Molecular characteristics of uterine sarcomas

JAZF1-SUZ12 dysregulates PRC2 function and gene expression during cell differentiation

Polycomb repressive complex 2 (PRC2) methylates histone H3 lysine 27 (H3K27me3) to maintain gene repression and is essential for cell differentiation. In low-grade endometrial stromal sarcoma (LG-ESS), the PRC2 subunit SUZ12 is often fused with the NuA4/TIP60 subunit JAZF1. We show that JAZF1-SUZ12 dysregulates PRC2 composition, genome occupancy, histone modification, gene expression, and cell differentiation. Loss of the SUZ12 N terminus in the fusion protein abrogates interaction with specific PRC2 accessory factors, reduces occupancy at PRC2 target genes, and diminishes H3K27me3. Fusion to JAZF1 increases H4Kac at PRC2 target genes and triggers recruitment to JAZF1 binding sites during cell differentiation. In human endometrial stromal cells, JAZF1-SUZ12 upregulated PRC2 target genes normally activated during decidualization while repressing genes associated with immune clearance, and JAZF1-SUZ12-induced genes were also overexpressed in LG-ESS. These results reveal defects in chromatin regulation, gene expression, and cell differentiation caused by JAZF1-SUZ12 that may underlie its role in oncogenesis.

Uterine cellular leiomyomas are characterized by common HMGA2 aberrations, followed by chromosome 1p deletion and MED12 mutation: morphological, molecular, and immunohistochemical study of 52 cases

Cellular leiomyoma (CL) represents an uncommon variant of uterine leiomyoma with limited data concerning its immunohistochemical and molecular profile. We performed a comprehensive analysis of 52 CL cases all of which were analyzed immunohistochemically. Molecular analysis was possible in 32 cases with sufficient DNA, and 38 cases with sufficient RNA. The immunohistochemical results showed a high expression of smooth muscle markers (calponin (100%), desmin (100%), smooth muscle actin (98.1%), caldesmon (96.1%), transgelin (96.1%), smooth muscle myosin heavy chain (86.5%), and smoothelin (61.5%)). Concerning markers of endometrial stromal differentiation, the expression of CD10 was observed in 65.4% cases (42.2% with H-score > 50), and IFITM1 in 36.5% cases (1.9% with H-score > 50). 36.5% showed HMGA2 overexpression at the IHC level, associated with increased mRNA expression in 14/14 cases. The rearrangement of the HMGA2 gene was detected in 13.2%. Chromosome 1p deletion was found in 19.3%, while 9.4% of tumors showed a pathogenic mutation in the MED12 gene. In conclusion, CL is immunohistochemically characterized by a high expression of "smooth muscle" markers commonly associated with a co-expression of "endometrial stromal" markers, where IFITM1 shows superior performance compared to CD10 regarding its specificity for differentiation from endometrial stromal tumors. The sensitivity of smoothelin in CL seems rather low, but no data is available to assess its specificity. On a molecular level, the most common mutually exclusive aberration in CL affects HMGA2, followed by chromosome 1p deletions and MED12 mutations.

The values of Transgelin, Stathmin, BCOR and Cyclin-D1 expression in differentiation between Uterine Leiomyosarcoma (ULMS) and Endometrial Stromal Sarcoma (ESS); diagnostic and prognostic implications

Background

Morphologic distinction between uterine leiomyosarcoma (ULMS) and endometrial stromal sarcoma (ESS) alone is not straightforward and has been shown to be challenging especially with poor differentiation, so immunohistochemistry (IHC) is often employed as an adjunct to morphology in uterine sarcoma.

Aim

We aimed to assess the diagnostic utility of Transgelin, Stathmin, BCOR and Cyclin-D1 separately and in-combinations in distinguishing ULMS from ESS, and to evaluate their prognostic value in patients with such sarcoma subtypes.

Material and Methods

We included 44 patients with uterine sarcoma. The diagnostic performances of Transgelin, Stathmin, BCOR and Cyclin-D1 were assessed in samples from all patients using immunohistochemistry.

Results

The combination of Stathmin and Transgelin expression has high sensitivity and specificity for diagnosis of LMS and differentiating it from ESS; 95.5% and associated with poor prognosis in LMS patients.

The combination of BCOR and Cyclin-D1 expression has high sensitivity and specificity for diagnosis of ESS and differentiating it from LMS; 90.9% and 95.5% respectively and associated with poor prognosis in ESS patients. The combination of Stathmin and Transgelin, BCOR and CyclinD1 expression has high sensitivity and specificity for diagnosis of LMS and differentiating it from ESS; 100%.

