Mesonephric adenocarcinomas in female genital tract: A case series

Mesonephric-like adenocarcinoma of the uterine corpus with focal sarcomatous differentiation: A case report

Mesonephric-like adenocarcinoma of the uterine corpus was first reported in 2016, and added as a new item to the 5th edition of the WHO classification in 2020. It accounts for approximately 1% of patients with uterine corpus cancer, being rare. The histology of this carcinoma varies, making pathological diagnosis difficult. A diagnosis is made at an advanced stage in comparison with other histological types of uterine corpus cancer, and the prognosis is reportedly poor with high-level malignancy. In addition, there are few case reports of mesonephric-like adenocarcinoma of the uterine corpus with sarcoma. In this study, we report a patient in whom preoperative chemotherapy was performed under a diagnosis of cervical carcinoma, but the resected specimen led to a diagnosis of sarcomatous component-mixed mesonephric-like adenocarcinoma of the uterine corpus after surgery.

Mesonephric and Mesonephric-like Adenocarcinomas of the Gynecologic Tract: A Case Series and a Review of the Literature

We sought to present and describe all cases of mesonephric adenocarcinoma (MNAC) and mesonephric-like adenocarcinomas (MLAs) at our institution. These cancers are rare, morphologically similar tumors of the female reproductive tract. In this case series, we present 13 new cases of MNAC/MLA that were identified at St. Luke's University Health Network from 2016 to 2024. Demographics, clinical characteristics, and pathologic findings were collected from chart review. There were 6 uterine, 5 ovarian, and 2 cervical MNAC/MLAs. At presentation, more than half of the patients presented at early stages with 7, 2, 3, and 1 diagnosed at stages I, II, III, and IV, respectively. All patients underwent upfront surgical resection and were recommended adjuvant therapy. One patient declined adjuvant treatment. At the time of writing, 9 of 13 patients have completed treatment and have no evidence of disease, 1 is alive with disease, 1 is currently undergoing treatment, and 2 died of disease. Median overall survival (OS) was 15 mo (95% CI: 2.2-27.8 mo). Current literature regarding MNACs/MLAs suggests an overall poor prognosis, with the majority presenting at advanced stages. This case series describes patients diagnosed with early-stage disease and reports on their histopathology, treatment regimens, and clinical outcomes. The majority of these patients are without recurrence after upfront treatment. Continued surveillance of these patients to determine long-term outcomes is necessary to further elucidate overall prognosis.

The Clinical Characteristics and Treatment Outcomes of Mesonephric Tumours of the Uterine Cervix: A Systematic Review and Proposal of Embryologically-Oriented Surgical Resection

Background/Objectives: Cervical mesonephric adenocarcinomas (MNACs) are among the rarest neoplasms of the female genital tract. Unlike the majority of cervical cancers, which are predominantly squamous in origin and strongly associated with HPV seropositivity, MNACs are distinct in both histology and pathophysiology. Despite their unique characteristics, MNACs have historically been managed in parallel with squamous cell carcinomas, resulting in a lack of optimised, evidence-based treatment protocols. In this systematic review, we aim to evaluate the current management strategies for MNACs and their associated clinical outcomes. Additionally, we critically appraise existing surgical and adjuvant therapies and propose embryologically oriented surgical techniques to achieve optimal tumour resection. Methods: We performed a systematic search across the MEDLINE, CENTRAL, EMBASE, and ClinicalTrials.gov databases from 1960 to June 2024. The search strategy employed a combination of keywords and MeSH terms, including "Uterine Cervical Neoplasms" [MeSH], "mesonephric tumour", "mesonephric neoplasm", and "mesonephric cancer". All relevant publications, including case reports and case series, were considered. Results: A total of 49 publications were finally included in the analysis, involving a thorough description of 91 MNAC cases. Most patients had stage I disease (70.8%) (n = 51). Hysterectomy was performed in 77 patients. The median follow-up was 29 months (range 1-199 months). Disease recurrence was observed in 35.2% (n = 25) of the cases, with the median disease-free survival (DFS) being 24 months (range 1-199). At the follow-up, 64.8% (n = 46) of patients remained in remission irrespective of the treatment modality, while 27.4% (n = 20) died due to disease progression. Conclusions: Mesonephric neoplasms of the uterine cervix are rare and clinically aggressive cancers that signify poor prognosis. Accurate identification and effective management can be challenging due to their particular anatomic and immunohistochemical characteristics. Therefore, a more tailored embryological-based approach should be considered for an optimal oncologic outcome.

