Safety and efficacy of sirolimus in recurrent intravenous leiomyomatosis, pulmonary benign metastatic leiomyomatosis, and leiomyomatosis peritonealis disseminata: a pilot study

BACKGROUND

Intravenous leiomyomatosis (IVL), pulmonary benign metastatic leiomyomatosis (PBML), and leiomyomatosis peritonealis disseminata (LPD) are leiomyomas with special growth patterns and high postoperative recurrence rates. We report the safety and efficacy of a pilot study of sirolimus in the treatment of recurrent IVL, PBML, and recurrent LPD.

METHODS

This was a pilot study to evaluate the safety and efficacy of sirolimus in the treatment of leiomyomatosis (ClinicalTrials.gov identifier NCT03500367) conducted in China. Patients received oral sirolimus 2 mg once a day for a maximum of 60 months or until disease progression, intolerable toxicity, withdrawal of consent, or investigator decision to stop. The primary end point of this study was the objective response rate. Secondary end points included safety and tolerability, disease control rate, and progression-free survival.

RESULTS

A total of 15 patients with leiomyomatosis were included in the study, including five with recurrent IVL, eight with PBML and two with recurrent LPD. The median follow-up time was 15 months (range 6-54 months), nine patients (60%) had treatment-related adverse events (including all levels), and two patients had treatment-related grade 3 or 4 adverse events. The objective response rate was 20.0% (95% CI, 7.1-45.2%), and the disease control rate was 86.7% (95% CI, 62.1-96.3%). Partial response was achieved in three patients. The median response time in the three partial response patients was 33 months (range 29-36 months), and the sustained remission time of these three patients reached 0, 18, and 25 months, respectively.

CONCLUSIONS

Sirolimus was safe and effective in the treatment of recurrent IVL, PBML, and recurrent LPD.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03500367. Registered on 18 April 2018.

Synthetically Lethal Interactions of Heme Oxygenase-1 and Fumarate Hydratase Genes

Elevated expression of heme oxygenase-1 (HO-1, encoded by HMOX1) is observed in various types of tumors. Hence, it is suggested that HO-1 may serve as a potential target in anticancer therapies. A novel approach to inhibit HO-1 is related to the synthetic lethality of this enzyme and fumarate hydratase (FH). In the current study, we aimed to validate the effect of genetic and pharmacological inhibition of HO-1 in cells isolated from patients suffering from hereditary leiomyomatosis and renal cell carcinoma (HLRCC)-an inherited cancer syndrome, caused by FH deficiency. Initially, we confirmed that UOK 262, UOK 268, and NCCFH1 cell lines are characterized by non-active FH enzyme, high expression of Nrf2 transcription factor-regulated genes, including HMOX1 and attenuated oxidative phosphorylation. Later, we demonstrated that shRNA-mediated genetic inhibition of HMOX1 resulted in diminished viability and proliferation of cancer cells. Chemical inhibition of HO activity using commercially available inhibitors, zinc and tin metalloporphyrins as well as recently described new imidazole-based compounds, especially SLV-11199, led to decreased cancer cell viability and clonogenic potential. In conclusion, the current study points out the possible relevance of HO-1 inhibition as a potential anti-cancer treatment in HLRCC. However, further studies revealing the molecular mechanisms are still needed.

Bevacizumab Plus Erlotinib Combination Therapy for Advanced Hereditary Leiomyomatosis and Renal Cell Carcinoma-Associated Renal Cell Carcinoma: A Multicenter Retrospective Analysis in Korean Patients

PURPOSE

Hereditary leiomyomatosis and renal cell carcinoma (HLRCC) is a rare genetic syndrome resulting from germline mutations in fumarate hydratase. The combination of bevacizumab plus erlotinib showed promising interim results for HLRCC-associated RCC. Based on these results, we analyzed the outcome of bevacizumab plus erlotinib in Korean patients with HLRCC-associated RCC.

MATERIALS AND METHODS

We retrospectively reviewed the efficacy and safety of bevacizumab plus erlotinib in patients with HLRCC-associated RCC who were confirmed to have germline mutations in fumarate hydratase. The primary endpoint was the objective response rate (ORR), while the secondary endpoints were progression-free survival (PFS) and overall survival (OS).

RESULT

We identified 10 patients with advanced HLRCC-associated RCC who received bevacizumab plus erlotinib. Median age at diagnosis was 41 years, and five of the patients had received the combination as first- or second-line treatments. The ORR was 50% and the median PFS and OS were 13.3 and 14.1 months, respectively. Most adverse events were predictable and manageable by conventional measures, except for one instance where a patient died of gastrointestinal bleeding.

CONCLUSION

This is the first real-world outcome of the treatment of advanced HLRCC-associated RCC. Bevacizumab plus erlotinib therapy showed promising activity with moderate toxicity. We should be increasingly aware of HLRCC-associated RCC and bevacizumab plus erlotinib should be a first-line treatment for this condition, unless other promising data are published.

Potential synergism between ulipristal acetate and vitamin D3 in uterine fibroid pharmacotherapy - 2 case studies

This is a preliminary report of the first cases of successful simultaneous use of ulipristal acetate (UPA) and vitamin D3 in uterine fibroid (UF) oral treatment in humans. We present two cases of 37- and 49-year-old females with clinically symptomatic UFs and vitamin D deficiency. Both patients were treated with a standard 3 months of UPA scheme (5 mg daily) with the additional use of vitamin D3 (7000 IU daily orally). In the 37-year-old female all the symptoms (pain, pressure, frequent urination) decreased, total tumor volume after the treatment changed by 47.8%. In the 49-year-old female most symptoms perished, total tumor volume was reduced by 63.3%. UPA and vitamin D share synergistic anti-fibroid properties. Further studies are necessary to show the exact effect of UPA and vitamin D as co-drugs.

