Development of uterine sarcoma after tamoxifen treatment for breast cancer: report of four cases

[Uterine leiomyosarcoma - French guidelines from the GSF/NETSARC and TMRG groups]

Uterine leiomyosarcomas represent the most common uterine sarcomas. The prognosis is poor with metastatic recurrence in more than half of the cases. The purpose of this review is to make French recommendations for the management of uterine leiomyosarcomas within the framework of the French Sarcoma Group - Bone Tumor Study Group (GSF-GETO)/NETSARC+ and Malignant Rare Gynecological Tumors (TMRG) networks in order to optimize their therapeutic management. The initial assessment includes a MRI with diffusion perfusion sequence. The diagnosis is histological with a review in an expert center (Reference Network in Sarcoma Pathology (RRePS)). Total hysterectomy with bilateral salpingectomy, en bloc without morcellation, is performed when complete resection is possible, whatever the stage. There is no indication of systematic lymph node dissection. Bilateral oophorectomy is indicated in peri-menopausal or menopausal women. Adjuvant external radiotherapy is not a standard. Adjuvant chemotherapy is not a standard. It can be an option and consists in doxorobucin based protocols. In the event of local recurrence, the therapeutic options are based on revision surgery and/or radiotherapy. Systemic treatment with chemotherapy is most often indicated. In case of metastatic disease, surgical treatment remains indicated when resecable. In cases of oligo-metastatic disease, focal treatment of metastases should be considered. In the case of stage IV, chemotherapy is indicated, and is based on first-line doxorubicin-based protocols. In the event of excessive deterioration in general condition, management by exclusive supportive care is recommended. External palliative radiotherapy can be proposed for symptomatic purposes.

Evaluation of the Pelvic Floor of Women with Breast Cancer Using Tamoxifen by Transperineal 3D Ultrasonography

Objective

This study aimed to investigate the anatomical changes in the pelvic floor of women with breast cancer using tamoxifen by transperineal 3D ultrasonography and their effect on the urinary incontinence and sexual dysfunction.

Methods

Ninety-four patients with breast cancer using TAM in the study group and ninety-five healthy women of the same age in the control group were included in this prospective cohort study. Female Sexual Function Index and Incontinence Questionnaire-Short Form scales were applied to both groups. Ultrasonographic evaluation was performed at resting and Valsalva Maneuver with a convex (3-8 MHz) probe transperineally and the levator urethra gap and levator hiatus diameter were measured after 3-dimensional imaging. Independent t-tests were performed for statistical analysis.

Results

The mean age and body mass index of the experimental group versus control groups were 46.3 ± 6.12 years versus 46.4 ± 5.23 years and 27.6 ± 4.34 kg/m2 versus 29.2 ± 6.45 kg/m2, respectively. LUG and LH values were found significantly higher for the experimental groups compared to control groups at 17.23 ± 2.53 mm versus 14.1 ± 2.23 mm and 21 ± 2.45 cm2 versus 18 ± 4.56 cm2, respectively. (p < 0.05). The FSFI score significantly decreased (12.49 ± 3.58 versus 20.89 ± 3.69) and the ICIQ-SF score increased (4.02 ± 0.34 versus 2.34 ± 0.45) in the experimental group in comparison to control group (p < 0.05).

Conclusion

This study demonstrated that the effects of TAM usage on pelvic floor can be detected by measuring the changes in the levator ani muscle using the transperineal 3D USG. With transperineal USG screening, pelvic floor changes can be early diagnosed and clinical measures can be taken before they become symptomatic.

Leiomyosarcoma of the Uterus: A Rare Diagnosis

Uterine leiomyosarcoma is a rare malignant tumor that accounts for almost 2-5% of all uterine malignancies. It has the highest prevalence during pre and perimenopause. Further, it clinically resembles benign conditions like leiomyoma, and the diagnosis is confirmed with the histologic findings of the mass. Here, we present the case of a 70-year-old female who presented with lower abdominal pain for two years. Exploratory laparotomy with hysterectomy was performed, and the diagnosis of leiomyosarcoma was confirmed after histological examination of the resected tumor.

