterectomy and bilateral salpingectomy with ovarian preservation. She was diagnosed with a stage IB low-grade ESS. She is currently undergoing observation. Discussion of classification, surgical options, and adjuvant therapy is presented.

Gene expression profiling of low-grade endometrial stromal sarcoma indicates fusion protein-mediated activation of the Wnt signaling pathway

OBJECTIVE

Low-grade endometrial stromal sarcomas (LGESS) harbor chromosomal translocations that affect proteins associated with chromatin remodeling Polycomb Repressive Complex 2 (PRC2), including SUZ12, PHF1 and EPC1. Roughly half of LGESS also demonstrate nuclear accumulation of β-catenin, which is a hallmark of Wnt signaling activation. However, the targets affected by the fusion proteins and the role of Wnt signaling in the pathogenesis of these tumors remain largely unknown.

METHODS

Here we report the results of a meta-analysis of three independent gene expression profiling studies on LGESS and immunohistochemical evaluation of nuclear expression of β-catenin and Lef1 in 112 uterine sarcoma specimens obtained from 20 LGESS and 89 LMS patients.

RESULTS

Our results demonstrate that 143 out of 310 genes overexpressed in LGESS are known to be directly regulated by SUZ12. In addition, our gene expression meta-analysis shows activation of multiple genes implicated in Wnt signaling. We further emphasize the role of the Wnt signaling pathway by demonstrating concordant nuclear expression of β-catenin and Lef1 in 7/16 LGESS.

CONCLUSIONS

Based on our findings, we suggest that LGESS-specific fusion proteins disrupt the repressive function of the PRC2 complex similar to the mechanism seen in synovial sarcoma, where the SS18-SSX fusion proteins disrupt the mSWI/SNF (BAF) chromatin remodeling complex. We propose that these fusion proteins in LGESS contribute to overexpression of Wnt ligands with subsequent activation of Wnt signaling pathway and formation of an active β-catenin/Lef1 transcriptional complex. These observations could lead to novel therapeutic approaches that focus on the Wnt pathway in LGESS.

RNA-sequencing identifies novel GREB1-NCOA2 fusion gene in a uterine sarcoma with the chromosomal translocation t(2;8)(p25;q13)

Sarcomas account for 3% of all uterine malignancies and many of them are characterized by acquired, specific fusion genes whose detection has increased pathogenetic knowledge and diagnostic precision. We describe a novel fusion gene, GREB1-NCOA2, detected by transcriptome sequencing and validated by reverse transcriptase polymerase chain reaction and Sanger sequencing in an undifferentiated uterine sarcoma. The chimeric transcript was an in-frame fusion between exon 3 of GREB1 and exon 15 of NCOA2. The fusion is reported here for the first time, but it involves the GREB1 gene, an important promoter of tumor growth and progression, and NCOA2 which is known to be involved in transcriptional regulation. The alteration and recombination of these genes played a role in the tumorigenesis and/or progression of this sarcoma.

Analysis of diagnosis and treatment of complicated cervical severe adhesion atresia after removal of endometrial stromal nodule: A case report

RATIONALE

Endometrial stromal nodule (ESN) is a rare benign endometrial stroma tumor.Experiences are helpful for avoiding and treating similar postoperative complications (cervical adhesions and atresia).

PATIENT CONCERNS

When appearing in the cervical, this tumor can easily lead to complications after the surgical resection. The diagnosis and postsurgery complication of a young woman's ESN was reported here.

DIAGNOSES

The postoperative pathological diagnosis was ESN.

INTERVENTIONS

A 29-year-old young woman was diagnosed and treated for ESN in cervical parts with postsurgery complications of cervical complex adhesion atresia.

OUTCOMES

The complication was complex cervix adhesion atresia with very special imaging performance-the cervix and the palace imaged as "Twisted and Angled Staircase." This particular cervix adhesion was challenging for operation. We achieved a successful treatment through the carefully designed surgical procedure including the application of hysteroscopy and laparoscopy.

LESSONS

The lower uterine segment and cervix should be paid attention during suturing in this situation. Close and positive follow-ups should be planned after the endometrial stromal resection. The reconstruction of the tunnel is a solution for the problem of menstruation.

Endometrial stromal sarcoma in combination with mixed type endometrial carcinomas: A case report and literature review

RATIONALE

Endometrial stromal sarcoma (ESS) is rare, representing only approximately 0.2% of all uterine malignancies. Mixed type endometrial carcinomas (MT-ECs) are rare tumors with both type I and II features, and are difficult to diagnose. Cases of ESS and MT-ECs coexisting in the same patient are extremely rare. This study aimed to describe a case of ESS in combination with MT-ECs in a 47-year-old premenopausal woman.

PATIENT CONCERNS

A woman presented to the hospital complaining of occasional abdominal pain and had high tumor markers: cancer antigen (CA) 19-9 (263.6 U/mL) and CA 125 (428.0 U/mL). Transvaginal ultrasound examination revealed a complex mass (12.3 × 9.1 × 6.3 cm) with solid and cystic components on the right rear wall of the uterus. Abdominopelvic computed tomography images showed a pelvic cystic-solid mixed mass. The patient underwent an exploratory midline laparotomy. The mass was hypothesized to be malignant on the uterine posterior wall. Tumor deposits were found on bilateral parametrium. On peritoneal implantation, multiple metastases were seen on the serosal surface of the bowel and greater omentum. A frozen section revealed a spindle cell sarcoma.