Unexpected uterine leiomyosarcoma in a woman with multiple myomas treated with ulipristal acetate: case report and literature review

Ulipristal acetate (UPA) has been recognized as an alternative strategy to surgery in the management of symptomatic women with uterine fibroids. We present a case report on a woman with hereditary fibrinogen deficiency exclusively treated with UPA for myoma-related menorrhagia and abdominal pain, who subsequently underwent a hysterectomy because of clinical worsening. A FIGO IB uterine leiomyosarcoma was found among multiple myomas. A review of the literature found two other cases of uterine leiomyosarcoma in patients treated with UPA: clinical data are reported. The aim of this case report is to increase clinicians' awareness that, although rare, leiomyosarcoma can develop in a uterus with multiple myomas and no reliable diagnostic tools exist yet. Thus, a clinical and instrumental careful reevaluation and patient counseling should be a priority when planning to repeat UPA treatment cycles.

Two sisters with Reed's syndrome: treatment with pregabalin

Cutaneous leiomyomas, which originate in the arrector pili muscles of the skin are rarely seen benign cutaneous tumors. Sometimes familial cutaneous and uterine leiomyomatosis can occur together, an autosomal dominant genetic condition called Reed syndrome or familial leiomyomatosis cutis et uteri. This disorder can be accompanied by malignancies, particularly by renal carcinoma. In this paper, two sisters with Reed syndrome are presented in view of the rarity of the disorder and good response to pregabalin therapy.

Novel hormone treatment of benign metastasizing leiomyoma: an analysis of five cases and literature review

OBJECTIVE

To evaluate novel hormonal therapies in patients with unresectable benign metastasizing leiomyoma (BML) disease.

DESIGN

Case series.

SETTING

National Institutes of Health (NIH).

PATIENT(S)

Five subjects with the diagnosis of BML based on imaging and/or histopathologic diagnosis.

INTERVENTION(S)

Four patients were treated with single or combination therapy of leuprolide acetate and/or an aromatase inhibitor. One patient was treated with an antiprogestin (CDB-2914).

MAIN OUTCOME MEASURE(S)

Response to therapy was measured by tumor burden on cross-sectional imaging employing RECIST (Response Evaluation Criteria in Solid Tumors) 1.1 guidelines.

RESULT(S)

Four patients treated with single or combination therapy of leuprolide acetate and/or an aromatase inhibitor demonstrated stable disease with reduction in tumor burden. The fifth patient treated with antiprogestin (CDB-2914) had degeneration of her tumor, progression of its size, and an improvement in symptoms.

CONCLUSION(S)

Hormone treatment with GnRH agonist and/or aromatase inhibition may be a therapeutic option to reduce tumor burden in unresectable BML disease or for those patients who wish to avoid surgical intervention. RECIST 1.1 guidelines, while traditionally used to evaluate tumor response to cancer therapeutics, may be useful in evaluating BML tumor burden response to hormone therapy.

Pruritus as an unusual symptom in multiple piloleiomyoma

A 30-year-old woman presented with multiple pruritic raised skin lesions at the proximal part of her left arm for the past 15 years. At the age of 15, the patient noticed red nodules accompanied with severe pruritus over the arm, which started to spread and involved the dorsal aspect of her scapula (Figure 1). They had been increasing in number during the past 15 years. There was no history of pain either spontaneously or in response to cold, tactile, or emotional stress, with no bleeding or oozing. There was no family history of similar skin lesions; however, she had a history of gynecologic problems for 10 years, and examination of her uterus showed uterine leiomyomas. The patient complained about severe pruritus. This symptom was exaggerated with sun exposure, cold, emotional stress, and rough cloths. It was so severe that it caused sleep disturbances. Clinical examination showed multiple pink and red nodules ranging from 5 mm to 20 mm over the above-described sites. The lesions were firm, smooth, not mobile, and nontender, with no pain on touch. Routine hematologic and biochemical investigations were normal. Kidney and pelvic ultrasonography showed myomatous uterus and normal kidneys. Microscopic examination of one of the nodules in hematoxylin and eosin-stained sections showed proliferation of smooth muscle cells with fascicular aspect in dermis. These cells had thin, elongated eel-like nuclei with blunt edges (Figure 2 and Figure 3). The diagnosis of leiomyoma was made and the patient was referred for surgical excision. Due to the extension and site of the lesions, the plastic surgeon did not recommend surgical procedure and the patient was treated with an antihistamine (loratadine 10 mg/d).

A study of visuospatial working memory pre- and post-Gonadotropin Hormone Releasing Hormone agonists (GnRHa) in young women

Gonadotropin Hormone Releasing Hormone agonists (GnRHa) produce an acute decline in ovarian hormone production leading to a 'pseudo' menopause. This is therapeutically useful in the management of a variety of gynaecological conditions but also serves as a powerful model to study the effects of ovarian hormones on cognition. Animal and human behavioral studies report that memory is particularly sensitive to the effects ovarian hormone suppression (e.g. post GnRHa). Further, it has recently been reported that ovariectomy in young women increases the risk of cognitive impairment in later life. However, the underlying brain networks and/or stages of memory processing that might be modulated by acute ovarian hormone suppression remain poorly understood. We used event-related fMRI to examine the effect of GnRHa on visual working memory (VWM). Neuroimaging outcomes from 17 pre-menopausal healthy women were assessed at baseline and 8 weeks after GnRHa treatment. Seventeen matched wait-listed volunteers served as the control group and were assessed at similar intervals during the late follicular phase of the menstrual cycle. We report GnRHa was associated with attenuation of left parahippocampal (BA 35) and middle temporal gyri (BA 21 ,22, 39) activation, with a significant group-by-time interaction at left precuneus (BA 7) and posterior cingulate cortex (PCC) (BA 31) at encoding, and with cerebellar activation at recognition in the context of unimpaired behavioral responses. Our study suggests that acute ovarian hormone withdrawal following GnRHa, and perhaps at other times, (e.g. following surgical menopause and postpartum) alters the neural circuitry underlying performance of VWM.

