Stage-specific outcomes of patients with uterine leiomyosarcoma: a comparison of the international Federation of gynecology and obstetrics and american joint committee on cancer staging systems

Uterine Leiomyosarcoma in a Young Woman: A Report of a Rare Case

Uterine leiomyosarcoma (LMS) is an uncommon disease that arises from the smooth muscles present in the uterus. It usually occurs in post-menopausal women. Due to its aggressive nature, it has a very poor prognosis. We present a case of uterine LMS, which presented at a young age of 35 years for infertility, which is rare at this age. She had a fundal fibroid for which myomectomy was done. On histopathology, she was diagnosed with LMS. It is very difficult and nearly impossible to diagnose LMS preoperatively by available imaging modalities. There is an urgent need for a reliable preoperative risk scoring system that can help in diagnosing malignancy so that a correct surgical pathway and treatment can be offered to patients. A total abdominal hysterectomy (TAH) with bilateral salpingo-oophorectomy (BSO) was done and was advised adjuvant chemotherapy. The patient remained disease-free and was put on chemotherapy.

Treatment patterns and outcomes for primary uterine leiomyosarcoma with synchronous isolated lung metastases: A National Cancer Database study of primary resection and metastasectomy

Background

One third of patients with uterine leiomyosarcomas (uLMS) present with distant metastases. Current guidelines do not include recommendations around surgery for metastatic uLMS. Patients with distant metastases commonly receive primary tumor resection for symptoms and so oncologic outcomes after surgery warrant exploration. We describe treatment patterns and outcomes for uLMS patients with synchronous isolated lung metastases (SILM).

Methods

This retrospective analysis of the National Cancer Database identified patients with uLMS and SILM. Patients with non-pulmonary metastases were excluded. We collected demographic, disease, and treatment characteristics and assessed clinicopathologic factors associated with the receipt of surgery on multivariate regression. Median, 1-year, and 5-year overall survival (OS) across treatment approaches were compared using Kaplan-Meier curves and log-rank tests. Multivariate Cox proportional hazard regressions identified independent predictors of survival.

Results

We identified 905 patients with uLMS and SILM between 2004 and 2017. 600 patients had primary tumor resection; 63 also had curative intent surgery with metastasectomy. Patients who did not receive chemotherapy were older (p<0.01) with a higher comorbidity index (p<0.05). Women with private health insurance were more likely to receive chemotherapy (p<0.01) and primary tumor resection (p<0.01). Patients who underwent curative intent surgery had 1-year OS of 71.2% and 5-year survival of 18% compared to 1-year survival of 35.6 % and 5-year survival of 5.16 % for patients who had no surgery. Black women had poorer survival on multivariate regression.

Conclusions

Primary tumor resection and curative intent surgery are associated with improved OS in uLMS with SILM and may be a reasonable treatment option in appropriately selected patients.

Establishment of a staging system for visceral sarcoma

BACKGROUND

Visceral sarcoma is a rare malignancy with a poor prognosis. However, there is no recommended prognostic staging system for the malignant disease.

METHOD

We analyzed the data of patients diagnosed with primary soft tissue sarcoma (STS) of the abdomen and thoracic visceral organs between 2006 and 2017 at our hospital. Prognostic factors (size, tumor grade, and lymph node metastasis) were analyzed in our cohort (n = 203) and the SEER validation cohort (n = 5826).

RESULTS

Tumor size, grade, and lymph node metastasis were important prognostic factors for visceral sarcoma in both our and the SEER cohorts. Based on these prognostic factors, we established a new staging system for visceral sarcoma, by which patients could be stratified into clinically meaningful and non-overlapping stages in both our cohort and the SEER validation series. Moreover, the area under the curve (AUC) value of the staging system for 5-year survival was 0.84 (95% CI: 0.78-0.89) in our series and 0.80 (95% CI: 0.79-0.81) in SEER series, respectively. In addition, compared with the widely used FIGO staging system for female genital sarcoma, the visceral sarcoma staging system could more effectively and reliably stratify patients into four different prognostic groups.

CONCLUSIONS

The visceral sarcoma staging system is applicable for STS of the abdomen and thoracic visceral organs and is better than the current FIGO staging system for female genital sarcoma and should be incorporated into the AJCC Cancer Staging Manual.

Impact of perioperative characteristics on the recurrence risk and survival of patients with uterine leiomyosarcoma

OBJECTIVES

To analyze the impact of perioperative characteristics on the risk of recurrence in patients with uterine leiomyosarcomas.

METHODS

A sub-analysis of the SARComa of the UTerus (SARCUT) study, which is a multicentric cross-sectional pan-European study that included 390 patients diagnosed with leiomyosarcoma, between 2001 and 2007. Perioperative factors related to risk of recurrence and survival were analyzed.

RESULTS

The 5-year and 10-year disease-free survivals (DFS) were 46% and 55%, respectively. Overall survival at 5 and 10 years was 34% and 47%, respectively. The most important factors related to global recurrence were the incomplete cytoreduction (hazard ratio [HR] 2.87; 95% confidence interval [CI] 1.91-4.31); performing bilateral adnexectomy (HR 2.71; 95% CI 1.23-5.93); tumor persistence after any treatment (HR 2.38; 95% CI 1.39-4.06); and adjuvant chemotherapy administration (HR 2.55; 95% CI 1.82-3.58) or adjuvant radiotherapy (HR 2.26; 95% CI 1.53-3.32). The major factors significantly associated with pelvic relapse were tumor persistence after any treatment (HR 3.63; 95% CI 1.83-7.20) and adjuvant radiotherapy (HR 2.74; 95% CI 1.44-5.20). Incomplete cytoreduction was the most important factor associated with distant relapse (HR 1.91; 95% CI 1.22-2.97). The most important factors related to overall survival were tumor persistence after any treatment (HR 4.59; 95% CI 2.51-8.40), incomplete cytoreduction (HR 3.68; 95% CI 2.44-5.56), tumor margin involvement (HR 2.41; 95% CI 1.64-3.55) and adjuvant chemotherapy (HR 1.91; 95% CI 1.31-2.78).

CONCLUSIONS

Complete cytoreduction is the main prognosis factor impacting the DFS and overall survival of patients with uterine leiomyosarcoma. Adjuvant chemotherapy administration was associated with decreased rates of DFS and overall survival. The adjuvant radiotherapy was associated with a higher risk of global recurrence.

Prognostic Impact of Tumor-Infiltrating Lymphocytes, Tertiary Lymphoid Structures, and Neutrophil-to-Lymphocyte Ratio in Pulmonary Metastases from Uterine Leiomyosarcoma

BACKGROUND

The presence of tumor-infiltrating lymphocytes (TILs) and tertiary lymphoid structures (TLSs) in tumor tissue has been related to the prognosis in various malignancies. Meanwhile, neutrophil-to-lymphocyte ratio (NLR) as a systemic inflammation marker also has been associated with the prognosis in them. However, few reports have investigated the relationship between pulmonary metastases from sarcoma and these biomarkers.

METHODS

We retrospectively recruited 102 patients undergoing metastasectomy for pulmonary metastases from uterine leiomyosarcoma at Okayama University Hospital from January 2006 to December 2019. TILs and TLSs were evaluated by immunohistochemical staining of surgically resected specimens of pulmonary metastases using anti-CD3/CD8/CD103/Foxp3/CD20 antibodies. NLR was calculated from the blood examination immediately before the most recent pulmonary metastasectomy. We elucidated the relationship between the prognosis and these factors. Because we considered that the status of tumor tissue and systemic inflammation were equally valuable, we also assessed the impact of the combination of TILs or TLSs and NLR on the prognosis.