Cervical Mesonephric Adenocarcinoma Treated with Neoadjuvant Chemotherapy: A Case Report and a Literature Review

INTRODUCTION

Cervical mesonephric ductal adenocarcinoma (MA) is an HPV-independent adenocarcinoma that occurs in middle-aged women. MA originates from remnants of the Wolffian duct that usually regress in females once the induction of sex differentiation is activated. MA is a rare disease that accounts for less than 1% of all cervical adenocarcinomas.

CLINICAL CASE

We report a case of MA in which abdominal radical hysterectomy (ARH) was performed after neoadjuvant chemotherapy (NAC). The patient was a 66-year-old woman with abnormal genital bleeding. A colposcopy examination revealed macroscopic invasive cancer. A pelvic MRI scan revealed a 53 × 26 mm tumor in the cervix, and the histological diagnosis of the cervix was endometrioid carcinoma, with the diagnosis being cervical adenocarcinoma cT1b3N0M0. One course of NAC with paclitaxel-carboplatin (PC) was administered to shrink the tumor and stop the bleeding, and ARH was performed. Postoperative histopathological diagnosis was MA. The surgical margins of the resected specimen were negative, and NAC had been effective, so the patient underwent five courses of PC therapy after surgery. There has been no recurrence 12 months after surgery.

CONCLUSIONS

There is no established standard treatment, but there are reports that PC therapy is effective. It is necessary to search for effective treatments by following up and accumulating further cases.

Mesonephric adenocarcinoma of the uterine cervix with a prominent spindle cell component

Mesonephric adenocarcinomas (MAs) with spindle cell components are rare malignant cervical tumours. In the present study, a retrospective analysis of these tumours was performed. Clinicopathological data were gathered from electronic surgical pathology records, and both immunohistochemistry and targeted next-generation sequencing (NGS) were performed. The present study included three postmenopausal female patients diagnosed with primary uterine cervical MA with prominent spindle cell components, aged 51-60 years. All patients underwent hysterectomy with bilateral salpingo-oophorectomy and pelvic lymph node dissection. There were no recurrences or deaths after surgery. NGS analysis identified KRAS mutations in 2 cases and a PIK3-catalytic subunit α (PIK3CA) mutation in another. Spindle cell components may indicate MAs at an advanced stage. Spindle cell components in MAs are diagnostic pitfalls, and the use of immunohistochemical panels and molecular detection cases with overlapping morphological features is recommended. While KRAS mutations are the most common types of mutations in MAs with spindle cell components, the present study demonstrates that PIK3CA mutations can also occur independently in cases without KRAS mutations.

Mesonephric-like adenocarcinoma of the female genital tract: possible role of KRAS-targeted treatment-detailed molecular analysis of a case series and review of the literature for targetable somatic KRAS-mutations

PURPOSE

Mesonephric-like adenocarcinomas (MLA) of the female genital tract represent a rare and relatively recently described neoplasm exhibiting characteristic morphologic and immunohistochemical findings commonly associated with a KRAS-mutation. Most cases display an aggressive clinical behavior, but knowledge about treatment approaches is limited, especially for targeting KRAS.

METHODS

We report a series of eight cases with a detailed molecular analysis for KRAS. These cases as well as the data of previously published cases with detailed information regarding KRAS-mutational events were reviewed for a potential targeted approach and its prognostic impact.

RESULTS

Both the uterine and ovarian MLA harbor a somatic KRAS-mutation in about 85% of the reported cases, affecting the hotspot codons 12 and 13. 15.7% of the endometrial and 15.6% of ovarian MLA are wild type for KRAS. A p.G12A-alteration was seen in 5.6% (5/89) of the endometrial and in 6.2% (2/32) of the ovarian tumors, for p.G12C in 7.9% and 6.2%, for p.G12D in 32.6% and 34.5% and for p.G12V in 36% and 37.5%, respectively. Very limited data are available regarding the prognostic impact of different mutational sites within the KRAS-gene without significant prognostic impact.

CONCLUSION

Because of a specific p.G12C-KRAS somatic mutation, only the minority of MLA (7.9% with uterine and 6.2% with ovarian primary) are potentially targetable by sotarasib in that rare but aggressive subtype of adenocarcinoma of the female genital tract. Until now, the different location of a somatic KRAS-mutation is of no prognostic impact.

Diagnosis, Treatment and Prognosis of Mesonephric Adenocarcinoma of the Vagina: A Literature Review and a Case Report

BACKGROUND

Mesonephric adenocarcinoma (MA) of the vagina is a rare tumor that arises from mesonephric remnants (Wolffian) in the female genital tract. It is a neoplasm with no significant evidence about its diagnosis, treatment, follow-up and prognosis.