Presurgical short term treatment of uterine fibroids with different doses of cetrorelix acetate: A double-blind, placebo-controlled multicenter study

OBJECTIVE

To assess the efficacy and safety of different dosing schedules of cetrorelix acetate as a short term treatment for 4 weeks prior to surgery in patients with uterine fibroids.

STUDY DESIGN

Randomized, double-blind, placebo-controlled study. Patients were 109 premenopausal women, with at least one uterine fibroid, more than 4 cm in diameter. Groups 1-3 received placebo, 5 and 10 mg of cetrorelix on days 1, 8, 15 and 22, respectively group 4 received 10mg of cetrorelix on days 1 and 15. MRI scan was performed at screening and on day 29. The main outcome measure was the reduction of uterine volume on day 29 and response, defined as >30% size reduction.

RESULTS

Mean (+/-S.D.) reduction of uterine volume on day 29 (MRI scan) was 5.1+/-32.1% with placebo, 15.6+/-20.2% with 4 x 5 mg, 15.4+/-34.6% with 4 x 10 mg and 0.6+/-30.6% with 2 x 10 mg cetrorelix. Significant response versus placebo (p<0.05) occurred in the 4 x 10 mg group (42.3% versus 11.1%)

CONCLUSIONS

Best objective response after 4 weeks of treatment was achieved after therapy with 4 x 10 mg of cetrorelix acetate. Short term presurgical treatment with the LHRH-antagonist cetrorelix is a flexible treatment protocol without any major side effects.

The Effect of Anastrazole on Symptomatic Uterine Leiomyomata

OBJECTIVE

To evaluate the effect of anastrazole on symptomatic uterine leiomyomata.

METHODS

This was a prospective intervention study carried out in a university department of obstetrics and gynecology. Forty-one premenopausal women eligible for hysterectomy with 45 uterine leiomyomata were enrolled and treated with anastrazole 1 mg daily for three cycles of 28 days each. The effect of treatment was evaluated on leiomyoma and uterine volumes, endometrial thickness, gonadotrophins, estradiol and hematocrit levels, menstrual pattern, severity of leiomyoma-related symptoms, and adverse effects. The effects of leiomyoma location, size, and age of participants on tumor volume changes were evaluated.

RESULTS

Thirty-five women with 39 leiomyomata finished the study. Anastrazole resulted in a mean 55.7% reduction of leiomyoma volumes (163 mL to 72 mL, P<.001), a 29.9% reduction in total uterine volumes (278 mL to 195 mL, P<.001), and an 11.3% increase of the hematocrit levels (33.4% to 37.2%, P<.001) at the end of the treatment. Leiomyoma location had no significant effect on volume decrease. Leiomyoma volume decreased in women aged older than 40 years (P=.002), whereas no difference was found in women younger than 40. The size of large (greater than 50 mm) leiomyomata decreased significantly (P=.004). Less difference was observed in small (50 mm or less) leiomyomata (P=.031). No differences were detected in hormonal status. Anastrazole improved leiomyoma-related symptomatology and caused no serious adverse effects.

CONCLUSION

In premenopausal women, anastrazole reduces the size of uterine leiomyomata, improves symptomatology, and is generally well tolerated.

LEVEL OF EVIDENCE

III.

Effect of mifepristone for symptomatic leiomyomata on quality of life and uterine size: a randomized controlled trial

OBJECTIVE

To assess the effect of low-dose mifepristone on quality of life, pain, bleeding, and uterine size among women with symptomatic leiomyomata.

METHODS

Forty-two women with symptomatic uterine leiomyomata and uterine volume of 160 mL or more were randomized to mifepristone, 5 mg daily, or placebo for 26 weeks. Quality of life (Uterine Fibroid Symptoms Quality of Life Questionnaire and Medical Outcomes Study 36-Item Short Form survey) and uterine and leiomyoma size (ultrasonography) were assessed at baseline, and at 1 month, 3 months, and 6 months of treatment. Bleeding (daily logs and pictorial charts) and pain (McGill Pain Questionnaire) were assessed monthly. Endometrial pathology was assessed at baseline and 6 months.

RESULTS

Forty-two women were randomized; 37 women completed all 6 months. Women randomized to mifepristone showed an improvement in leiomyoma-specific quality of life. Forty-one percent became amenorrheic, rates of anemia improved, and adjusted uterine size was reduced by 47%. Compared with the placebo group, improvements in these outcomes in the treatment group were significantly greater (P<.05 to .001). There were no significant differences in adverse effects between the groups. No endometrial hyperplasia was noted in any participant.

CONCLUSION

Low-dose mifepristone improves leiomyoma-specific quality of life and reduces leiomyoma size among women with symptomatic leiomyomata.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov www.clinicaltrials.gov NCT00133705

LEVEL OF EVIDENCE

I.

Pulmonary benign metastasizing leiomyoma: a report of 2 cases with different outcomes

BACKGROUND

Benign metastasizing leiomyoma (BML) of the lung is a rare manifestation of metastasis from a uterine myoma, in which its benign characteristics are maintained. The majority of cases are asymptomatic.

CASES

Case 1 responded to the classic treatment of oophorectomy, after which an improvement in symptoms was achieved. In case 2, however, symptoms appeared following oophorectomy and were treated with raloxifene.