DIAGNOSES

Pathological reports following surgery revealed concurrent ESS and MT-ECs.

INTERVENTIONS

The patient underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, total omentectomy, and macroscopic clearance of the tumor. Adjuvant chemotherapy was given.

OUTCOMES

The patient was still alive when this report was written.

LESSONS

Considering the rarity of ESS in combination with MT-ECs, this study presented an overview of the literature and discussed a number of histological and clinical issues. Nevertheless, etiology and pathogenesis of these tumors need further investigation.

Macrophage infiltration and genetic landscape of undifferentiated uterine sarcomas

Endometrial stromal tumors include translocation-associated low- and high-grade endometrial stromal sarcomas (ESS) and highly malignant undifferentiated uterine sarcomas (UUS). UUS is considered a poorly defined group of aggressive tumors and is often seen as a diagnosis of exclusion after ESS and leiomyosarcoma (LMS) have been ruled out. We performed a comprehensive analysis of gene expression, copy number variation, point mutations, and immune cell infiltrates in the largest series to date of all major types of uterine sarcomas to shed light on the biology of UUS and to identify potential novel therapeutic targets. We show that UUS tumors have a distinct molecular profile from LMS and ESS. Gene expression and immunohistochemical analyses revealed the presence of high numbers of tumor-associated macrophages (TAMs) in UUS, which makes UUS patients suitable candidates for therapies targeting TAMs. Our results show a high genomic instability of UUS and downregulation of several TP53-mediated tumor suppressor genes, such as NDN, CDH11, and NDRG4. Moreover, we demonstrate that UUS carry somatic mutations in several oncogenes and tumor suppressor genes implicated in RAS/PI3K/AKT/mTOR, ERBB3, and Hedgehog signaling.

Uterine sarcoma with ambiguous histomorphology: A case report

Background

Leiomyosarcomas (LMS) and endometrial stromal sarcomas (ESS) may display overlapping histomorphology, which may challenge diagnostic accuracy. Since LMS and ESS have vastly different clinical behavior and adjuvant therapy recommendations, accurate diagnosis is critical.

Case

We present the case of an 83-year-old female with postmenopausal bleeding who underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy for clinically atypical appearing leiomyomata. Histologically, dual populations of cells with morphologic features of low-grade ESS and high-grade spindle cell sarcoma were seen. Immunohistochemistry and molecular studies revealed the cells to be of smooth muscle derivation, rendering a diagnosis of high-grade LMS with heterogeneous morphology (stage IB). The patient received adjuvant gemcitabine plus docetaxel. She recurred 8 months after completion of chemotherapy and was transferred to hospice care.

Conclusion

Ancillary studies, such as immunohistochemistry and molecular testing, aid in accurate subcategorization of uterine sarcomas with ambiguous histomorphology.

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LMS and ESS may display overlapping histomorphology.

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Immunohistochemistry and molecular testing aid classification of uterine sarcomas.

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Classification of uterine sarcomas is critical for selection of adjuvant therapy.

Uterine sarcoma Part II-Uterine endometrial stromal sarcoma: The TAG systematic review

Endometrial stromal tumors are rare uterine tumors (<1%). Four main categories include endometrial stromal nodule, low-grade endometrial stromal sarcoma (LG-ESS), high-grade endometrial stromal sarcoma (HG-ESS), and uterine undifferentiated sarcoma (UUS). This review is a series of articles discussing the uterine sarcomas. LG-ESS, a hormone-dependent tumor harboring chromosomal rearrangement, is an indolent tumor with a favorable prognosis, but characterized by late recurrences even in patients with Stage I disease, suggesting the requirement of a long-term follow-up. Patients with HG-ESS, based on the identification of YWHAE-NUTM2A/B (YWHAE-FAM22A/B) gene fusion, typically present with advanced stage diseases and frequently have recurrences, usually within a few years after initial surgery. UUS is, a high-grade sarcoma, extremely rare, lacking a specific line of differentiation, which is a diagnosis of exclusion (the wastebasket category, which fails to fulfill the morphological and immunohistochemical criteria of translocation-positive ESS). Surgery is the main strategy in the management of uterine sarcoma. Due to rarity, complex biological characteristics, and unknown etiology and risk factors of uterine sarcomas, the role of adjuvant therapy is not clear. Only LG-ESS might respond to progestins or aromatase inhibitors.

Uterine sarcoma Part I-Uterine leiomyosarcoma: The Topic Advisory Group systematic review

Uterine sarcomas account for 3-7% of all uterine cancers. Because of their rarity, unknown etiology, and highly divergent genetic aberration, there is a lack of consensus on risk factors for occurrence and predictive poor outcomes as well as optimal therapeutic choices. Tumor types according to the World Health Organization classification include leiomyosarcoma, endometrial stroma sarcoma, and undifferentiated sarcoma. Staging is done using the 2014 Federation International Gynecology and Obstetrics and 2010 American Joint Committee on Cancer tumor, lymph node, and metastases systems. Tumor grade can be classified based on the French Federation of Cancer Centers Sarcoma Group system or the Broder's system that incorporates tumor differentiation, mitotic count, and tumor necrosis. This review is a series of articles discussing uterine sarcoma, and this is Part I, which focuses on one of the subtypes of uterine sarcomas-uterine leiomyosarcoma. The clinical characteristics, diagnosis, outcome, and recent advances are summarized in this article.