Pleomorphic Rhabdomyosarcoma of the Uterine Corpus in an Adult Who Underwent Multi-gene Panel Testing

Background/Aim

Rhabdomyosarcoma (RMS) is the most common malignant soft tissue tumor in children. Adult primary RMS of gynecological origin is a rare condition and uterine RMS is an aggressive malignancy with a poor prognosis. The genetic variants associated with uterine RMS in adults have yet to be fully elucidated, and there is no established therapeutic strategy for rare tumors.

Case Report

A 69-year-old Japanese woman was referred to our hospital with abdominal bloating. Imaging examination revealed a tumor with diameter of 85 mm located in the uterus and multiple regional lymph node metastases. Biopsy of the uterine corpus indicated possible uterine carcinosarcoma or RMS. Following debulking surgery, the patient was diagnosed with stage IVB pleomorphic RMS. The patient was treated with two courses of doxorubicin every three weeks and one course of combination chemotherapy with vincristine, actinomycin, and cyclophosphamide. Because of rapid progression of the disease, we decided to perform multi-gene panel testing to determine the most effective therapeutic strategy. However, no therapeutic plan based on genetic information was identified. The patient with chemotherapy-refractory RMS died 11 weeks after surgery.

Conclusion

Our patient had advanced uterine RMS with an unresectable tumor that was resistant to chemotherapy, resulting in poor outcomes. Despite conducting multi-gene panel testing, no tailored therapeutic approach based on genetic information was found. This case highlights the challenges in managing uterine RMS in adults and underscores the urgent need for further research to identify effective treatment modalities.

[A Case of Recurrent Breast Cancer with Improving Activities of Daily Living by Olaparib Treatment]

The patient is a 67-year-old woman who underwent surgery for left breast cancer in 1990 and right breast cancer in 2003. In 2013, local recurrence of right breast cancer was detected. Then she underwent removal of the local recurrence, axillary lymph node dissection, and post mastectomy irradiation. In 2017 lung metastasis appeared, and she underwent endocrine therapy and chemotherapy. BRCA1/2 analysis showed BRCA1 mutation, so olaparib was started in 2020. The metastatic lesions were reduced markedly, and the skin metastases were crusted over. Although it is necessary to decide when to use olaparib in each case, there is a possibility that olaparib may be effective even in the terminal stage, and it may be considered as one of the treatment options.

[A Case of Lynch Syndrome with Seven Cancers in Five Organs]

The case is a woman in her 70s with a history of colon and cervical cancer in her 40s. She had gastric cancer and breast cancer in her 70s. Her eldest son died of colon cancer in his 20s, and her eldest daughter had cervical cancer in her 40s. She was suspected to have Lynch syndrome and a genetic diagnosis was performed and then confirmed. Later she developed gastric cancer and ureteral cancer. We report a case of Lynch syndrome in which she developed seven cancers in five organs, all of which were early stage cancers.

Texture Analysis of Apparent Diffusion Coefficient Maps in Cervical Carcinoma: Correlation with Histopathologic Findings and Prognosis

Purpose

To determine the feasibility of texture analysis of apparent diffusion coefficient (ADC) maps and to assess the performance of texture analysis and ADC to predict histologic grade, parametrial invasion, lymph node metastasis, International Federation of Gynecology and Obstetrics (FIGO) stage, recurrence, and recurrence-free survival (RFS) in patients with cervical carcinoma.

Materials and Methods

This retrospective study included 58 patients with cervical carcinoma who were examined with a 1.5-T MRI system and diffusion-weighted imaging with b values of 0 and 1000 sec/mm². Software with volumes of interest on ADC maps was used to extract 45 texture features, including higher-order texture features. Receiver operating characteristic (ROC) analysis was performed to compare the diagnostic performance of ADC map random forest models and of ADC values. Dunnett test, Spearman rank correlation coefficient, Kaplan-Meier analyses, log-rank test, and Cox proportional hazards regression analyses were also used for statistical analyses.

Results

The ADC map random forest models showed a significantly larger area under the ROC curve (AUC) than the AUC of ADC values for predicting high-grade cervical carcinoma (P = .0036), but not for parametrial invasion, lymph node metastasis, stages III-IV, and recurrence (P = .0602, .3176, .0924, and .5633, respectively). The random forest models predicted that the mean RFS rates were significantly shorter for high-grade cervical carcinomas, parametrial invasion, lymph node metastasis, stages III-IV, and recurrence (P = .0405, < .0001, .0344, .0001, and .0015, respectively); the random forest models for parametrial invasion and stages III-IV were more useful than ADC values (P = .0018) for predicting RFS.

Conclusion

The ADC map random forest models were more useful for noninvasively evaluating histologic grade, parametrial invasion, lymph node metastasis, FIGO stage, and recurrence and for predicting RFS in patients with cervical carcinoma than were ADC values.Keywords: Comparative Studies, Genital/Reproductive, MR-Diffusion Weighted Imaging, MR-Imaging, Neoplasms-Primary, Pathology, Pelvis, Tissue Characterization, UterusSupplemental material is available for this article.© RSNA, 2020See also the commentary by Reinhold and Nougaret in this issue.