Leiomyosarcoma of Uterus in a Nulliparous Female: Mimicking as Ovarian Malignancy

Uterine sarcoma is a rare verity of smooth muscle tumor, accounting for 2 to 6% of uterine malignancies. Leiomyosarcoma (LMS) represents ~1% of overall uterine tumors and ~25 to 36% of uterine sarcomas. Here we present a case of uterine LMS in a 34-year-old nulliparous woman presented with huge distension of abdomen which was confused to be an ovarian malignancy. She underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. The diagnosis of LMS is made by histopathological examination after surgery. Surgery is the only treatment and role of adjuvant therapy has not been clearly defined.

Designing and Formulation Optimization of Hyaluronic Acid Conjugated PLGA Nanoparticles of Tamoxifen for Tumor Targeting

BACKGROUND

Tamoxifen is widely used for the treatment of estrogen receptor-positive breast cancer. However, it is associated with severe side effects of cancerous proliferation on the uterus endometrium. The tumor-targeting formulation strategies can effectively overcome drug side effects of tamoxifen and provide safer drug treatment.

OBJECTIVE

This study aimed to design tumor-targeted PLGA nanoparticles of tamoxifen by attaching hyaluronic acid (HA) as a ligand to actively target the CD44 receptors present at breast cancer cells surface.

METHODS

PLGA-PEG-HA conjugate was synthesized in the laboratory, and its tamoxifen-loaded nanoparticles were fabricated and characterized by FTIR, NMR, DSC, and XRD analysis. Formulation optimization was done by Box-Behnken design using Design-Expert software. The formulations were evaluated for in vitro drug release and cytotoxic effect on MCF-7 cell lines.

RESULTS

The particle size, PDI, and drug encapsulation efficiency of optimized nanoparticles were 294.8, 0.626, and 65.16%, respectively. Optimized formulation showed 9.56% burst release and sustained drug release for 8h. The drug release was affected by non-Fickian diffusion process and supplemented further by the erosion of polymeric matrix which followed the Korsmeyer-Peppas model. MTT cell line assay showed 47.48% cell mortality when treated with tamoxifen-loaded PLGA- PEG-HA nanoparticles.

CONCLUSION

Hyaluronic acid conjugated PLGA-PEG nanoparticles of tamoxifen were designed for active targeting to cancerous breast cells. The results of the MTT assay showed that tamoxifen nanoparticles formulation was more cytotoxic than tamoxifen drug alone, which is attributed to their preferential uptake by cell lines by the affinity of CD44 receptors of cell lines to HA ligand present in nanoparticles.

Incidence of unexpected uterine malignancies after electromechanical power morcellation: a retrospective multicenter analysis in Germany

PURPOSE

During the last decade, electromechanical power morcellation (EMM) was more frequently used but it may be associated with the dissemination of occult malignancies. The aim of the present study was to determine the frequency of unexpected uterine malignancies after EMM.

METHODS

This retrospective study consisted of patients who were treated at three departments of Gynecology in Germany from 2008 to 2017. We identified women who underwent an operation with the use of EMM. Clinical records, risk factors, and the outcomes of the patients were reviewed.

RESULTS

We performed an analysis of 1683 patients who had undergone laparoscopic supracervical hysterectomy (LASH), total hysterectomy, or myomectomy (LM) (48.6%, 8.4%, and 43.0%, respectively). Unexpected malignancies were detected in 4 of 1683 patients (0.24%). In all cases, the malignancy proved to be a sarcoma and was detected after LASH. All patients with occult sarcomas were older than 45 years and the most common (75%) risk factor was the appearance of a solitary tumor. The patients underwent secondary laparotomy for complete oncological staging, and no histological dissemination of the sarcoma was registered. Two patients had a recurrence. At the final follow-up investigation all four patients were in good general health.

CONCLUSION

Occult malignancies are liable to spread after EMM, although the overall risk of being diagnosed with an occult malignancy and the risk of dissemination appear to be low. Once the preoperative diagnostic investigation has yielded no suspicious findings, laparoscopic morcellation may be considered a safe method, especially LM in patients of reproductive age.