METHODS

Systematic research of the literature was conducted in Scopus, PubMed/MEDLINE, ScienceDirect and the Cochrane Library, including observational prospective and retrospective studies, case series and case reports. We collected data regarding studies related to diagnosis and treatment options evaluating the following aspects: study design, population, treatment type, rate of surgical complications and fertility outcome. We further included a case report of laparoscopic management of MA with pictorial assays.

RESULTS

Thirteen cases of MA of the vagina are available in the literature, including our case report. The median age at diagnosis was 52 years old; the majority of patients reported vaginal bleeding as a symptom (38%); and ultrasound, followed by a magnetic resonance and CT scan were the diagnostic tools most used. In 54% of the cases, a surgical biopsy was performed, and 92% of the patients underwent upfront surgery with an open access or vaginal resection except one case fully managed by minimally invasive surgery. Most of the patients (68%) received adjuvant treatment with chemotherapy or radiotherapy or a combination of them. The mean follow-up period was 6 years.

CONCLUSIONS

Despite the rarity of this cancer and bizarre location, a minimally invasive approach seems feasible after multidisciplinary evaluation. According to the rarity of this tumor, any future case and follow-up data must be reported in the literature in order to enlarge the knowledge about it.

Extrauterine Mesonephric-like Carcinoma: A Comprehensive Single Institution Study of 33 Cases

Extrauterine mesonephric-like carcinoma (ExUMLC) shares histologic, immunohistochemical (IHC), and molecular (MOL) features with endometrial mesonephric-like carcinoma (EnMLC). Its rarity and histologic overlap with Mullerian carcinomas contribute to underrecognition of ExUMLC. Aggressive behavior of EnMLC is well-documented; behavior of ExUMLC is yet to be characterized. This study presents the clinicopathologic, IHC, and MOL features of 33 ExUMLC identified over a 20-year time period (2002-2022) and compares the behavior of this cohort to more common upper gynecologic Mullerian carcinomas (low-grade endometrioid, LGEC; clear cell, CCC; high-grade serous, HGSC) and EnMLC diagnosed over the same time period. ExUMLC patients ranged from 37 to 74 years old (median=59 y); 13 presented with advanced stage (FIGO III/IV) disease. Most ExUMLC had the characteristic mixture of architectural patterns and cytologic features, as previously described. Two ExUMLC had sarcomatous differentiation, 1 with heterologous rhabdomyosarcoma. Twenty-one ExUMLC (63%) had associated endometriosis, and 7 (21%) arose in a borderline tumor. In 14 (42%) cases, ExUMLC was part of a mixed carcinoma representing >50% of the tumor in 12. Twenty-six cases (79%) were incorrectly classified as follows: LGEC or HGEC (12); adenocarcinoma, not otherwise specified (3); HGSC (3); LGSC (2); mixed carcinoma (1); carcinosarcoma, Mullerian type (2); seromucinous carcinoma (1); transitional pattern of HGSC (1); and female adnexal tumor of probable Wolffian origin (1). Three patients had occult synchronous endometrial LGEC. IHC facilitated diagnosis in all cases with an expression of GATA-3 and/or TTF-1 in conjunction with decreased hormone receptor expression in most tumors. MOL testing (n=20) identified a variety of mutations, most frequently: KRAS (15); TP53 (4); SPOP (4); and PIK3CA (4). ExUMLC and CCC were more likely to be associated with endometriosis ( P <0.0001). ExUMLC and HGSC had more recurrences compared with CCC and LGEC ( P <0.0001). Histologic subtype was associated with longer disease-free survival for LGEC and CCC versus HGSC and ExUMLC ( P <0.001). ExUMLC trended towards a similar poor overall survival as HGSC compared with LGEC and CCC, and EnMLC trended to shorter survival compared with ExUMLC. Neither finding reached significance. No differences were seen between EnMLC and ExUMLC with respect to presenting stage or recurrence. Staging, histotype, and endometriosis were associated with disease-free survival, but on multivariate analysis, only stage remained as an independent predictor of outcome. The tendency of ExUMLC to present at an advanced stage and have distant recurrence points to more aggressive behavior compared with LGEC with which it is most frequently confused, underscoring the importance of an accurate diagnosis.

Radiologic Findings of Mesonephric-Like Adenocarcinoma of the Uterine Corpus: A Case Report

According to the 2020 World Health Organization classification, mesonephric-like adenocarcinoma (MLA) is newly categorized as a subtype of endometrial carcinoma and remains a relatively unknown disease owing to its rarity. To the best of our knowledge, radiological findings of MLA have not been reported in the English literature. The uterine MLAs show a worse clinical prognosis and a more aggressive biological behavior than the usual endometrial carcinoma. Herein, we present the imaging findings of a 65-year-old female with a MLA in the uterine corpus. The tumor was a solid endometrial mass with deep myometrial invasion, poor contrast enhancement, and moderate diffusion restriction.