CONCLUSION

These cases show the uncertainty that exists with respect to the evolution and treatment of symptomatic BML. Raloxifene is a therapeutic agent that has not been widely studied for this purpose but should be considered for inclusion in the arsenal of therapeutic options available.

[Leiomyomatosis of the lung]

The paper describes a case of diffuse leiomyomatosis of the lung in a 45-year-old female. Leiomyomatosis, a disease noted in females, is considered to include 4 types of multiple smooth muscle lesions: 1) benign metastasizing leiomyoma; 2) lymphangioleiomyomatosis; 3) leiomyomatous peritoneal dissemination; and 4) intravenous leiomyomatosis. The authors present a classification proposed by E. Martin who attempts to pool in it all multiple leiomyomatous lesions observed in females, males, and children.

Gestrinone in the treatment of uterine leiomyomata: effects on uterine blood supply

Gestrinone has been shown to reduce uterine volume and stop bleeding in women with uterine leiomyomata. In the present study, we demonstrated a reduction in the volume of uterine myomas and in the uterine artery blood perfusion over a 6-month period of gestrinone administration in premenopausal women.

Comparative Study of Different Dosages of Goserelin in Size Reduction of Myomatous Uteri

STUDY OBJECTIVE

To compare uterine size reduction obtained with three monthly subcutaneous injections of 3.6 mg of goserelin versus a single subcutaneous injection of 10.8 mg.

DESIGN

Prospective, randomized clinical trial (Canadian Task Force classification I).

SETTING

Department of Gynecology and Obstetrics at the Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo.

PATIENTS

Forty-five premenopausal women with uterine leiomyomas and uterine size greater than 600 cm(3) randomized to one of two groups.

INTERVENTION

Group A: 23 women received three monthly subcutaneous 3.6-mg doses of goserelin. Group B: 22 women received a single subcutaneous injection of 10.8 mg of goserelin. Follicle-stimulating hormone (FSH), estradiol, and hemoglobin levels were measured monthly. After 3 months, uterine size was determined by transvaginal and/or abdominal ultrasound.

MEASUREMENTS AND MAIN RESULTS

In group A, mean reduction of uterine size was 43% (426 cm(3)) at the end of treatment. In Group B, mean reduction of uterine size was 54% (494 cm(3)). Serum levels of FSH and estradiol were in postmenopausal range during treatment. Hemoglobin level improvement was equivalent in both groups.

CONCLUSION

Use of single injection of 10.8 mg of goserelin promoted significantly greater reduction in uterine size than three monthly 3.6-mg injections in patients with voluminous uterine leiomyomas.

Effects of gonadotropin-releasing hormone agonists on uterine volume and vasculature and on the immunohistochemical expression of basic fibroblast growth factor (bFGF) in uterine leiomyomas

We investigated the effect of the GnRH agonist (GnRH-a) on the uterine volume and on the immunohistochemical expression of basic fibroblast growth factor (bFGF) and the vasculature of leiomyomas. Twenty-five women were treated with leuprorelin acetate for 3 months; 46 untreated patients were enrolled as a control group. The uterine volume was measured by ultrasonography. After myomectomy or hysterectomy, the immunoexpression of bFGF and the endothelial marker, CD34, was studied and compared in treated and untreated leiomyomas. Uterine volume decreased after therapy. The number of cells expressing bFGF and the vascularity were diminished in treated leiomyomas. Reduction in the blood supply might be responsible, in part, for uterine-volume shrinkage after GnRH-a therapy.

Effect of gonadotropin-releasing hormone agonist and medroxyprogesterone acetate on calcium metabolism: a prospective, randomized, double-blind, placebo-controlled, crossover trial

OBJECTIVE

The purpose of this study was to prospectively compare the effectiveness of administering medroxyprogesterone acetate (MPA; 20 mg/d) in either the first (protocol A) or last (protocol B) 12-week period as well as a 6-month course of the GnRH agonist (GnRH-a; leuprolide acetate; 1 mg/d, SC) on calcium (Ca) metabolism.

DESIGN

Prospective, randomized, double-blind, placebo-controlled, crossover trial.

SETTING

Clinical research center, university hospital.

PATIENT(S)

Twenty women were randomized into protocol A or B, received either MPA or placebo along with GnRH-a, and were then crossed over at 12 weeks to placebo or MPA, for the final 12-week interval of GnRH-a therapy.

INTERVENTION(S)

Collection of serum and urine samples and measurement of bone density. Sex hormone, calcitropic hormone, and bone density studies were performed at baseline and at 12 and 24 weeks.

RESULT(S)

In both protocol A and B, LH and E(2) levels declined by 79%-81% and 83%-90% of the baseline, respectively, at 12 and 24 weeks. Serum Ca, phosphorus, alkaline phosphatase, and osteocalcin; 2-h fasting and 24-h urinary Ca excretion; and urinary hydroxyproline levels all increased significantly during GnRH-a treatment alone. Estimated Ca balance decreased significantly during GnRH-a treatment alone. The addition of MPA attenuated the increases in phosphorus, alkaline phosphatase, osteocalcin, and 2-h fasting and 24-h urinary Ca excretion, and the decrease in estimated Ca balance. Comparison of phase order demonstrated that MPA prevented 24-h urinary Ca excretion and urinary hydroxyproline loss and decline in estimated Ca balance when it was added back during the second 12 weeks (protocol B) but not during the first 12 weeks (protocol A). CONCLUSION (S): We conclude that sequential MPA appears to reverse in part the negative effects of GnRH-a on calcitropic hormones and estimated Ca balance.

Intravenous leiomyomatosis of the uterus

BACKGROUND

Intravenous leiomyomatosis is a rare uterine tumor defined as an intraluminal growth of benign smooth muscle cells in either venous or lymphatic vessels outside the confines of, or even in absence of leiomyomas. We report a case of intravenous leiomyomatosis of the uterus managed at our institution.