Unexpected Histopathological Diagnosis of Undifferentiated Uterine Sarcoma after Simple Hysterectomy: Extrapolating Limited Evidence

Uterine sarcomas are a rare malignancy, often retrospectively diagnosed after myomectomy or hysterectomy. Undifferentiated uterine sarcomas (UUS) are a particularly aggressive variant of this condition. Little evidence exists regarding the postoperative management of undifferentiated sarcomas diagnosed after hysterectomy performed for presumed benign conditions. We describe the case of a 33-year-old woman who presented with heavy bleeding and subsequently underwent hysterectomy on an emergency basis after failed medical management. Cut-section of the uterus revealed a grossly benign-looking sub-mucosal fibroid. However, the final histopathology report revealed undifferentiated uterine sarcoma. We worked up the patient postoperatively with MRI to rule out metastasis and performed bilateral salpingo-oophorectomy based on hormone receptivity status. We followed this with single-agent chemotherapy with adriamycin, which was followed by continuous therapy with oral letrozole (aromatase inhibitor). The patient was found doing well at the two-year follow-up, with no evidence of relapse. Postoperative diagnosis of UUS should include imaging to rule out metastasis, consideration for completion of surgery based on hormone receptivity of tumour, and lymphadenectomy based on the subtype of tumour.

Benign uterine mass-discrimination from leiomyosarcoma by a preoperative risk score: a multicenter cohort study

PURPOSE

Discrimination of uterine leiomyosarcoma (LMS) and leiomyoma (LM) prior to surgery by basic preoperative characteristics and development of a preoperative leiomyosarcoma score.

METHODS

A predominantly prospective cohort of 826 patients with LM from a clinical institution and an outpatient center was included in the study. Further a predominantly retrospective cohort of 293 patients with LMS was included from the counseling database of the German Clinical Center of Excellence for Genital Sarcoma and Mixed Tumors (DKSM, University Medicine Greifswald, Germany). We analyzed and compared anamnestic, epidemiological and clinical findings between both cohorts. Tenfold cross-validated logistic regression and random forest was performed on the 80% training set. The preoperative LMS score (pLMS) was developed based on logistic regression and independently evaluated by analyzing the area under the receiver operating characteristic curve (AUC) with the 20% test set.

RESULTS

In the LMS cohort, 63.1% had initially surgery for presumed LM and only 39.6% of endometrial biopsies revealed LMS. Key features for LMS discrimination were found to be bleeding symptoms: intermenstrual bleeding [RR_c = 2.71, CI = (1.90-3.49), p < 0.001], hypermenorrhea [RR_c = 0.28, CI = (0.15-0.50), p < 0.001], dysmenorrhea [RR_c = 0.22, CI = (0.10-0.51), p < 0.001], postmenstrual bleeding [RR_c = 2.08, CI = (1.30-2.75), p < 0.001], suspicious sonography [RR_c = 1.21, CI = (1.19-1.22), p < 0.001] and the tumor diameter (each centimeter difference: β = 0.24, SD = 0.04, p < 0.001). pLMS achieved a mean cross-validated AUC of 0.969 (SD = 0.019) in the training set and an AUC of 0.968 in the test set.

CONCLUSIONS

The presented score is based on basic clinical characteristics and allows the prediction of LMS prior to a planned surgery of a uterine mass. In case pLMS is between - 3 and + 1, we suggest subsequent diagnostics, such as endometrial biopsy, color Doppler sonography, LDH measurement, MRI and transcervical biopsy.

Possibility of Operative Treatment of Uterine Sarcoma: Case Report

Uterine sarcomas make up only 5% of all malignancies in gynecology. Their classification is complicated due to low incidence and large histological differences. Uterine sarcoma is usually diagnosed in postmenopausal women, and this is most often done accidentally at the postoperative stage. The existence of uterine sarcoma should be suspected in cases of rapid uterine growth in postmenopausal state. Postmenopausal abnormal bleeding is the most common reason for a medical examination.