RESULTS

As for TILs, CD3-positive cells and CD8-positive cells were correlated with the prognosis. The prognosis was significantly better in patients with CD3-high group, CD8-high group, TLSs-high group, and NLR-low group, respectively. The prognosis of CD8-high/NLR-low group and TLSs-high/NLR-low group was significantly better than that of CD8-low/NLR-high group and TLSs-low/NLR-high group, respectively.

CONCLUSIONS

CD3-positive TILs, CD8-positive TILs, TLSs, and NLR are correlated with the prognosis, respectively. The combination of CD8-positive TILs or TLSs and NLR may be the indicators to predict the prognosis of patients with pulmonary metastases from uterine leiomyosarcoma.

Low-Grade Uterine Leiomyosarcoma Is Highly Sensitive to Hormonal Treatment

PURPOSE

According to the World Health Organization classification system, uterine leiomyosarcomas (ULMS) are high-grade. A diagnosis of smooth-muscle tumors of uncertain malignant potential (STUMP) is made when Stanford Criteria for ULMS are not met. When a STUMP recurs, the tumor is diagnosed as ULMS and medical treatment is the same as for ULMS. In recent years, some sarcoma centers valued the less aggressive clinical behavior of several recurring STUMP and, given their expression of estrogen and progesterone receptors, started to treat them with hormonal therapy.

EXPERIMENTAL DESIGN

This was a retrospective cohort analysis conducted at three referral centers joining the Leiomyosarcoma Foundation Roundtable. We selected all cases of uterine smooth muscle tumors consistent with STUMP and treated with hormonal therapy.

RESULTS

27 consecutive patients were identified. Median age at diagnosis was 43 years. Stage was IA-IB in more than 70% of patients. In these patients, median time to relapse was 62 months. Sites of first relapses were mostly pelvis and peritoneum (76%). After a median follow-up of 49 months, 14 patients (52%) had a partial response while 10 (37%) had a minor response or stable disease. Median time to progression was not reached.

CONCLUSIONS

We observed a response or long-term stability rate on hormonal therapy in the 90% range; in all cases the time to relapse was significantly longer than in ULMS and in most cases the relapse was abdominal. On the basis of these findings, we conclude that a proportion of patients with uterine smooth muscle neoplasms actually present with a "low-grade ULMS."

Brain and lung metastasis of uterine leiomyosarcoma: illustrative case

BACKGROUND

Uterine leiomyosarcoma is a rare, extremely aggressive tumor with a high rate of metastasis. Five-year survival for individuals with metastatic disease is only 10%-15%. Metastases to the brain are exceptionally rare and are associated with poor survival.

OBSERVATIONS

The authors report a case of uterine leiomyosarcoma that metastasized to the brain in a 51-year-old woman. A single lesion on magnetic resonance imaging was discovered in the right posterior temporo-occipital region 44 months after resection of the primary uterine tumor. The patient underwent a right occipital craniotomy with gross-total resection of the tumor and is receiving adjuvant stereotactic radiosurgery and chemotherapy with gemcitabine and docetaxel. At 8 months postresection, the patient remains alive and asymptomatic with no sign of recurrence. A literature review of prior reported cases was conducted to analyze patterns of approach to patient treatment and survival.

LESSONS

The authors found an apparent survival benefit in patients receiving adjuvant radiation therapy.

[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.

Treatment strategies in patients with gynecological sarcoma: Results of the prospective intergroup real-world registry for gynecological sarcoma in Germany (REGSA-NOGGO RU1)

OBJECTIVE

Gynecological sarcomas account for 3% of all gynecological malignancies and are associated with a poor prognosis. Due to the rarity and heterogeneity of gynecological sarcomas there is still no consensus on optimal therapeutic strategies. This study's objective was to describe the treatment strategies used in patients with gynecological sarcomas in the primary course of disease.

METHODS

The German prospective registry for gynecological sarcoma (REGSA) is the largest registry for gynecological sarcomas in Germany, Austria and Switzerland. Primary inclusion criteria for REGSA are histological diagnosis of sarcoma of the female genital tract, sarcoma of the breast or uterine smooth muscle tumors of uncertain malignant potential (STUMP). We evaluated data of the REGSA registry on therapeutic strategies used for primary treatment from August 2015 to February 2021.

RESULTS

A total of 723 patients from 120 centers were included. Data on therapeutic strategies for primary treatment were available in 605 cases. Overall, 580 (95.9%) patients underwent primary surgery, 472 (81.4%) of whom underwent only hysterectomy. Morcellation was reported in 11.4% (n=54) of all hysterectomies. A total of 42.8% (n=202) had no further surgical interventions, whereas an additional salpingo-ophorectomy was performed in 54% (n=255) of patients. An additional lymphadenectomy was performed in 12.7% (n=60), an omentectomy in 9.5% (n=45) and intestinal resection in 6.1% (n=29) of all patients. Among 448 patients with available information, 21.4% (n=96) received chemo- or targeted therapies, more commonly as single-agent treatment than as drug combinations. Information about anti-hormonal treatment was available for 423 patients, among which 42 (9.9%) received anti-hormonal treatment, 23 (54.8%) of whom with low-grade endometrial stroma sarcomas. For radiotherapy, data of 437 patients were available, among which 29 (6.6%) patients underwent radiotherapy.

CONCLUSION

Our study showed that treatment of patients with gynecologic sarcomas is heterogeneous. Further trials are needed along with more information on treatment modalities, therapy response and patient-reported outcomes to implement new treatment strategies.

A nomogram-based overall survival stratification to identify uterine sarcoma patients without distant metastases who may benefit from adjuvant radiotherapy

OBJECTIVE

Adjuvant radiotherapy has been commonly performed in uterine sarcoma patients, but its role in overall survival (OS) remains controversial. Therefore, our study aimed to build a nomogram-based prognostic stratification to identify uterine sarcoma patients who might benefit from adjuvant radiotherapy.

METHODS

Uterine sarcoma patients without distant metastases between 2004 and 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The LASSO Cox regression was performed to identify essential prognostic predictors and a nomogram was built to predict the 1-, 3-, and 5-year OS. Receiver operating characteristic (ROC), calibration curves, and decision curve analysis (DCA) were used to validate the nomogram. Finally, prognostic stratification was performed by decision tree analysis based on the total points of the nomogram.

RESULTS

2871 patients with uterine sarcoma were included. Preliminary analysis suggested that adjuvant radiotherapy failed to provide an OS benefit for the total population without our nomogram. The built nomogram showed good discrimination and calibration abilities to predict the OS in uterine sarcoma patients and the patients were stratified into three risk groups based on the nomogram. For patients in the high-risk group, adjuvant radiotherapy significantly improved the 5-year OS and median survival time by 26.4% and 17 months, respectively (P < 0.001); while radiotherapy failed to improve the survival outcomes of patients in the low- and intermediate-risk groups.

CONCLUSIONS

The nomogram-based prognostic stratification provides preliminary characterization of uterine sarcoma patients who may benefit from radiotherapy. The newly defined high-risk patients may gain significant OS benefit from adjuvant radiotherapy.