CASE REPORT

The patient, a 47-year-old woman; gravida 2 para 2, presented without complaints for a routine gynecological examination. An irregular-shaped enlarged uterus with a nodular pelvic mass extending into the broad ligament was found Laparotomy revealed a large retroperitoneal, moderately firm tumor which demonstrated fingerlike projections into the pelvic veins. Due to great blood loss, surgery had to be discontinued with substantial residual disease and our patient was set on a regimen of the GnRH analogue Leuprolide, which was applied over 5 months. This led to a reduction of the tumor which facilitated successful surgery. The primary tumor as well as the residual disease were classified as a leiomyoma with intravenous extension consisting of uniform, spindle-shaped smooth muscle cells in a whorled arrangement. Mitotic activity was low and pleomorphism was missing. Areas with degenerative changes were found, as well as prominent vascularity. At the right parametrium, the lumina of the dilated veins were filled with tumor. Immunhistochemically, the intravascular parts of the tumor revealed a positive staining reaction for vimentin, desmin and alpha-smooth muscle actin. The tumor also reacted for antibodies against estrogen- and progesterone-receptors.

CONCLUSION

Knowledge about this rare uterine tumor is important for adequate treatment and exact differential diagnosis. Though intravenous leiomyomatosis imitates a malignant neoplasm regarding its pattern of growth and extension, it must be differentiated histologically from malignant tumors to prevent overtreatment. Since intravenous leiomyomatosis demonstrates a tendency to recur, long-term follow-up of the patient is recommended.

Gabapentin treatment of multiple piloleiomyoma-related pain

Familial leiomyomatosis cutis et uteri may present with numerous cutaneous leiomyomas, or piloleiomyomas, which can be painful. Pharmacologic agents have had limited efficacy in mitigating leiomyoma-associated discomfort. We describe a case of familial piloleiomyomas in which intermittent pain at the site of the lesions was substantially reduced by the administration of oral gabapentin. The unusual unilateral distribution of leiomyomas in this case is discussed.

Late intracaval and intracardiac leiomyomatosis following hysterectomy for benign myomas treated by surgery and GnRH agonist

BACKGROUND

The aim of this study was to report an exceptional case of a patient presenting with intracaval and intracardiac leiomyomatosis treated by combined surgical and medical treatment.

CASE

A 48-year-old presented with intracaval and intracardiac leiomyomatosis (IL) discovered 6 years following a total hysterectomy with ovarian conservation for myomas. Surgical resection of the pelvic myomas and intracaval leiomyomatosis was performed during the same surgical procedure. Given the presence of a small tumor residuum in the pelvic cavity, postoperative medical treatment based on a gonadotropin-releasing hormone (GnRH) agonist was delivered for 1 year. The patient was followed-up using clinical examination and systematic CT scan. Ten months following the end of medical treatment, she is still in good health and the pelvic residuum has stabilized.

CONCLUSIONS

Patients with pelvic tumor combined with IL could be treated using a one-stage surgical procedure. In cases of incomplete surgical resection, medical treatment based on GnRH agonist could be successfully delivered.

Predicting the effect of gonadotropin-releasing hormone (GnRH) analogue treatment on uterine leiomyomas based on MR imaging

PURPOSE

To test the hypothesis that the simple assessment of signal intensity on T2-weighted MR images is predictive of the effect of hormonal treatment with gonadotropin-releasing hormone (GnRH) analogue.

MATERIAL AND METHODS

The correlation between T2-weighted MR imaging of uterine leiomyomas and histologic findings was evaluated using 85 leiomyomas from 62 females who underwent myomectomy or hysterectomy. We also correlated the pretreatment MR images features obtained in 110 women with 143 leiomyomas with the effect of GnRH analogue treatment. The size (length x width x depth) of the leiomyoma was evaluated before and at 6 months after treatment by ultrasound.

RESULTS

The proportion of leiomyoma cell fascicles and that of extracellular matrix affected signal intensities of uterine leiomyomas on T2-weighted MR images. The amount of extracellular matrix was predominant in hypointense leiomyomas on T2-weighted images, while diffuse intermediate signal leiomyomas were predominantly composed of leiomyoma cell fascicles. Marked degenerative changes were noted in leiomyomas with heterogenous hyperintensity. The homogeneously intermediate signal intensity leiomyomas showed significant size reduction after treatment (size ratio; posttreatment volume/pretreatment volume 0.29+/-0.11). The size ratio for the hypointense tumors was 0.82+/-0.14, and 0.82+/-0.18 for the heterogeneously hyperintense tumors. There was a significant difference in the response to treatment between the homogeneously intermediate signal intensity leiomyomas and the hypointense or heterogeneously hyperintense leiomyomas (both p<0.01).

CONCLUSION

Signal intensity on T2-weighted MR images depends on the amount of leiomyoma cell fascicles and extracellular matrix. Simple assessment of the MR signal intensity is useful in predicting the effect of GnRH analogue on uterine leiomyomas.

GnRH agonist for intravenous leiomyomatosis with cardiac extension. A case report

BACKGROUND

Intravenous leiomyomatosis with cardiac extension is an extremely rare disease.

CASE

We recently treated a case of intravenous leiomyomatosis with extension from the inferior vena cava into the right atrium. Three operations--exploratory laparotomy, debulking of the pelvic mass and resection of the intracardiac leiomyoma--were performed. Since cells of the resected leiomyomatosis were estrogen receptor positive, we postoperatively administered GnRH agonist (leuprorelin acetate) for six months to prevent regrowth of the residual mass in the pelvis. The residual mass began to enlarge immediately after cessation of leuprorelin acetate. The same medication was readministered, and regrowth of the residual mass was completely inhibited for 15 months, until this writing.