In this paper, a 48-year-old patient is presented in whose case during a regular gynecological examination; the existence of tumour change in the uterine part of uterus has been noticed. The patient did not have gynecological problems until then. The patient was then subjected to a diagnostic exploratory curettage. The pathohistological finding was negative. Given that the onset change is present after the control check, it is decided to proceed with an operative procedure. A pathohistological finding (uterus and adnexa) indicates that it is a uterine sarcoma. After that, the patient was re-treated with two more operations and then had chemotherapy and radiation therapy. After completing the whole treatment, for the period of six years, the patient now feels well and performs her usual work tasks.

Clinical Characteristics Differentiating Uterine Sarcoma and Fibroids

Background and Objectives:

Uterine fibroids are a common indication for laparoscopy. Unsuspected sarcoma can pose a serious risk if morcellation is used in the procedure. We sought to determine the clinical factors associated with uterine sarcoma compared with uterine fibroids.

Methods:

We conducted a case–control study of 66 women who had hysterectomy for uterine sarcoma from April 1, 2007, to March 31, 2014. Sixty-six patients who had hysterectomy for fibroids were randomly selected as controls.

Results:

Women with sarcoma vs women with fibroids, tended to be older (mean ± SD 62.1 ± 10.1 vs 46.5 ± 6.6; P < .0001), were more likely to be postmenopausal (81.8% vs 9.2%; P < .0001), and were more likely to have a history of another nonuterine malignancy (16.7% vs 4.6%; P = .02). Women with sarcoma were more likely to have masses that were subserosal (69.4% vs 34.8%; P < .0001), rather than intramural (11.1% vs 37.0%; P = .01), and to have a solitary rather than multiple uterine mass (56.3% vs 18.5%; P < .0001). They were also more likely to have a history of documented rapid growth (16.7% vs 4.6%; P = .02).

Conclusion:

Despite limitations in sample size related to infrequency of uterine sarcoma, our results suggest some preoperative clinical differences between women who have uterine sarcoma vs uterine fibroids. Further studies on such features may assist us in identifying patients who are at higher risk of having a uterine sarcoma among women with a uterine mass contemplating surgery.

Surgical Methods for the Treatment of Uterine Fibroids - Risk of Uterine Sarcoma and Problems of Morcellation: Position Paper of the DGGG

The appropriate surgical technique to treat patients with uterine fibroids is still a matter of debate as is the potential risk of incorrect treatment if histological examination detects a uterine sarcoma instead of uterine fibroids. The published epidemiology for uterine sarcoma is set against the incidence of accidental findings during surgery for uterine fibroids. International comments on this topic are discussed and are incorporated into the assessment by the German Society for Gynecology and Obstetrics (DGGG). The ICD-O-3 version of 2003 was used for the anatomical and topographical coding of uterine sarcomas, and the "Operations- und Prozedurenschlüssel" (OPS) 2014, the German standard for process codes and interventions, was used to determine surgical extirpation methods. Categorical qualifiers were defined to analyze the data provided by the Robert Koch Institute (RKI), the German Federal Bureau of Statistics (DESTATIS; Hospital and Causes of Death Statistics), the population-based Cancer Register of Bavaria. A systematic search was done of the MEDLINE database and the Cochrane collaboration, covering the period from 1966 until November 2014. The incidence of uterine sarcoma and uterine fibroids in uterine surgery was compared to the literature and with the different registries. The incidence of uterine sarcoma in 2010, standardized for age, was 1.53 for Bavaria, or 1.30 for every 100 000 women, respectively, averaged for the years 2002-2011, and 1.30 for every 100 000 women in Germany. The mean incidence collated from various surveys was 2.02 for every 100 000 women (0.35-7.02; standard deviation 2.01). The numbers of inpatient surgical procedures such as myoma enucleation, morcellation, hysterectomy or cervical stump removal to treat the indication "uterine myoma" have steadily declined in Germany across all age groups (an absolute decrease of 17 % in 2012 compared to 2007). There has been a shift in the preferred method of surgical access from an abdominal/vaginal approach to endoscopic or endoscopically assisted procedures to treat uterine fibroids, with the use of morcellation increasing by almost 11 000 coded procedures in 2012. Based on international statements (AAGL, ACOG, ESGE, FDA, SGO) on the risk of uterine sarcoma as an coincidental finding during uterine fibroid surgery and the associated risk of a deterioration of prognosis (in the case of morcellation procedures), this overview presents the opinion of the DGGG in the form of four Statements, five Recommendation and four Demands.