Five-Year Retrospective Study of Uterine STUMP and Leiomyosarcoma

Taking into account the unpredictable evolution of uterine STUMP and leiomyosarcomas, there are no clearly established therapeutic protocols to date, the only certified treatment being total hysterectomy. We performed a 5-year retrospective study including cases of malignant tumors and those with uncertain malignant potential originating in the smooth muscle tissue of the uterine body. The clinical data, pathological aspects, and the immunohistochemical results were statistically analyzed using SPSS Statistics Version 26. The main associations of the p53 gene were identified with age, atypia, and the occurrence of metastases. The average number of CD8+ T cells correlated with the hormonal status of the patients, the presence of diabetes, and alteration of thyroid function, but also with the severity of the atypia. The therapeutic method was represented by total hysterectomy, and 30% of the patients with leiomyosarcoma also benefited from adjuvant chemotherapy. The average period until death was 25.66 months. The present study showed that the mutant expression of p53 could have a role in assessing the clinical evolution of patients, given the association with exitus and metastasis. In addition, the average number of CD8+ T cells corresponded to severe atypia, indicating the possibility of applying targeted immunotherapies in these cases.

A novel morphology-based risk stratification model for stage I uterine leiomyosarcoma: an analysis of 203 cases

Uterine leiomyosarcoma is the most common uterine mesenchymal malignancy. The majority present at stage I, and clinical outcomes vary widely. However, no widely accepted risk stratification system for stage I uterine leiomyosarcoma is currently available. We studied 17 routinely evaluated clinicopathologic parameters in 203 stage I uterine leiomyosarcoma from three institutions to generate a novel risk stratification model for these tumors. Mitoses >25 per 2.4 mm2 (10 high-power fields), atypical mitoses, coagulative necrosis, lymphovascular invasion, and serosal abutment were significantly associated with disease-free and disease-specific survival in univariate and multivariate analyses. These prognostic parameters were each scored as binary ("yes" or "no") variables and fitted to a single optimized algebraic risk model:Risk score = (coagulative necrosis)(1) + (mitoses > 25 per 2.4 mm2)(2) + (atypical mitoses)(2) + (lymphovascular invasion)(3) + (serosal abutment)(5)By logistic regression, the risk model was significantly associated with 5-year disease-free (AUC = 0.9270) and 5-year disease-specific survival (AUC = 0.8517). Internal and external validation substantiated the model. The continuous score (range, 0-13) was optimally divided into 3 risk groups with distinct 5-year disease-free and disease-specific survival: low risk (0-2 points), intermediate risk (3-5 points), and high risk (6-13 points) groups. Our novel risk model performed significantly better than alternative uterine leiomyosarcoma risk stratification systems in predicting 5-year disease-free and disease-specific survival in stage I tumors. A simplified risk model, omitting terms for serosal abutment and lymphovascular invasion, can be accurately applied to myomectomy or morcellated specimens. We advocate routine application of this novel risk model in stage I uterine leiomyosarcoma to facilitate patient counseling and proper risk stratification for clinical trials.

Stage IV uterine leiomyosarcoma resection: A case report

We present a case of stage IV uterine leiomyosarcoma that was treated with total hysterectomy, bilateral salpingo-oophorectomy, and extensive resection of a 14 kg abdominal mass, as well as complete eradication of accompanying symptoms. This case may prompt researchers to look for other surgical solutions to similar issues.

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Stage IV Uterine Leiomyosarcoma can be surgically curable.

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Total Hysterectomy and Bilateral Salpingo-Oophorectomy is the surgical choice in massive Uterine Leiomyosarcoma.

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Post-operation Follow-ups with Ultrasonography at a 3-months intervals are crucial to detect early relapse.

Development of a Multi-Institutional Prediction Model for Three-Year Survival Status in Patients with Uterine Leiomyosarcoma (AGOG11-022/QCGC1302 Study)

Simple Summary

Uterine leiomyosarcoma is an aggressive tumor and the current staging system cannot differentiate the patients into different prognostic groups. This leads to difficulty in predicting the patients’ outcomes and planning for adjuvant therapy. We aimed to develop a prediction model that can predict the chance of survival by the third year. In this article, we had used different statistical tests to identify five readily available clinicopathologic parameters to build the prediction model. Internal validation was performed with satisfactory accuracy. Such a prediction model might help to predict survival outcome, and guide future research on the treatment modality.

Abstract

Background: The existing staging systems of uterine leiomyosarcoma (uLMS) cannot classify the patients into four non-overlapping prognostic groups. This study aimed to develop a prediction model to predict the three-year survival status of uLMS. Methods: In total, 201 patients with uLMS who had been treated between June 1993 and January 2014, were analyzed. Potential prognostic indicators were identified by univariate models followed by multivariate analyses. Prediction models were constructed by binomial regression with 3-year survival status as a binary outcome, and the final model was validated by internal cross-validation. Results: Nine potential parameters, including age, log tumor diameter, log mitotic count, cervical involvement, parametrial involvement, lymph node metastasis, distant metastasis, tumor circumscription and lymphovascular space invasion were identified. 110 patients had complete data to build the prediction models. Age, log tumor diameter, log mitotic count, distant metastasis, and circumscription were significantly correlated with the 3-year survival status. The final model with the lowest Akaike’s Information Criterion (117.56) was chosen and the cross validation estimated prediction accuracy was 0.745. Conclusion: We developed a prediction model for uLMS based on five readily available clinicopathologic parameters. This might provide a personalized prediction of the 3-year survival status and guide the use of adjuvant therapy, a cancer surveillance program, and future studies.

Can American Joint Committee on Cancer prognostic groups be individualized in patients undergoing surgery for Stage IV invasive upper tract Urothelial Carcinoma?

Purpose: We explored whether the modified American Joint Committee on Cancer tumor-node-metastasis prognostic stage group IV can be individualized in a large population-based cohort of surgically treated invasive upper tract urothelial carcinoma (UTUC) patients.

Methods: Invasive UTUC patients from the Surveillance, Epidemiology and End Results database (2004-2015) were screened for inclusion. A total of 10,482 eligible cases were identified. Cancer-specific survival (CSS) after surgery was analyzed using Kaplan-Meier plots.

Results: According to the most recent pathological prognostic group classification, the 5-year mortality rates of T4NxM0 (n=493), TxN1M0 (n=597), TxN2M0 (n=424) and pTxNxM1 (n=677) patients were 41.1% (95% CI 35.2% to 47.0%), 38.6% (95% CI 33.1% to 44.1%), 40.4% (95% CI 33.0% to 47.8%) and 14.2% (95% CI 9.9% to 18.5%), respectively (T4N0M0 vs. TxNxM1, P<0.001; TxN1M0 vs. TxNxM1, P<0.001; TxN2M0 vs. TxNxM1, P<0.001). Stage IV tumors were subdivided on the basis of the mortality data (Modification 1): stage IVa tumors were considered nonmetastatic (T4NxM0, TxN1-2M0; 5-year CSS 39.9%), and stage IVb tumors were considered metastatic (pTxNxM1; 5-year CSS 14.2%). Stage IV tumors were also subdivided according to the grade classification (Modification 2): stage IVa tumors were considered low grade (T4NxM0, TxN1-2M0, TxNxM1; G1-2; n=141), and stage IVb tumors were considered metastatic (T4NxM0, TxN1-2M0, TxNxM1; G3-4; n=2050). The 5-year CSS rates for stage IVa and IVb patients were 76.3% (95% CI 68.7% to 83.9%) and 31.4% (95% CI 28.5% to 34.3%), respectively (P<0.001).