CONCLUSION

Intravenous leiomyomatosis seems to be hormone dependent, as in the case of uterine leiomyomas. In the absence of total resection, functioning ovarian tissue may remain. Therefore, long-term treatment with GnRH agonist may be useful in preventing recurrence of this disease.

Treatment with a gonadotrophin releasing hormone agonist before hysterectomy for leiomyomas: results of a multicentre, randomised controlled trial

OBJECTIVES

To ascertain whether uterine shrinkage induced by a gonadotrophin releasing hormone agonist before hysterectomy for fibroids increases the possibility of a vaginal procedure.

DESIGN

A multicentre, prospective, randomised, controlled study.

PARTICIPANTS

One hundred and twenty-seven premenopausal women with a uterine volume of 12 to 16 gestational weeks.

INTERVENTIONS

Twelve weeks of triptorelin depot treatment before hysterectomy or immediate surgery.

MAIN OUTCOME MEASURES

Number of vaginal and abdominal hysterectomies, operating time, blood loss, degree of difficulty of the procedure, perioperative serum haemoglobin and haematocrit levels, hospital stay, and patients' overall satisfaction with treatment.

RESULTS

After randomisation, four women withdrew from the study, leaving 60 women in the triptorelin arm and 63 in the immediate surgery arm. At baseline evaluation a vaginal hysterectomy was indicated in seven women allocated to pre-operative medical therapy (12%), and in 10 of those allocated to immediate surgery (16%). Clinical assessment after the 12-week GnRH agonist course showed that abdominal hysterectomy was no longer indicated in 25/53 women (47%) as a vaginal procedure appeared appropriate. Thus the overall rate of indication for a vaginal procedure in the pre-operative medical treatment arm was 32/60 cases (53%), with a between-group difference of 37% (95% CI, 26% to 51%; chi2(1) = 19.18, P < 0.0001; OR 6.06; 95% CI, 2.60 to 14.10). Pre- and post-operative serum haemoglobin and haematocrit levels were significantly higher in the GnRH agonist than in the immediate surgery arm. No appreciable difference was observed between the groups in the other intra- and post-operative variables, including patients' satisfaction.

CONCLUSIONS

Pre-operative GnRH agonist therapy increased the rate of vaginal hysterectomy in selected women with fibroids and uterine volume of 12 to 16 gestational weeks.

Clinical significance of cytogenetic abnormalities in uterine myomas

OBJECTIVE

To investigate the clinical characteristics of uterine myomas with cytogenetic rearrangements.

DESIGN

Comparative study of myomas with normal and abnormal karyotype.

SETTING

University hospital.

PATIENTS

Premenopausal, GnRH-agonist (GnRH-a) treated and menopausal patients.

INTERVENTIONS

Myomectomy or hysterectomy.

MAIN OUTCOME MEASURES

Karyotype analysis and clinical characteristics.

RESULTS

Clonal abnormalities occurred in 29% of uterine myomas but were not related to the age of the patient or, in untreated menopausal patients, to the size of the myoma. In GnRH-a treated and menopausal women, 48% of the myomas larger than 4 cm were associated with clonal abnormalities. Submucous myomas had significantly fewer clonal abnormalities (12%) than subserosal (29%) or intramural myomas (35%).

CONCLUSIONS

The data support the hypothesis that cytogenetic rearrangements in uterine myomas are associated with loss of steroid hormones dependency and alter the growth potential of the tumor.

[Bilateral multifocal pulmonary leiomyomatosis]

A case of diffuse primary pulmonary leiomyomatosis with a 24-years-old asymptomatic woman having a pulmonary radiological aspect of miliary dissemination 3 years after a myomectomy for sub-serous uterine fibroma. The diagnosis was established after a surgical pulmonary biopsy. The case presented certain peculiar features: a young woman; the inter-relation between pulmonary leiomyomatosis and the operated sub-serous uterine fibroma; the aggravating factor--the pregnancy; a confirmed probably hormonal cause (hyperestrogenemia); a progressive aggravating evolution.

[Uterine fibromas and the hormonal pattern: the therapeutic considerations]

Uterine fibromyomatosis is a widely recognised and well studied pathology that is found in around 30% of over 35-year-old women. It has been extensively demonstrated that the etiology of fibromyomas is hormone dependent and to date the main pathogenetic role in the development of these benign tumours has largely been attributed to estrogens. Uterine fibromyomas have been found to contain a higher level of estrogen and progesterone receptors than in normal uterus. This suggests an etiopathogenetic role also for progesterone, which is confirmed by the higher mitotic index of myomatous tissue cells in luteal phase. Growth factors also seem to be involved in the origin of uterine fibromyomatosis: concentrations of epidermal growth factor (EGF), insulin like growth factor 1 (IGF-I) and platelet derived growth factor (PDGF AB) are present in myomatous tissues together with their receptors. Recent studies have shown that the administration of an anti-progestin compound, like RU 486, causes a reduction in fibromyoma size. The role of progesterone in promoting uterine growth opens new horizons in the treatment of uterine fibromyomatosis. Treatment with GnRH analogs has proved effective in reducing the size of fibromyomas, even if the problem of their regrowth once treatment has been suspended remains unsolved. The administration of 100 mg of danazol for 6 months after treatment using GnRH analogs reduce fibromyoma rebound growth by around 30%.