Tamoxifen in breast cancer ipse dixit in uterine malignant mixed Müllerian tumor and sarcoma-A report of 8 cases and review of the literature

AIM

Report the outcome of 8 patients (pts) with breast cancer (BC) treated with Tamoxifen (TAM) that developed malignant mixed Müllerian tumor (MMMT) and rare uterine sarcoma (RUS).

PATIENTS AND METHODS

Retrospective study based on data collected from the department medical records between April 1999 and September 2010 among 583 pts with endometrial cancer, 36 pts with MMMT and RUS histopathology. Among them, 8 pts underwent TAM between 4 and 10 years due to a previous diagnosis of BC; all pts were post-menopausal with regular gynecological surveillance; 6 pts (75%) with abnormal uterine bleeding. The diagnosis of 6 pts (MMMT) and 2 pts (RUS) occurred at median interval of 8 years (range 4-12) after initial BC treatment. Pts underwent surgical treatment and were staged as stage I (3pts), IIIA (3pts) and IIIC (2 pts) (FIGO 1988); followed by whole pelvis irradiation (50 Gy) and intracavitary HDR brachytherapy boost (24 Gy). Two pts underwent chemotherapy (CT). Overall and disease free survival was calculated by Kaplan Meier method.

RESULTS

With a median follow-up of 47 months (range 17-130), 3 pts remain alive recurrence-free of BC and RUS. Four pts died with distant metastasis within the first follow-up year, without BC. One pt died from non-related cancer cause. No evidence of local recurrence was found in the whole group of pts. At two years, DFS and OS were 40% and 80%, respectively.

CONCLUSION

As reported in the literature, TAM administration and causal effect on MMMT and RUS in BC pts is still unknown. No reports about outcome from these specific pts were found.

A case of endometrial stromal sarcoma with synchronous bilateral adenocarcinoma of ovary

Endometrial stromal tumor is a rare mesenchymal uterine tumor. We report the case of a patient with endometrial stromal sarcoma and concomitant bilateral endometrioid adenocarcinoma of the ovary in the context of pelvic endometriosis. The patient underwent a complete cytoreduction including total hysterectomy and bilateral adnexectomy, pelvic lymphadenectomy, appendicectomy, infracolic omentectomy, and pelvic peritonectomy. This is the first report to our knowledge that describes a synchronous endometrial stromal sarcoma and bilateral endometrioid adenocarcinoma of the ovary.

A uterine leiomyoma in which a leiomyosarcoma with osteoclast-like giant cells and a metastasis of a ductal breast carcinoma are present

Leiomyosarcoma of the uterus is a rare tumor, and the presence of osteoclast-like giant cells in this tumor is even rarer. A leiomyosarcoma arising in a leiomyoma is also quite unique. Breast cancer metastasizing to the uterus is seldom seen as well. A 70-year-old woman presented with metastasized breast cancer to the bones. An evaluation of the computed tomographic scan was made, which showed an enlarged uterus with a tumor. The tumor was a leiomyoma in which a leiomyosarcoma with osteoclast-like giant cells as well as a metastasis of a ductal breast carcinoma was present. To our knowledge, this is the first report of a leiomyosarcoma containing osteoclast-like giant cells, present in a leiomyoma, in a uterus also containing a ductal breast cancer metastasis present in the leiomyoma and myometrium.

Co-expression of GPR30 and ERbeta and their association with disease progression in uterine carcinosarcoma

OBJECTIVE

We sought to evaluate the expression of G protein-coupled receptor 30 (GPR30) and estrogen receptor (ER)beta in uterine carcinosarcoma (CS).

STUDY DESIGN

Immunohistochemistry was performed using antibodies to GPR30, ERbeta, ERalpha, and progesterone receptor (PR). The staining intensity and percentage of positive cells were scored for each tissue section. Expression levels were compared using the Wilcoxon rank sum test. Correlation was evaluated by Spearman rho and logistic regression.