Not Your Typical Adenocarcinoma: A Case of Mesonephric Adenocarcinoma of the Cervix With Fibroblast Growth Factor Receptor 2 (FGFR2) Mutation

Cervical cancer is one of the leading causes of cancer mortality in women. However, there have been great advances in its prevention and treatment. Nevertheless, there are certain rare forms of this cancer that are under-recognized, underreported, and have a paucity of evidence in terms of treatment. Mesonephric adenocarcinoma (AC) is one such rare disease, with less than 50 cases reported in the literature so far. We report a case of mesonephric AC of the cervix in a 73-year-old female who presented with abnormal vaginal bleeding. Our case is unique in that the patient had recurrence with lung metastases as well as fibroblast growth factor receptor 2 (FGFR2) mutation on genetic sequencing. She responded well to platinum-based chemotherapy and is currently on maintenance therapy with lenvatinib and bevacizumab. We aim to bring this patient’s disease course and treatment options chosen to the attention of the medical community as this is only the second reported case of mesonephric AC with FGFR2 mutation, and probably the first one to be treated with tyrosine kinase inhibitors and immunotherapy with a favorable response.

The complex and often confusing history, histology and histogenesis of mesonephric, STK11 adnexal tumour and mesonephric-like neoplasms of the upper female genital tract (including broad ligament)

Mesonephric lesions in the female genital tract are uncommon, with those arising from the upper tract being much less frequent than those developing in the lower tract (mesonephric hyperplasia and carcinoma). The most common upper tract lesions include rete cyst/cystadenoma and female adnexal tumour of Wolffian origin (FATWO). The integration of morphological, immunohistochemical and molecular studies on FATWOs has enabled recognition of a novel entity, the STK11 adnexal tumour, which is often associated with Peutz-Jeghers syndrome (~50%) and frequently has a salivary gland morphology but an unknown origin. Similarly, 'mesonephric-like' adenocarcinoma, an entity with striking similarities to mesonephric carcinoma but currently favoured to be of Müllerian derivation based on its association with other Müllerian tumours and molecular findings, has also been recently described, and may histologically mimic both FATWOs and STK11 adnexal tumours. In this review, we provide a historical overview of upper female genital tract mesonephric proliferations and discuss mesonephric lesions, STK11 adnexal tumour, mesonephric-like adenocarcinoma, and mimickers, the most common being endometrioid carcinoma.

Mesonephric Adenocarcinoma of the Vagina Harboring TP53 Mutation

Mesonephric adenocarcinoma (MA) of the female genital tract is a rare but distinct entity, exhibiting unique morphological, immunophenotypical, and molecular characteristics. Vaginal MA is hypothesized to arise from the mesonephric remnants located in the lateral vaginal wall. A 52-year-old woman presented with vaginal bleeding. Physical examination revealed a protruding mass in the left vaginal wall. Pelvic magnetic resonance imaging revealed a 2.5-cm mass arising from the left upper vagina and extending posterolaterally to the extravaginal tissue. The punch biopsy was diagnosed as poorly differentiated adenocarcinoma. She received radical surgical resection. Histologically, the tumor displayed various architectural patterns, including compactly aggregated small tubules, solid cellular sheets, endometrioid-like glands and ducts, intraluminal micropapillae, cribriform structure, and small angulated glands accompanied by prominent desmoplastic stroma. The tubules and ducts possessed hyaline-like, densely eosinophilic intraluminal secretions. The tumor extended to the subvaginal soft tissue and had substantial perineural invasion. Immunostaining revealed positivity for the mesonephric markers, including GATA3, TTF1, and PAX2, while showing very focal and weak positivity for estrogen receptor and negativity for progesterone receptor. Additionally, we observed a complete absence of p53 immunoreactivity. Targeted sequencing analysis revealed that the tumor harbored both activating KRAS p.G12D mutation and truncating TP53 p.E286* mutation. A thorough review of the previous literature revealed that 4.5% (3/67) of vaginal/cervical MAs and 0.9% (1/112) of uterine/ovarian mesonephric-like adenocarcinomas harbor TP53 mutations, indicating that this is very uncommon in malignant mesonephric lesions. In summary, we presented a rare case of vaginal MA uniquely harboring pathogenic TP53 mutation, resulting in p53 aberration.