Add-back therapy for long-term use in dysfunctional uterine bleeding and uterine fibroids

The gonadotrophin-releasing hormone (GnRH) agonists are an efficacious medical approach for the management of both dysfunctional uterine bleeding (DUB) and uterine fibroids. However, due to the long-term effects of GnRH agonists on bone mass, their use is restricted to short courses. Add-back hormone replacement therapy (HRT) is one strategy that could minimise the hypo-oestrogenic effects of GnRH agonists, without nullifying their therapeutic effects. In one study of add-back therapy with cyclical oestradiol/norgestrol in combination with Zoladex (goserelin acetate) in women with subjective DUB, the duration of menstruation, the number of days of heavy bleeding and objective blood loss were all significantly (P < 0.001) reduced. There was also significant (P < 0.001) symptomatic improvement. Furthermore, in 51 patients with symptomatic uterine fibroids, combined oestrogen/progestogen given for 21 months after initial GnRH agonist treatment for 3 months did not promote fibroid regrowth. In contrast, in women randomised to progestogen only, there was a gradual increase in uterine volume. The combination of GnRH agonists and add-back HRT appears beneficial for women with either DUB or fibroids.

Malignant degeneration in leiomyomatosis peritonealis disseminata

Leiomyomatosis peritonealis disseminata (LPD) is a rare clinico-pathologic entity typically observed in women of reproductive age. Its malignant degeneration has been reported in literature in only three cases. In this report we describe the clinical course of two more cases with proved malignant transformation of LPD; both cases were treated with combined chemotherapy.

Pulmonary benign metastasising leiomyoma: response to treatment with goserelin

Benign metastasising leiomyoma is a rare disease occurring predominantly in women of childbearing age and is hormonally influenced. The response of the disease to the luteinising hormone releasing hormone analogue goserelin is reported.

Leuprolide acetate and intravascular leiomyomatosis

BACKGROUND

Intravascular leiomyomatosis is an uncommon uterine tumor characterized by grossly visible intravascular proliferation of benign smooth muscle. Based on its role in reducing the size of leiomyomas, leuprolide acetate was given as induction therapy for extensive inoperable intravascular leiomyomatosis.

CASE

A 44-year-old woman, gravida 1, para 1-0-0-1, presented in July 1992 with abnormal uterine bleeding. Pelvic examination and ultrasonography revealed the presence of a large irregular pelvic mass. At laparotomy, uterine and bilateral adnexal masses were noted extending up to the pelvic inlet and into the broad and infundibulopelvic ligaments. This tumor was not resectable. Based on histologic and immunoperoxidase studies, the lesion was interpreted as a plexiform epithelioid smooth-muscle tumor of uncertain malignant potential. Leuprolide acetate depot therapy (7.5 mg every 4 weeks) was begun in September 1992 and continued for a total of 20 months. Maximal tumor regression was achieved after 9 months. Subsequent reexploration at 20 months revealed a resectable tumor. Resection was accomplished successfully, leaving no apparent residual disease.

CONCLUSION

Leuprolide acetate induced tumor regression and rendered debulking surgery feasible in a patient with previously unresectable, widespread, retroperitoneal intravascular leiomyomatosis. Primary hormone therapy may provide alternative therapeutic options for certain cases of intravascular leiomyomatosis.

Regression of uterine leiomyomata to the antiprogesterone RU486: dose-response effect

OBJECTIVE

To study the response of uterine leiomyomata to three daily doses of RU486 (5, 25, and 50 mg).

DESIGN

Prospective nonrandomized trial of women with symptomatic leiomyomata.

SETTING

Patients from the clinical practice of the authors at the University of California, San Diego Medical Center.

PATIENTS

Ten patients with symptomatic leiomyomata previously reported after treatment with 50 mg of RU486 daily for 3 months. Eleven patients treated with 25 mg of RU486 daily and nine patients placed on 5 mg of RU486 daily for 12 weeks.

MAIN OUTCOME MEASURES

Changes in leiomyomata volume as measured with vaginal ultrasounds at baseline and monthly thereafter. Frequent blood samples for hematology, chemistry, and hormone levels were obtained. Twenty-four-hour urine collections for free cortisol and creatinine were obtained at baseline and at 12 weeks.

RESULTS

All three doses induce ovarian acyclicity. Administration of 50 mg of RU486 decreases leiomyomata volume to 78.1% +/- 4.8% of baseline at 4 weeks, 60.5% +/- 6.6% at 8 weeks, and 51.0% +/- 9.2% after 12 weeks of treatment. Regressive response in patients treated with 25 mg of RU486 daily was 76.3% +/- 5.0% of baseline at 4 weeks, 54.0% +/- 5.1% at 8 weeks, and 44.0% +/- 5.0% after 12 weeks. At 5 mg of RU486 leiomyomata volume was 80.6% +/- 8.3% of baseline after 4 weeks, 63.7% +/- 14.6% after 8 weeks, and 74.4% +/- 19.8% after 12 weeks of therapy.

CONCLUSIONS

Although acyclicity is seen at all three doses, an effective dose to cause a clinically significant (50%) decrease in leiomyomata volume appears to be 25 mg daily.

Adjuvant surgical and hormonal treatment of leiomyomatosis peritonealis disseminata. A case report

Leiomyomatosis peritonealis disseminata (LPD) is a rare condition that usually presents during pregnancy or in women during the reproductive years and who are taking oral contraceptives. An unusual case of extensive LPD occurred in a 39-year-old woman who was not pregnant and had never taken oral contraceptives. The condition was treated successfully with total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, limited debulking and adjuvant hormonal therapy with megestrol acetate. Complete, rapid remission of residual tumor occurred in two months, as substantiated by clinical examination and serial sonography and laparoscopy. This is the first time that adjuvant hormonal therapy has been used successfully in the treatment of LPD. Radical surgery in patients with LPD is probably not indicated, and the use of adjuvant hormonal therapy may accelerate regression of residual tumor. Further evaluation of this form of therapy is recommended.