RESULTS

Compared with normal endometrium, CS had lower ERalpha and PR expression (both P < .01) but higher GPR30 epithelial expression (P = .03). Advanced-stage CS had higher GPR30 (P < .01) and ERbeta (P = .02) epithelial expression compared with early-stage CS. Expression of GPR30 and ERbeta correlated with each other (P < .01), and not with ERalpha or PR.

CONCLUSION

In uterine CS, GPR30 and ERbeta are coordinately overexpressed and expression levels increase in advanced-stage disease, supporting the involvement of alternative ERs in disease progression.

[Uterine sarcoma associated with tamoxifen use after breast cancer: Review of the pathogenesis]

Tamoxifen is widely used in the breast cancer treatment. Its side effects on the endometrium are well-known, but more and more worse prognosis uterine sarcoma are described. Based on recent literature review, the cause and effect chain between tamoxifen and uterine sarcoma is argued, which confirms that a risk exists as from 2 years of treatment, a cumulative dose of 15 g, and that malignant mixed mesodermal tumours appear to be the most frequent.

Primary malignant mixed mullerian tumor of the uterus: findings on sonography, CT, and gadolinium-enhanced MRI

OBJECTIVE

The purpose of our study was to evaluate the sonographic, contrast-enhanced CT, and gadolinium-enhanced MRI findings of primary malignant mixed müllerian tumors (MMMTs) of the uterus.

CONCLUSION

Uterine MMMT most commonly presents as an intracavitary mass with coexistent dilatation of the endometrial canal. Tumors tend to appear hyperechoic on sonography, heterogeneously hypodense and ill defined on contrast-enhanced CT, and heterogeneously hyperintense on T2-weighted MR images with signal abnormalities indicating subacute hemorrhage on T1-weighted MR images. Myometrial invasion is common and has a predilection for the uterine fundus.

The risk of developing uterine sarcoma after tamoxifen use

The treatment of breast cancer with tamoxifen results in an increased risk of uterine cancer. The objective of this study was to evaluate the association between tamoxifen use and the risk of developing uterine sarcomas and endometrial carcinomas in a historical cohort of women diagnosed with breast cancer in 1987–1988. The medical records of all women diagnosed in Israel with breast cancer in the years 1987–1988 were sought. Clinical data, including use of hormone therapy, were extracted from oncology records. In 2004, patient identifiers were linked to the Israel Cancer Registry database to identify all uterine cancers that occurred within 15 years of the diagnosis of breast cancer. The records for 1507 breast cancer cases (84%) were retrieved. Among these cases, 32 uterine malignancies were identified; 11 occurred prior to the diagnosis of breast cancer and 21 occurred during the follow-up period. Eight hundred seventy-five women in the cohort had used tamoxifen (59%). There were 17 uterine cancers observed among the 875 exposed to tamoxifen (1.9%), compared to 4 uterine cancers among the 621 women (0.6%) who did not use tamoxifen (odds ratio = 3.1; 95% CI: 1.0–9.1; P = 0.04). There were four uterine sarcomas among the tamoxifen users, but none among nonusers (P = 0.15). Five of the 875 tamoxifen users (0.6%) died of uterine cancer, compared to no deaths among nonusers (P = 0.08). We conclude that in this national breast cancer cohort, tamoxifen use was associated with elevated risks of uterine cancer incidence and mortality. Uterine sarcomas appear to be overrepresented among women who use tamoxifen.

Uterine sarcomas

A wide variety of sarcomas occur in the uterus but two subtypes - leiomyosarcoma and endometrial stromal sarcoma - account for a majority of those more routinely encountered. Using the 2003 World Health Organization classification, this review focuses on six uterine sarcomas: endometrial stromal sarcoma, undifferentiated endometrial sarcoma, leiomyosarcoma, rhabomyosarcoma, angiosarcoma and liposarcoma. The epidemiological, clinical, pathological and molecular features are presented along with therapeutic approaches. Familiarity with molecular aspects of these tumors and application of novel technologies in their assessment should be encouraged as they may provide alternate therapies resulting in improved survival for the patient. Clinical information necessary for accurate diagnosis of these lesions is emphasised. A multidisciplinary approach to management of patients with uterine sarcomas is essential for optimal management.