Conclusions: Stage IV patients were stratified into two prognostically different risk groups depending on metastasis or grade. The subclassification of stage IV can increase the level of prognostic detail and individualize the prediction of survival in invasive UTUC patients.

Proposing the 3-tier staging system for improving prognostication in Stage I uterine leiomyosarcoma

BACKGROUND AND OBJECTIVES

To examine the utility of a 3-tier schema (≤5 cm, 5.1-10 cm, and > 10 cm) in determining characteristics and survival in Stage I uterine leiomyosarcoma.

METHODS

This retrospective observational study queried the National Cancer Institute's Surveillance, Epidemiology, and End Result Program from 1988 to 2016. Surgically treated stage I uterine leiomyosarcomas with known tumor size were examined (N = 2217). Trends, characteristics, and survival were assessed based on tumor size.

RESULTS

The most common tumor size was 5.1-10 cm (45.7%) followed by >10 cm (35.0%) and ≤5 cm (19.4%). Tumor size-shift occurred during the study period; the percentage of tumor size >10 cm increased from 12.9% to 44.5% and the groups with smaller tumor sizes decreased (p < .001). In weighted models, 5-year overall survival rates ranged from 49.9% to 71.6% in the 3-tier system and 55.2%-70.6% in the 2-tier system: the absolute difference was larger in the 3-tier system (21.7% vs. 15.4%). In the 3-tier system, all-cause mortality risk of tumor size >10 cm versus ≤5 cm nearly doubled (hazard ratio 1.96, 95% confidence interval 1.78-2.16).

CONCLUSION

In the past decades, tumors of stage I uterine leiomyosarcoma have become larger. Our study suggests that a tumor size-based 3-tier staging system may be useful to differentiate survival in stage I uterine leiomyosarcoma.

Retrospective Analysis of Patients with Gynecological Uterine Sarcomas: Leiomyosarcomas and other Histological Subtypes at a Single Institution from 1996 to 2015

Uterine sarcomas are a rare group of malignancies that account for less than 10% of all uterine malignancies. They are histologically diverse and fall into two broad groups: mesenchymal and epithelial tumors. The treatment in both these groups is marked by high failure rates and quick progression of disease. Patients with stage I to II with resectable disease benefit from operative cytoreduction. Those with advanced stages, benefit from chemotherapy with or without external beam radiation therapy. Our research in this paper looks at the number of LMS cases at our institution, Wyckoff Heights Medical Center in Brooklyn, NY for a period of 20 years from 1996 until 2015 and assesses our cohort's age at diagnosis and their survival in accordance to grade and stage of diagnosis. Our findings suggest that disease stage is a strong prognostic factor with good survival rates in stage I and II, with higher incidence in African-American women. All LMS patients with distant metastasis died within five years.

Diagnosis, treatment and survival of uterine sarcoma: A retrospective cohort study of 122 cases

The present study aimed to assess the diagnosis, treatment and follow-up of uterine sarcoma cases. A retrospective cohort study with 122 women recruited between 2001 and 2016 was performed. The data regarding epidemiology, clinical presentation, treatment and follow-up were analyzed based on the following histological types: Carcinosarcoma, leiomyosarcoma, endometrial stromal sarcoma (ESS) and adenosarcoma. Statistical analysis included descriptive statistics, logistic regression and survival curves. The diagnosis of uterine sarcoma exhibited an increasing trend of +1.2 new cases every 2 years (P=0.044) and comprised 10% of all uterine cancer diagnoses. There were 47% carcinosarcomas, 22% leiomyosarcomas, 16% ESS and 14% adenosarcomas. The majority of the women was ≥60 years old (62%). Among the subjects, 77% were postmenopausal, 61% had a body mass index up to 29.9 kg/m² and 71% presented with a comorbidity. Regression analysis exhibited an association between post menopause and the histological type associated with lower overall survival (OS), namely leiomyosarcoma or carcinosarcoma (odds ratio, 5.45, P<0.001). Stage I malignancy was present in 44% and Stage IV in 22%. The treatment included primary surgery in 78% of the cases, whereas 79% received adjuvant therapy. Only 55 cases achieved disease control and 20 relapsed (36%) with a 5-year OS rate of 33%. The OS was lower for carcinosarcoma and leiomyosarcoma (20%; P=0.003). In summary, the present study indicated that the number of uterine sarcoma cases had increased between 2001 and 2016. The majority of the women were >60 years old and diagnosed in advanced stages. The postmenopausal status was associated with histological types of poor prognosis. The OS was low and worse for patients with carcinosarcoma and leiomyosarcoma.

Efficacy and safety of trabectedin in metastatic uterine leiomyosarcoma: A retrospective multicenter study of the Spanish ovarian cancer research group (GEICO)

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Trabectedin confers clinical benefit in patients with recurrent/metastatic uterine leiomyosarcoma.

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Our data are similar to those previously reported in clinical studies.

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Trabectedin is especially effective when administered in earlier lines.

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Trabectedin has a manageable safety profile.

Objective

We assessed trabectedin in patients with advanced uterine leiomyosarcoma (uLMS) in real-life clinical practice given according to the marketing authorization.

Methods

Thirty-six women from 11 tertiary hospitals across Spain who received trabectedin after anthracycline-containing regimen/s were retrospectively analyzed. The primary endpoint was progression-free survival (PFS).

Results

Median PFS and overall survival (OS) since starting trabectedin treatment were 5.4 (95%CI: 3.5–7.3) and 18.5 months (95%CI: 11.5–25.6), respectively. Median OS was significantly higher (P = 0.028) in patients receiving trabectedin in ≤ 2nd line (25.3 months) than in ≥ 3rd (15.1 months) and with ECOG performance status ≤ 1 at trabectedin start (19.8 months) than ECOG 2–3 (6.0 months, P = 0.013). When calculating OS since diagnosis, patients had longer OS with localized disease at diagnosis (87.4 months) vs. locally advanced (30.0 months) or metastatic (44.0 months, P = 0.041); and patients who received adjuvant therapy (87.4 months) compared with those who did not (30.0 months, P = 0.003), especially when receiving radiochemotherapy (106.7 months, P = 0.027). One patient (2.8%) had a complete response (CR) and nine patients (25.0%) achieved a partial response (PR) for an objective response rate of 27.8% with median response duration of 11 months (range: 4–93). Eighteen patients (50.0%) had disease stabilization for a disease control rate (DCR) of 77.8%. More patients receiving trabectedin in 1st-line of advanced disease achieved CR (16.7%) and PR (50.0%) than those in ≥ 2nd line/s (0.0% and 20.0%), whereas the DCR was similar across treatment lines. Reversible neutropenia was the most common grade 3/4 laboratory abnormality (19.4%).

Conclusions

Trabectedin confers clinical benefit in patients with recurrent/metastatic uLMS, given after failure to an anthracycline-based regimen being comparable to those reported in clinical trials and with a manageable safety profile.