Conclusion

Combination of Stathmin, Transgelin, BCOR and Cycline-D1 raised the accuracy of differentiation between ULMS and ESS to 100% and has prognostic roles in such sarcomas.

Outcome of adjuvant radiotherapy after total hysterectomy in patients with uterine leiomyosarcoma or carcinosarcoma: a SEER-based study

BACKGROUND

The clinical impact of adjuvant radiotherapy on uterine sarcoma is unclear, and may depend on the histological type. Hence, the aim of this study was to evaluate clinical outcomes of adjuvant radiotherapy after total hysterectomy in patients with leiomyosarcoma or carcinosarcoma.

METHODS

Data were obtained from the Surveillance, Epidemiology, and End Results (SEER) program. Cox proportional hazards regression analyses were performed to identify risk factors for overall mortality and cancer-specific mortality. In addition, a 1:1 propensity score matching approach was performed, in which age group, disease stage, tumor grade, tumor size, and lymphadenectomy status were matched.

RESULTS

A total of 566 leiomyosarcoma and 1069 carcinosarcoma patients with stage I-III disease were included. Both regular Cox regression analysis and propensity score matching analysis revealed that utilization of adjuvant radiotherapy did not affect overall and cancer-specific mortality in patients with leiomyosarcoma. In contrast, for patients with carcinosarcoma, total mortality risk was significantly decreased with EBRT, brachytherapy, and combination radiotherapy compared with no radiotherapy. Cancer-specific mortality risk was significantly decreased with brachytherapy and combination radiotherapy as compared with no radiotherapy. Propensity score matching analyses revealed similar results in overall mortality, but not cancer-specific mortality, in patients with carcinosarcoma. Furthermore, the frequency of patients who did not receive any form of adjuvant radiotherapy was four times higher than those underwent adjuvant radiotherapy.

CONCLUSIONS

Adjuvant radiotherapy may provide a survival benefit for uterine carcinosarcoma, but not leiomyosarcoma. In addition, adjuvant radiotherapy is underutilized, and increased utilization of adjuvant radiotherapy may improve the survival rate of patients with carcinosarcoma.

Management of uterine sarcomas and prognostic indicators: real world data from a single-institution

Background

Uterine sarcomas consist a heterogeneous group of mesenchymal gynecological malignancies with unclear therapeutic recommendations and unspecific but poor prognosis, since they usually metastasize and tend to recur very often, even in early stages.

Methods

We retrospectively analyzed all female patients with uterine sarcomas treated in our institution over the last 17 years. Clinico-pathological data, treatments and outcomes were recorded. Kaplan-Meier curves were plotted and time-to-event analyses were estimated using Cox regression.

Results

Data were retrieved from 61 women with a median age of 53 (range: 27–78) years, at diagnosis. Fifty-one patients were diagnosed with leiomyosarcoma (LMS), 3 with high grade endometrial stromal sarcoma (ESS), 5 with undifferentiated uterine sarcoma (UUS), 1 with Ewing sarcoma (ES) and 1 with Rhabdomyosarcoma (RS). 24 cases had stage I, 7 stage II, 14 stage III and 16 stage IV disease. Median disease-free survival (DFS) in adjuvant approach was 18.83 months, and median overall survival (OS) 31.07 months. High mitotic count (> 15 mitoses) was significantly associated with worse OS (P < 0.001) and worse DFS (P = 0.028).

Conclusions

Mitotic count appears to be independent prognostic factor while further insights are needed to improve adjuvant and palliative treatment of uterine sarcomas.

Hexane fraction of adlay (Coix lachryma-jobi L.) testa ethanolic extract inhibits human uterine sarcoma cancer cells growth and chemosensitizes human uterine sarcoma cells to doxorubicin

BACKGROUND

Cancer has remained among the top ten causes of death in Taiwan since 1982. Uterine sarcoma is a rare gynecologic cancer, and chemotherapy is one type of cancer treatment. Doxorubicin (Dox) is widely used for treating several cancers, including uterine sarcoma, however, multidrug resistance (MDR) is a major clinical problem and a critical cause of treatment failure. The ethanolic extracts of adlay testa (ATE) exhibited significant anticancer activities against many cancer types.

PURPOSE

In this study we investigated the antitumor effects of the hexane fraction of the adlay testa ethanolic extracts (ATE-Hex) on the human uterine sarcoma cancer cell line MES-SA, as well as on the multidrug-resistant human uterine sarcoma cancer cell line MES-SA/Dx5.