Endometrial Carcinoma: Texture Analysis of Apparent Diffusion Coefficient Maps and Its Correlation with Histopathologic Findings and Prognosis

PURPOSE

To determine the feasibility of texture analysis (TA) of apparent diffusion coefficient (ADC) maps for predicting histologic grade (HG) and recurrence-free survival (RFS) in patients with endometrial carcinoma (EMC).

MATERIALS AND METHODS

One hundred twenty-one patients with EMC were examined by using a 1.5-T MRI system and diffusion-weighted imaging (DWI) with b values of 0 and 1000 sec/mm². Software with volumes of interest on ADC maps was used to extract 45 texture features including higher-order texture features. Receiver operating characteristic analysis was performed to compare the diagnostic performance of the random forest (RF) model and ADC values for HG and recurrence.

RESULTS

Area under the curve (AUC) for predicting high-grade EMCs was significantly larger for RF model than for ADC values (0.967 vs 0.898; P = .0336). AUC for predicting recurrence was larger for the RF model than for ADC values (0.890 vs 0.875; P = .7248), although the difference was not significant. Mean RFS was significantly shorter for high-grade EMCs than for low-grade EMCs (P = .0002; hazard ratio, 4.9) and for ADC values less than or equal to 0.802 × 10^-3 mm²/sec than for ADC values greater than 0.802 × 10^-3 mm²/sec (P < .0001; hazard ratio, 32.9). RF model showed that the mean RFS was significantly shorter for the presence of recurrence than for its absence (P < .0001; hazard ratio, 94.7).

CONCLUSION

TA of ADC maps had significantly higher diagnostic performance than did ADC values for predicting HG and was a more useful indicator than HG and ADC values for predicting RFS in patients with EMC.Keywords: Comparative Studies, Genital/Reproductive, MR-Diffusion Weighted Imaging, MR-Imaging, Neoplasms-Primary, Pathology, Pelvis, Tissue Characterization, Uterus© RSNA, 2019.

Port site recurrence and unusual diffuse subcutaneous metastases of unexpected early stage ovarian cancer after laparoscopic surgery: a case report

Port site recurrence is a rare but well-documented adverse event peculiar to laparoscopic surgery. We report an unusual outcome of unexpected early stage ovarian cancer in which port site recurrence occurred after laparoscopic surgery and was followed by diffuse subcutaneous metastases. A 31-year-old Japanese woman with a large tumor in her abdomen visited our hospital. Because no intratumoral solid component was detected on diagnostic imaging, the tumor was diagnosed as a benign ovarian tumor and the patient underwent left ovarian laparoscopic cystectomy. Contrary to our expectations, however, the ovarian tumor was a mucinous carcinoma. We performed additional surgery, but the tumor recurred in the umbilical area, and multiple subcutaneous metastases later appeared. The curative effect of chemotherapy and radiation was limited. This atypical metastatic distribution of an extremely small amount of cancer might have been caused by the laparoscopic procedure. Protection against tumor cell dissemination is necessary during all forms of laparoscopic surgery.

SLUG expression is an indicator of tumour recurrence in high-grade endometrial carcinomas

AIMS

To investigate how SNAIL and SLUG were involved in the nature of high-grade endometrial carcinomas (grade 3 endometrioid carcinoma, serous carcinoma and clear cell carcinoma), we analysed the correlation of their expression status with clinicopathological characteristics and evaluated their prognostic significance.

METHODS AND RESULTS

We performed immunohistochemical staining in 52 high-grade endometrial carcinomas. Expression status of SNAIL and SLUG was classified into a high expression (positive in more than 50% of the tumour cells) and a low expression. Thirteen cases (25%) showed a high expression of SLUG, whereas all 52 cases showed a low expression of SNAIL. High expression of SLUG was correlated significantly with tumour recurrence (P = 0.0203) and aberrant p53 expression (P = 0.000559). Overall survival was worse in patients with high SLUG expression at all stages (P = 0.0327) and in those who underwent adjuvant therapy (P = 0.00963). Among the patients with complete tumour resection, high SLUG expression was associated with worse recurrence-free survival (RFS) in the patients at all stages (P = 0.00264), at stages III/IV (P = 0.0146), and who underwent adjuvant therapy (P = 0.000743). SLUG expression was identified as an independent factor of RFS by multivariate analysis (hazard ratio 5.938, 95% confidence interval 1.251-28.18, P = 0.025).

CONCLUSIONS

SLUG expression could be correlated with TP53 mutational status and could be involved in therapeutic resistance resulting in tumour recurrence. A high expression level of SLUG can be an indicator of recurrence and a therapeutic target for long-term remission in high-grade endometrial carcinomas.