A nomogram for predicting overall survival in patients with uterine leiomyosarcoma: a SEER population-based study

Aim: To establish and validate a nomogram for the estimation of overall survival of patients with uterine leiomyosarcoma (uLMS). Methods: Information on patients diagnosed as uLMS was retrospectively retrieved from the Surveillance, Epidemiology, and End Results database. The patients were randomly assigned into the training and the validation cohorts. Univariate and multivariate analyses were used to determine the independent prognostic factors for building a nomogram for predicting overall survival. The predictive accuracy was evaluated based on the concordance indices and the calibration plots. Results: A nomogram that combined age, marital status, tumor size, Surveillance, Epidemiology, and End Result stage, surgery and radiation was established. The internal and external concordance indices were 0.748 and 0.745, respectively. The calibration plots approached 45 degrees. Conclusion: The nomogram might be an effective tool for predicting the survival of patients with uLMS.

Response to eribulin in a patient with metastatic uterine leiomyosarcoma: a case report

We report the case of a 51 year-old patient affected by an advanced uterine leiomyosarcoma treated with eribulin as fourth-line therapy. The patient, with a previous history of leiomyomas of the myometrium, had undergone total hysterectomy for repeated metrorrhagias. After 7 years, metastases in the liver, bone and lung were documented. A fine needle liver biopsy demonstrated leiomyosarcoma metastasis. The patient was treated with first-line doxorubicin chemotherapy; after six cycles, disease progression was observed. A second-line trabectedin chemotherapy and a third-line gemcitabine chemotherapy were performed; no objective responses were seen after two cycles. The patient was then treated with eribulin on the basis of an EORTC Phase II trial showing preliminary activity in uterine leiomyosarcoma. After six cycles, CT scan showed partial remission of liver lesion. Disease progression was observed after nine cycles with eribulin, without severe side effects and preserving a good quality of life.

Effectiveness of adjuvant treatment for morcellated, International Federation of Gynecology and Obstetrics stage I uterine leiomyosarcoma: A Korean multicenter study

AIM

To evaluate the effectiveness of adjuvant treatment for morcellated, uterus-confined leiomyosarcoma in a multicenter setting.

METHODS

We identified patients with International Federation of Gynecology and Obstetrics stage I uterine leiomyosarcoma primarily treated with surgery between 2003 and 2016. Among them, patients who underwent one of the following morcellation methods were included: (i) power morcellation; (ii) intracorporeal morcellation using scalpels or electrocautery; and (iii) vaginal morcellation. Patients' survival outcomes were compared according to the implementation of adjuvant treatment.

RESULTS

From 13 institutions, 55 patients were included; 31 for adjuvant treatment group and 24 for surgery only group. The clinicopathological characteristics including the mass size, morcellation methods, extent of surgery, and mitotic count were similar between the groups. In the adjuvant treatment group, 67.7%, 19.4% and 12.9% of patients received chemotherapy, chemoradiation and radiation, respectively. After a median follow-up of 50.5 months, the adjuvant treatment and surgery only groups showed similar overall survival (5-year rate, 92.0% vs 90.4%; P = 0.959). No significant difference in progression-free survival was observed between the two groups (3-year rate, 46.1% vs 78.2%; P = 0.069). On multivariate analyses, adjuvant treatment did not affect progression-free survival (adjusted HR, 2.138; 95% CI, 0.550-8.305; P = 0.273). The adjuvant treatment group showed a trend towards more common distant metastasis, compared to the surgery only group (25.8% vs 4.2%; P = 0.062). The incidences of pelvic, retroperitoneal, and abdominal recurrences were not different between the groups.

CONCLUSION

Despite its frequent use in clinical practice, adjuvant treatment did not improve the survival outcomes of patients with morcellated, International Federation of Gynecology and Obstetrics stage I uterine leiomyosarcoma.

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.

Secondary surgical resection for patients with recurrent uterine leiomyosarcoma

OBJECTIVES

To assess outcomes after secondary surgical resection in patients with recurrent uterine leiomyosarcoma (uLMS).

METHODS

We retrospectively identified all patients who had no evidence of disease after initial surgery for uLMS, who underwent surgery for a first recurrence at our institution between 1/1991 and 10/2013. We excluded patients who received any therapy for recurrence prior to secondary resection, and patients who underwent surgery soon after morcellation [of presumed benign fibroids] showed widespread disease. Overall survival (OS) was determined from time of first recurrence to death or last follow-up.

RESULTS

We identified 62 patients: 29 with abdominal/pelvic recurrence only, 30 with lung recurrence only, 3 with both. Median time to first recurrence was 18 months (95% CI: 13.3-23.3): 15.8 months (95% CI: 13.0-18.6) abdominal/pelvic recurrence; 24.1 months (95% CI: 14.5-33.7) lung-only recurrence (p = 0.03). Median OS was 37.7 months (95% CI: 25.9-49.6) abdominal/pelvic recurrence; 78.1 months (95% CI: 44.8-11.4) lung recurrence (p = 0.02). Complete gross resection (CGR) was achieved in 58 cases (93%), with gross residual ≤1 cm in 2 (3.5%) and >1 cm in 2 (3.5%). Median OS based on residual disease was 54.1 months (95% CI: 24.9-83.3), 38.7 months (95% CI: NE), 1.7 months (95% CI: NE), respectively (p < 0.001). In cases with CGR, neither adjuvant radiation (N = 9), chemotherapy (N = 8) nor hormonal therapy (N = 10) was associated with improved OS.

CONCLUSIONS

Secondary surgical resection of recurrent uLMS is reasonable in patients with a high probability of achieving CGR. Lung-only recurrences were associated with more favorable outcome. Following CGR, additional therapy may not offer benefit.

Overexpression of carbonyl reductase 1 inhibits malignant behaviors and epithelial mesenchymal transition by suppressing TGF-β signaling in uterine leiomyosarcoma cells

Carbonyl reductase 1 (CBR1) has been reported to be involved in cancer progression. Recently, we found that CBR1 overexpression inhibited malignant behaviors and the epithelial mesenchymal transition (EMT) in uterine cervical cancer. It remained unclear whether this was also the case in uterine leiomyosarcoma (uLMS), which is derived from mesenchymal cells and is a much more malignant gynecological tumor. A number of previous studies suggested that malignant behaviors are associated with EMT, even in mesenchymal malignant tumors. In the present study, we investigated whether CBR1 inhibits malignant behaviors and EMT in uLMS. We established clones of uLMS cells (SKN cells) and uterine sarcoma cells (MES-SA cells) that overexpressed CBR1. Cell proliferative, migratory and invasive activities were suppressed by CBR1 overexpression, accompanied by increases in the expressions of epithelial markers (E-cadherin and cytokeratin) and decreases in the expressions of mesenchymal markers (N-cadherin and fibronectin), suggesting that CBR1 overexpression inhibits malignant behaviors and EMT in uLMS cells. In addition, transforming growth factor-β (TGF-β) production and the subsequent signaling and phosphorylation of Smad were suppressed in the clones. To investigate the association between TGF-β and EMT, SKN cells were treated with TGF-β or a TGF-β receptor blocker (SB431542). EMT was promoted by TGF-β and inhibited by SB431542. In conclusion, this is the first study, to the best of the authors' knowledge, showing that CBR1 overexpression inhibits malignant behaviors and EMT in uLMS cells. The present study provided novel insight demonstrating that the suppressive effect of CBR1 is mediated through TGF-β signaling.