METHODS

The MTT assay was performed to assess the effects of the extracts of different parts of the adlay on the proliferation of human uterine sarcoma cells (MES-SA and MES-SA/Dx5) and human uterine smooth muscle cells (HUtSMCs). To determine whether ATE-Hex has a chemosensitizing effect on drug-resistant uterine sarcoma cells, the MTT assay was performed to examine the synergistic effects of ATE-Hex, the chemotherapeutic drug Dox alone, and in combination. Rhodamine accumulation was analyzed using fluorescence detection. Apoptotic cells were analyzed via flow cytometry. In addition, employing a flame ionization detector (GC/FID) gas chromatography was also developed as the analysis platform for ATE-Hex.

RESULTS

The results demonstrated that ATE-Hex exhibited the best effects of inhibition on MES-SA and MES-SA/Dx5 cells. Co-treatment of ATE-Hex and Dox could synergistically inhibit the proliferation of cancer cells. ATE-Hex reduced the rhodamine efflux in MES-SA/Dx5 cells, indicating that ATE-Hex could reduce the expression of P-gp. In addition, our results showed that treatment with ATE-Hex alone or in combination with Dox significantly inhibited the growth of cancer cells and induced apoptosis by increasing the sub-G1 phase and poly(ADP-ribose) polymerase (PARP) being cleaved. Flow cytometry revealed that ATE-Hex induced apoptosis.

CONCLUSION

These results suggest that ATE-Hex can inhibit human uterine sarcoma cancer cells by inducing apoptosis and increasing the chemosensitivity of the multidrug-resistant human uterine sarcoma cancer cell MES-SA/Dx5 to Dox. Furthermore, the combination of ATE-Hex and Dox could decrease MDR and increase the synergistic effect.

Molecular biomarkers for uterine leiomyosarcoma and endometrial stromal sarcoma

Uterine leiomyosarcoma (u‐LMS) and endometrial stromal sarcoma (ESS) are among the most frequent soft tissue sarcomas, which, in adults, lead to fatal lung metastases and patients have an extremely poor prognosis. Due to their rarity and heterogeneity, there are no suitable biomarkers for diagnosis and prognosis, although some biomarker candidates have appeared. In 2017, The Cancer Genome Atlas (TCGA) Research Network's work on u‐LMS has confirmed mutations and deletions in RB1,TP53 and PTEN. In addition, whole‐exome sequencing of u‐LMS has confirmed and demonstrated frequent alterations in TP53,RB1, α‐thalassemia/mental retardation syndrome X‐linked (ATRX) and mediator complex subunit 12 (MED12). MED12 is a useful biomarker to diagnose uterine‐derived LMS and tumors arising from (LM) with a relatively favorable prognosis. TP53 and ATRX mutations can be important mechanisms in the pathogenesis of u‐LMS and are correlated with a poor prognosis. In an update based on the 2014 WHO classification, low‐grade ESS is often associated with gene rearrangement bringing about the JAZF 1‐SUZ12 (formerly JAZF1‐JJAZ1) fusion gene, whereas high‐grade ESS is associated with the YWHAE‐NUTM fusion gene. Low‐grade ESS with JAZF1 rearrangement may correlate with metastasis. However, high‐grade ESS with metastasis with YWHAE rearrangement shows a relatively favorable prognosis. The genetic/molecular genetic aberrations in u‐LMS and ESS are reviewed, focusing on molecular biomarkers for these primary and metastatic tumors.

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.

Myxoid Mesenchymal Tumors of the Uterus: An Update on Classification, Definitions, and Differential Diagnosis

Tumors with a predominant myxoid stroma are rare in the uterus. When encountered, however, they pose a diagnostic challenge. Traditionally myxoid leiomyosarcoma has been the most important consideration in this category, given its adverse prognosis and deceptively bland morphology. Conventional features of malignancy are variably present; in contrast, an infiltrative tumor border is a consistent pathologic characteristic. More recently, previously under-recognized lesions have been identified, in part due to our growing knowledge of their underlying molecular alterations: uterine inflammatory myofibroblastic tumor frequently harbors ALK rearrangements and a novel ZC3H7B-BCOR gene fusion has been described in a subset of myxoid high-grade endometrial stromal sarcomas. These tumors need to be distinguished from myxoid leiomyosarcoma, as by comparison have a less aggressive course and are amenable to targeted treatments. In addition, uterine mesenchymal tumors with malignant potential need to be distinguished from benign tumors and epithelial and mixed malignancies. This review aims to discuss our current understanding of the most common uterine myxoid neoplasms: their clinical features, their distinguishing histopathologic, immunohistochemical, and molecular features and the clues and pitfalls in their diagnosis.