Vanishing intravenous leiomyomatosis after hysterectomy: Assessment of the need to perform complete resection

Intravenous leiomyomatosis (IVL) is a rare smooth muscle tumor that may extend into extrauterine veins. A high IVL recurrence rate has been reported after hysterectomy. A 44-year-old woman underwent total hysterectomy as a result of uterine leiomyoma, and IVL within the left uterine vein was incidentally found during the surgery. A residual tumor within the right ovarian vein was detected on contrast-enhanced computed tomography (CT) two days postoperatively. The tumor was diagnosed as IVL because it showed contrast enhancement on preoperative magnetic resonance imaging by retrospective re-interpretation. However, the tumor completely disappeared on contrast-enhanced CT without any medical treatment five months postoperatively. This is the first report of spontaneous regression of IVL. Postsurgical imaging was important to determine the residual extrauterine extension of IVL when it was incidentally found during gynecologic surgery. A hysterectomy alone may be adequate in selected cases, but long-term follow-up imaging is strongly recommended in all cases.

Involvement of GATA-4/-5 transcription factors in ovarian carcinogenesis

To clarify the role of GATA transcription factors in ovarian carcinogenesis, we analyzed the expression and methylation states of GATA-4/-5/-6 in eight human ovarian cancer cell lines. GATA-4/-5 were methylated in three and two cell lines without their expression, respectively. Methylation of GATA-4/-5 was also detected in nine and five of 15 primary ovarian cancers, respectively. GATA-6 was not methylated in any cases. We transiently over-expressed GATA-5 in the JHOC-5 cell line using an adenovirus system, resulting in that apoptosis was induced and apoptosis-related genes, such as Apaf-1, were up-regulated. These data suggest that GATA-4/-5 may be involved in ovarian carcinogenesis.

[Neoadjuvant intraarterial chemotherapy with nedaplatin, peplomycin and mitomycin C for advanced cervical cancer]

The aim of the present study was to examine the usefulness of neoadjuvant intraarterial chemotherapy (NAC) using nedaplatin as key drug to improve the prognosis in case of advanced cervical cancer. Twenty-five cases of advanced cervical cancer (15 cases of stage II with high risks, 10 of stage III, referred to as the 254-S group) treated by NAC using nedaplatin, mitomycin C and peplomycin were compared with 30 cases (22 cases of stage II with high risks, 8 of stage III, referred to as the CDDP group) treated using cisplatin and mitomycin C which is the conventional regimen, in terms of measurable response, pathological response, rate of lymph node metastasis, cumulative survival rate, side effects and relapse style. According to the evaluation by measurable responses, the response rate was 90% (CR 52%) in the 254-S group and 75% (CR 15%) in the CDDP group. For pathological response of the specimen, the CR rate was 16% in the 254-S group and 23% in the CDDP group. The rate of lymph node metastasis extracted surgically was 33% and 41%, respectively. The cumulative survival rate in the 254-S group was about 10% better than in the CDDP group, but no significant difference was found. Leucopenia of both groups was of the same grade. In the 254-S group, although thrombocytopenia was more critical than in the CDDP group, there was a slight tendency to kidney toxicity. The locoregional recurrence rate was 12% in the 254-S group and 30% in the CDDP group. The distant metastasis rate was 16% and 27%, respectively. Although neoadjuvant intraarterial chemotherapy using nedaplatin as a key drug was useful to improve the prognosis of advanced cervical cancer, measures against recurrence outside the pelvis and individualization of medical treatment were considered to lead to a further improvement of the prognosis.

Efficacy of ipriflavone in preventing adverse effects of leuprolide

The purpose of this study was to evaluate the efficacy of ipriflavone in preventing bone loss, decreasing in serum cholesterol and decreasing the rate of appearance of vasomotor symptoms, as well as the effects of ipriflavone on reduction of myoma volume by estrogen deficiency during treatment with the GnRH analog leuprolide. One hundred two women (mean age, 44.3 +/- 0.53 yr) receiving leuprolide therapy for uterine leiomyoma were randomly allocated to two groups (group A, leuprolide only; group B, leuprolide with ipriflavone). Bone mineral density of the lumbar spine was measured by dual-energy x-ray absorptiometry before and after treatment for 6 months. Levels of serum total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol (LDL-C) were measured before treatment and after 3 and 6 months of treatment. Subjects were asked to report the appearance of vasomotor symptoms throughout treatment. Myoma node volumes were measured before treatment and after treatment for 6 months. Bone mineral density was reduced in both groups, with reduction rates of -5.26% in group A and -3.70% in group B (P < 0.01 vs. group A). Changes in bone markers were not significant in either group. TC was significantly increased in both groups, and TG levels were increased significantly after 3 and 6 months of treatment in group A but not in group B. There was no significant difference between these two groups in amount of increase of either TC or TG. LDL-C levels were increased significantly after 3 and 6 months of treatment in both groups, and the differences between the groups (11.7% in group A vs. 7.5% in group B at 3 month and 22.6% in group A vs. 8.4% in group B at 6 month) were significant. Severe vasomotor symptoms were reduced in group B. The rates of reduction of myoma volume were 49.8% in group A and 52.9% in group B; this difference between groups was not significant. Ipriflavone efficaciously alleviated the adverse effects of estrogen deficiency such as bone loss and increase in LDL-C level, and the ability of leuprolide therapy to reduce myoma volume was not decreased by ipriflavone administration.