A randomized phase II study of letrozole vs. observation in patients with newly diagnosed uterine leiomyosarcoma (uLMS)

Objective

Up to 87% of uterine leiomyosarcomas have estrogen receptor positivity. There are no effective adjuvant therapies for LMS. The objective of this study was to determine the efficacy of letrozole in patients with newly diagnosed uterine leiomyosarcoma (uLMS). The primary endpoint of this study was a reduction in the recurrence rate for patients with this disease.

Methods

We performed a randomized, open-label, phase II study of letrozole (experimental arm) administered orally on a daily basis vs. observation (control) in patients with newly diagnosed early stage uLMS. Patient enrollment was to be open to any individual with newly diagnosed uLMS seen in the Gynecologic Oncology Center at M. D. Anderson Cancer Center. Hormone receptor positivity using CLIA approved lab testing was an eligibility requirement. No prior therapy was allowed.

Results

Nine patients were randomized. Four patients were in the experimental arm and five patients were in the observation arm. No patients had prior therapy. The median duration of protocol treatment was 43.9 months (range, 6.5–70.2). The median PFS for the experimental arm was not reached (NR) compared to 17.3 months. The percent progression free at 12 and 24 months was 100% for patients receiving letrozole compared to 80% at 12 months and 40% at 24 months for patients in the observation arm.

Conclusions

While no definitive conclusions can be made due to early study closure, these early observations warrant further investigation. We desperately need an effective adjuvant therapy for women with early stage uLMS.

•

Adjuvant therapy for patients with early stage uterine leiomyosarcoma (uLMS) represents an unmet medical need.

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We hypothesized that hormonal manipulation can positively impact survival in this group of patients.

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Results suggest aromatase inhibitor therapy may be an active agent in early stage uterine leiomyosarcoma.

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Low accrual due to rare disease type resulted in early study closure.

Uterine leiomyosarcoma: A review of the literature and update on management options

Uterine leiomyosarcoma is the most common type of uterine sarcoma. It is an extremely aggressive malignancy associated with a poor overall prognosis. Women affected may vary in age, but are most often diagnosed in their perimenopausal years. Presenting symptoms may be vague and mimic other benign uterine conditions. Preoperative diagnosis of leiomyosarcoma is difficult and often only made at time of surgical resection. These rare mesenchymal tumors are characterized by cytologic atypia, a high mitotic index, and tumor necrosis on histologic inspection. Management of early stage disease entails hysterectomy and complete surgical resection of gross tumor, though routine oophorectomy or lymph node dissection do not appear to confer much clinical benefit. Adjuvant therapy for early stage disease remains controversial as multiple clinical trials have failed to demonstrate benefit on overall survival. Recently, progress has been made in regards to therapy for advanced and recurrent disease. Novel chemotherapeutics, targeted therapies such as olaratumab and pazopanib, and new immunotherapies such as nivolumab and pembrolizumab have demonstrated promise in these previously difficult drug-resistant patients. In this article, we provide a detailed review of uterine leiomyosarcoma including epidemiology, clinical presentation, diagnosis, and pathologic characteristics. We then go on detail management strategies, including options for adjuvant therapy, and highlight new and developing regimens in the field.

Proposal for a New TNM Stage based on the 7th and 8th American Joint Committee on Cancer pTNM Staging Classification for Gastric Cancer

Background: The 8^th edition of the American Joint Committee on Cancer (AJCC) staging system for gastric cancer incorporated several new changes. We aimed to assess the comparative prognostic values of the 7^th and 8^th AJCC pTNM staging systems in patients with gastric cancer (GC), and accordingly, to put forward a refined staging classification. Methods: The SEER database was queried to identify GC patients between 2004 and 2009. GC patients from Sun Yat-sen University Cancer Center (SYSUCC) were used as external validation data. The Kaplan-Meier method and Cox proportional hazards regression models were used to analyze cause-specific survival (CSS). The prognostic performance of different staging schemes was assessed using the concordance index (c-index), Akaike's information criterion (AIC), and likelihood ratio χ² test. Results: In the SEER cohort, stage migration occurred in 8.74% of patients. Survival analysis showed that it was better to treat T4bN0M0 + T4aN2M0 as stage IIIB and T4bN3bM0 as stage IV. Based on this, we established a new staging system which exhibited a superior c-index (0.7501) to the 7^th and 8^th AJCC staging systems (0.7498 and 0.7500, respectively). The new staging system also outperformed the 7^th and 8^th AJCC staging systems in terms of AIC and the likelihood ratio χ² test. The predictive superiority of the new staging system remained valid in the SYSUCC database. Conclusions: We demonstrated that some stage modifications in the 8^th AJCC pathologic staging were unnecessary. Therefore we established a new staging system, which was superior to the 7^th and 8^th staging systems.

Long-Lasting Response to Trabectedin in a Patient with Metastatic Uterine Leiomyosarcoma: A Case Report

Background

Uterine leiomyosarcoma (uLMS) is a rare tumor that accounts for 1% of all uterine malignancies. In spite of adequate surgical resection of uLMS, even in the early stage, patients remain at high risk for local and distant recurrence. Therefore, the treatment of advanced uLMS represents a considerable challenge.

Methods

We report the case of a 47-year-old woman who presented with uLMS with abnormal vaginal bleeding.

Results

The patient underwent a total hysterectomy and bilateral adnexectomy, which was followed by 1 year progression-free survival without adjuvant therapy. Thereafter, new lung metastases and local progression at the vaginal stump were observed. Chemotherapy with ifosfamide and doxorubicin was administered. However, after 4 cycles, a CT scan revealed disease progression in the lung metastases. Subsequently, the patient was treated with trabectedin at a dose of 1.5 mg/m² for 6 cycles resulting in complete remission of the lung metastases as well as partial remission of the mass in the vaginal stump after 9 cycles of trabectedin. The patient is currently on maintenance therapy with trabectedin and has no recurrence.

Conclusion

Trabectedin seems to be an efficient option for patients with uLMS as demonstrated by a long-lasting response in a pretreated patient with an acceptable safety profile with no signs of cumulative toxicity.

External validation of a modified 8th AJCC TNM system for advanced gastric cancer: Long-term results in southern China

BACKGROUND

The 8th edition of AJCC TNM staging manual for gastric cancer (GC) has been validated by several studies. A modified staging system based on it and total harvested number of lymph nodes (LNs; cutoff: 30) is suggested to improve predictive capacities for advanced GC. This study is designed to validate the modified method using a single-center database in Southern China.

METHODS

Clinical data from 684 GC patients with stage II and III according to the 7th edition between 2001 and 2012 were reviewed. A modified staging system was applied to restage the cohort. The three staging systems were compared in terms of prognostic performance on long-term survival.

RESULTS

The median follow-up period of this cohort was 52 (range, 6-180) months, with a median 5-year overall survival rate of 52.4%. Stage migration was observed in 159 (23.2%) patients according to the 8th edition of TNM staging, and another migration was observed in 108 (15.8%) patients according to the modified TNM staging system. Compared with the modified staging system, both 7th and 8th edition of AJCC TNM staging systems did not prove survival concordance on stage IIIA (7th edition) and stage IIIC (8th edition) when <30 LNs were examined. The survival performance between two AJCC staging systems had no significant improvement (c-index, 0.607 vs. 0.609), with the best prognostic stratification obtained using the modified staging method (c-index, 0.631).

CONCLUSIONS

The modified staging system on basis of the 8th AJCC classification and the number of harvested LNs could provide an optimal predictive capacities for advanced gastric cancer.

Androgen receptor as a prognostic biomarker and therapeutic target in uterine leiomyosarcoma

OBJECTIVE

To investigate the expression of androgen receptor (AR) and its correlation with disease status and survival outcome in uterine leiomyosarcoma with other hormone receptors.

METHODS

The medical records and paraffin blocks of 42 patients were reviewed. The immunohistochemical expression of AR, estrogen receptor (ER), progesterone receptor (PR), gonadotropin releasing hormone (GnRH), and cytochrome P450, family 19, subfamily A, polypeptide 1 (CYP19A1) were assessed using tissue microarray.

RESULTS

In total, AR expression was observed in 11 patients (26.2%). International Federation of Gynecology and Obstetrics (FIGO) stage and AR were independent factors for disease-free survival (DFS) in multivariate regression analysis (odds ratio [OR]=5.8; 95% confidence interval [CI]=1.2-28.4 and OR=0.2; 95% CI=0.05-0.90; p=0.029 and 0.032, respectively). There were no deaths in the AR expression group, whereas the 5-year overall survival (OS) was 54.8% in the no expression group (p=0.014). Co-expression of ER and/or PR with AR was associated with significantly better 5-year DFS and OS than those with negative AR (72.7% vs. 28.6% and 100% vs. 64.3%; p=0.020 and 0.036, respectively). AR may be an independent prognostic marker regardless of ER/PR.

CONCLUSION

AR can be a potential prognostic biomarker in uterine leiomyosarcoma.

Validation of the American Joint Commission on Cancer (8th edition) changes for patients with stage III gastric cancer: survival analysis of a large series from a Specialized Eastern Center

The 8th edition of the TNM was released in 2016 and included major revisions, especially for stage III. We aimed to compare the prognostic value of the 7th and 8th editions of the AJCC TNM classification for stage III gastric cancer. Clinical data from 1557 patients operated on for stage III gastric cancer according to the 7th edition between 2007 and 2014 were analyzed and compared using the 7th and 8th TNM classifications. A proposed staging system was established, and the three systems were compared in terms of prognostic performance. The stage shifted for 669 (42.96%) patients. It shifted from IIIA to IIIB (one patient, 0.06%), IIIB to IIIA (230 patients, 14.8%), IIIB to IIIC (94 patients, 6.0%), and IIIC to IIIB (344 patients, 22.1%). However, the new AJCC subgroupings did not prove distinctive for survival levels between T3N3aM0 (stage IIIB) and T3N3bM0 (stage IIIC) or between T4aN3aM0 (stage IIIB) and T4aN3bM0 (stage IIIC) when <30 lymph nodes (LNs) were resected. The performance of the 8th edition (c-index, 0.614; 95% confidence interval [CI], 0.596-0.633) revealed no relevant improvement compared to the 7th edition (c-index, 0.624; 95% CI, 0.605-0.643). The proposed staging system generated the best prognostic stratification. The 8th TNM edition may not provide better accuracy in predicting the prognosis of stage III gastric cancer. The proposed staging system, comprised of a combination of the number of LNs harvested and the 7th and 8th AJCC classifications, may improve predictive capacities for stage III gastric cancer.

Misdiagnosis of a Giant Uterine Leiomyosarcoma: Clinic and Image Challenges

A 41-year-old woman (G₃P₂L₂Ab₁) was referred to gynecology clinic with chief complaints of abdominal distension and localized abdominal wall pruritus for three months. She was misdiagnosed with gastrointestinal disorder and ultimately had undergone imaging. Ultrasonography and computed tomography (CT) scan disclosed a huge solid-cystic mass originating from the ovary. On clinical examination the patient had no pain or tenderness and no gynecologic complaints. Laboratory tests showed normal tumor markers and hemoglobin at 8 g/dl. Laparotomy was carried out as diagnosis of ovarian serous cyst adenoma, but a huge tumor with attachment to uterus and ovaries and extension to pelvic floor, peripheral tissues of ureter, and upper abdomen was found. Hysterectomy with bilateral salpingooophorectomy was done. Pathology report demonstrated uterine leiomyosarcoma measuring 40 centimeters and weighing 10 kilograms. In conclusion, as pelvic masses even in a large size may present unspecific symptoms misdiagnosis may occur which lead to overgrowth, local invasion, or other complications. So, it is rather to suggest ultrasonography in patients with persistent abdominal or pelvic symptoms and if needed, more exact diagnostic modalities like magnetic resonance imaging (MRI) could be offered to avoid misdiagnosis and mismanagement.

Comparison of the 7th and 8th editions of the American joint committee on cancer TNM classification for patients with stage III gastric cancer

Background and Objectives

The eighth TNM edition for gastric cancer was released in 2016 and included major revisions, especially of stage III. The purpose of this study was to evaluate the prognostic value of the new AJCC TNM classification in comparison with the 7th edition for stage III gastric cancer.

Methods

Clinical and histopathological data on 1,496 patients operated on for stage III GC according to the seventh edition between 2005 and 2013 were analyzed and compared using 7th and 8th classifications. The 2 systems were compared in terms of prognostic performance.

Results

The stage shifted for 650 (43.45%) patients: from IIIA to IIIB (2 patient, 0.13%), from IIIB to IIIA (214 patients, 14.30%), from IIIB to IIIC (99 patients, 6.62%), and from IIIC to IIIB (335 patients, 22.39%). Cox regression multivariate analysis showed both the 8th and 7th TNM classification were independent prognostic factors. The 8th edition system had higher linear trend and likelihood ratio χ² scores, and smaller AIC values compared with those for the 7th edition. However, the performance of the eighth edition did not reveal significant improvement compared to the seventh edition (c-index 0.625 vs. c-index 0.616, p=0.085).

Conclusion

The eighth TNM edition may not provide significantly better accuracy in predicting the prognosis of stage III GC. However, to confirm our findings, further studies are warranted.

Involvement of the Toll-Like Receptor/Nitric Oxide Signaling Pathway in the Pathogenesis of Cervical Cancer Caused by High-Risk Human Papillomavirus Infection

Human papillomavirus (HPV) can activate Toll-like receptor (TLR)/nitric oxide (NO) signaling pathways; however, whether the TLR/NO pathway is involved in cervical cancer caused by high-risk HPV (HR-HPV) remains unclear. In this study, 43 HR-HPV-positive patients with cervical cancer (CC group), 39 HR-HPV-positive patients with a healthy cervix (HR-HPV group), and 33 HR-HPV-negative controls were recruited. NO concentration in cervical canal and expression of inducible NO synthase (iNOS) in cervical tissues were detected. Expressions of key TLR/NO pathway genes (TLR3/4/7/8, NF-κB p65, and iNOS) in cervical epithelial cells were detected by quantitative reverse transcription PCR. Expressions of TLR4, NF-κB p65, and iNOS in CaSki, HeLa, and C33a cells were determined by Western blot. NO concentration in cervical canal of CC group was significantly higher than in other groups (P < 0.05). Positive rates of iNOS in cervical tissues were 72.1%, 28.2%, and 3.1% in the CC group, HR-HPV group, and controls, respectively (P < 0.05). Levels of TLR3, TLR4, TLR7, TLR8, NF-κB p65, and iNOS in cervical epithelial cells were higher in CC group than in other groups (P < 0.05). Both mRNA and protein levels of TLR4, NF-κB p65, and iNOS were higher in HPV-positive HeLa and CaSki cells than in HPV-negative C33a cells (P < 0.05). Together, these results suggest that TLR/NO signaling pathway may be involved in pathogenesis of cervical cancer caused by HR-HPV.

Soft tissue sarcoma nomograms and their incorporation into practice

The accurate prediction of prognosis in patients with soft tissue sarcoma (STS) is a challenging issue. Extreme variability in the clinical and pathological characteristics of this family of tumors hinders the simple stratification of patients into meaningful prognostic cohorts. Precision medicine tools for the prediction of prognosis, such as nomograms, enable personalized computation of outcome based on clinical and pathological characteristics of both patient and tumor. The eighth edition of the American Joint Committee on Cancer staging manual moved from a "population-based" to a "personalized" approach endorsing high-quality nomograms to improve clinician prediction ability in definite patient subgroups. The first nomogram for STS was published in 2002, and this was followed by several prognostic predictors offered to clinicians. Focusing on a specific STS subgroup or site, nomograms can take into consideration highly specific factors relevant only in that particular scenario, thereby maximizing prognostic ability. The objective of this review was to critically evaluate available nomograms for patients with STS to provide clinicians and researchers with a choice of the most optimal tool for each specific patient. Cancer 2017;123:2802-20. © 2017 American Cancer Society.

Immunotherapy with single agent nivolumab for advanced leiomyosarcoma of the uterus: Results of a phase 2 study

BACKGROUND

Immunotherapy has changed the therapeutic landscape in oncology. Advanced uterine leiomyosarcoma (ULMS) remains an incurable disease in most cases, and despite new drug approvals, improvements in overall survival have been modest at best. The goal of this study was to evaluate programmed-death 1 (PD-1) inhibition with nivolumab in this patient population.

METHODS

This single-center phase 2 trial completed enrollment between May and October 2015. Patients received 3 mg/kg of intravenous nivolumab on day 1 of each 2-week cycle until disease progression or unacceptable toxicity. The primary endpoint was objective response rate. We assessed PD-1, PD-ligand 1 (PD-L1), and PD-L2 expression in archival tumor samples and variations in immune-phenotyping of circulating immune cells during treatment.

RESULTS

Twelve patients were enrolled in the first stage of the 2-stage design. A median of 5 (range, 2-6) 2-week cycles of nivolumab were administered. Of the 12 patients, none responded to treatment. The overall median progression-free survival was 1.8 months (95% confidence interval, 0.8-unknown). The study did not open the second stage due to lack of benefit as defined by the statistical plan. Archival samples were available for 83% of patients. PD-1 (>3% of cells), PD-L1, and PD-L2 (>5% and >10% of tumor cells, respectively) expression were observed in 20%, 20%, and 90% of samples, respectively. No significant differences were observed between pre- and posttreatment cell phenotypes.

CONCLUSION

Single-agent nivolumab did not demonstrate a benefit in this cohort of previously treated advanced ULMS patients. Further biomarker-driven approaches and studies evaluating combined immune checkpoint-modulators should be considered. Cancer 2017;123:3285-90. © 2017 American Cancer Society.

BGCS uterine cancer guidelines: Recommendations for practice

The British Gynaecological Cancer Society has issued the first Endometrial (Uterine) Cancer guidelines as recommendation for practice for the UK.

Overexpression of erythropoietin-producing hepatocyte receptor B4 and ephrin-B2 is associated with estrogen receptor expression in endometrial adenocarcinoma

Endometrial adenocarcinoma (EC) is one of the most frequently diagnosed types of endometrial cancer and is typically a consequence of continuous estrogen receptor stimulation. Erythropoietin-producing hepatocyte receptor B4 (EphB4) and its ligand ephrin-B2 have been reported to be overexpressed in EC cells; however, the function in EC remains unclear. The present study aimed to elucidate the role of EphB4 and ephrin-B2 in EC. The protein expression pattern of EphB4 and ephrin-B2 was analyzed through immunohistochemistry and western blot analysis in endometrium with adenomyosis or simple endometrial hyperplasia, atypical endometrial hyperplasia, double-positive estrogen receptor (ER)/progesterone receptor (PR) EC and double-negative ER/PR EC. The expression of EphB4 and ephrin-B2 was demonstrated to be increased in atypical EH and ER/PR-positive EC, but not ER/PR-negative EC. Furthermore, EphB4 and ephrin-B2 expression was positively associated with ER expression in EC tissue. The results of the present study suggest that the overexpression of EphB4 and ephrin-B2 in the endometrium serves a role in the pathogenesis of EC, in addition to being associated with ER expression.

Prognostic significance of preoperative ¹⁸F-FDG PET/CT in uterine leiomyosarcoma

Objective

Uterine leiomyosarcoma (LMS) is a rare and aggressive disease with poor outcome. Due to its rarity and conflict of data, investigation on finding prognostic factor is challenging. The aim of the study was to investigate the prognostic significance of preoperative ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) in uterine LMS.

Methods

This was a retrospective observational cohort study in 3 tertiary referral hospitals. We retrospectively evaluated data from patients with pathologically proven uterine LMS who underwent preoperative ¹⁸F-FDG PET/CT scans at 3 institutions. The prognostic implication of PET/CT parameters and other clinico-pathological parameters on disease-free survival (DFS) and overall survival (OS) was evaluated.

Results

Clinico-patholgical data were reviewed for 19 eligible patients. In the group overall, median DFS and OS were 12 and 20 months, respectively. As for the recurrence, large tumor size, and high tumor maximum standardized uptake value (SUV_max) were demonstrated as risk factors of recurrence. As for the OS, high tumor SUV_max was demonstrated as the unique risk factor. There were significant differences in tumor size, mitotic count, SUV_max, and DFS between patients with and without recurrence. Also, there were significant differences in tumor size, SUV_max, DFS, and OS between 2 subgroups stratified by cut-off SUV_max.

Conclusion

SUV_max at preoperative ¹⁸F-FDG PET/CT was associated with worse outcome in patients with uterine LMS. In the preoperative setting, SUV_max can be a valuable non-invasive prognostic marker. Additionally, SUV_max can help identify highly aggressive uterine LMS and may help in adjusting standard treatment toward an individualized, risk-adapted treatment.

Molecular Targets and Emerging Therapeutic Options for Uterine Leiomyosarcoma

Uterine leiomyosarcoma (uLMS) is an aggressive malignancy characterized by its early metastasis, high rates of recurrence, and poor prognosis. Multiple obstacles complicate the clinical management of uLMS. These include the fact that most uLMS are typically identified only after a woman has undergone hysterectomy or myomectomy, the limited efficacy of adjuvant therapy for early stage disease, and the poor response of metastatic disease to current treatments. Here, we discuss recent insights into the molecular basis of uLMS and discuss emerging options for its clinical management. Particular attention is given to the biologic basis of these strategies with the goal of understanding the rationale motivating their use.

The Morcellation Debate: The History and the Science

Intracorporeal electromechanical morcellation has been available for nearly 2 decades, and has allowed hundreds of thousands of women to undergo hysterectomy and myomectomy in a minimally invasive approach. Despite gains in postoperative pain, complications, quality of life, hospital stay, and return to work, it has recently come under attack. The risk of inadvertent morcellation of a uterine malignancy, and subsequent dissemination of occult cancer, must be balanced by the risks of increased numbers of laparotomies. Power morcellation should be available to appropriate surgical candidates.