Effects of two different doses of leuprolide acetate depot on uterine cavity area in patients with uterine leiomyomata

OBJECTIVE

To compare the effects of two different doses of a monthly depot injection of a GnRH agonist (GnRH-a) on uterine cavity area in patients with uterine leiomyomata.

DESIGN

Prospective, randomized study.

SETTING

Hospital department of obstetrics and gynecology.

PATIENTS

Thirty-six premenopausal women, 25 to 52 years of age, with uterine leiomyomata.

INTERVENTION

Leuprolide acetate (LA) depot, 1.88 or 3.75 mg, was administered SC every 4 weeks for 24 weeks.

MAIN OUTCOME MEASURE

Uterine cavity area before and after treatment was assessed by hysterosalpingography.

RESULTS

The 1.88- and 3.75-mg LA depots significantly reduced uterine cavity area by 40.8% and 40.2%, respectively. No significant difference was observed between the two groups.

CONCLUSION

Monthly injection of 1.88 or 3.75 mg LA depots appears to reduce uterine cavity area to a similar extent in patients with uterine leiomyomata.

[Leiomyomatosis of the esophagus]

A rare case of dysphagia caused by leiomyomatosis of the esophagus is presented. Esophageal leiomyomatosis is triggered by diffuse proliferation of smooth muscle cells in the wall of the entire esophagus. Only 1.0% of all tumors of the esophagus are benign lesions; 0.4% of all esophageal neoplasms are leiomyomas. Only a few cases of leiomyomatosis-a special form of diffuse leiomyomas-have been described so far in the literature. Modern diagnostic imaging techniques such as CT and MR are described in esophageal leiomyomatosis.

Influence of the ovary on parameters of LH secretion during the recovery from buserelin-induced desensitization

This study examined the effect of the ovary on LH pulsatility and on the secretory performance of gonadotrophs during the phase of recovery after treatment with buserelin, a GnRH analogue. We included 12 patients, who received buserelin (1.2 mg/day, intranasally for 3 months) as a reductive therapy for uterine leiomyomatosis prior to hysterectomy. Six patients were oophorectomized and the other 6 patients had their ovaries preserved. LH was measured in samples taken basally up to 36 days after suppression of buserelin. LH pulsatility was studied on day 9 along a 24-h cycle, and the response of the hormone to a double-stimulus GnRH test on days 0, 9, 20, and 34. The concentration of LH reached normal premenopausal levels after an average of 2 weeks in women with ovaries but increased until 4-5 weeks in oophorectomized patients. The pulsatility of LH on day 9 was similar for both groups, but parameters related to LH amplitude or to baseline secretory activity of gonadotrophs were higher in the oophorectomized women. The response of LH to the GnRH tests was also significantly higher in the oophorectomized group from day 9. The conclusions are as follows. (1) At the early stage of recovery from desensitization, as represented by day 9, LH pulsatility was not substantially influenced by the presence or absence of the ovary. (2) There was an increase in parameters related to the amplitude of the LH bursts in the oophorectomized women. Although a higher amplitude of the endogenous GnRH pulses cannot be discarded, most probably that difference is due to a higher sensitivity at a pituitary level, as reflected by the GnRH stimulation tests.

[Anomalous uterine bleeding in the perimenopause: fibromatosis, hyperplastic endometriopathy and GnRH analogs]

In the light of recent reports, the authors used GnRH analogues to treat 18 perimenopausal women with anomalous uterine bleeding, fibromatosis and endometrial hyperplasia. The aim of the study was to avoid the recurrence of anomalous bleeding, reduce hyperplastic endometriopathy and, having attained stable amenorrhea, avoid resorting to traditional surgical treatment. At the end of the study 9 women had reached the pre-established objective, 4 recommended regular menstruation, 2 reported an episode of metrorrhagia due to endometrial atrophy, and a further 2 suffered a recurrence of the initial problem and underwent hystero-annexiectomy. One patient interrupted the therapy due to the onset of arterial hypertension.

[Short-term treatment with leuprolide acetate depot before surgical intervention for uterine leiomyomatosis]

It has been amply demonstrated that uterine leiomyoma possess estrogen receptors. On the basis of this presupposition, it is considered logical to use GnRH-agonists which, by reducing the level of estrogen, also reduce the volume of the leiomyoma, although to a varying extent. The maximum reduction which can be obtained occurs, according to published data, between 3 and 6 months of treatment, attaining mean values of approximately 50%. In the author's experience the treatment period was shortened even further by administering only 2 vials of leuprolide depot each month to women who subsequently underwent hysterectomy. The sample group comprised 30 women with uterine leiomyomatosis, of whom 15 were treated with a GnRH analogue and 15 with placebo. The reduction of uterine volume was evaluated by echography and was found to be 40% in the treated group, whereas non change was detected in the "placebo-group".

Uterine leiomyosarcomas coexistent with cellular and atypical leiomyomata in a young woman during the treatment with luteinizing hormone-releasing hormone agonist

We report a case of a 28-year-old woman who had received 2 months of intranasal buserelin (a luteinizing hormone-releasing hormone agonist; LH-RH agonist) therapy for presumed uterine leiomyomata. In addition to no reduction of the tumor size evaluated by sonography, heavy vaginal bleeding and abdominal pain recurred and worsened during the therapy. Pathological examination of the myomectomy and hysterectomy specimens revealed leiomyosarcomas coexistent with cellular, atypical, and classical leiomyomata. We suggest that this is a case of leiomyosarcomas arising in preexisting leiomyomata rather than de novo from the smooth muscle fibers of the myometrium. Furthermore, the potential of LH-RH, agonist therapy to delay the surgical treatment of an unsuspected leiomyosarcoma is high-lighted. Close monitoring of the treatment response by improvement of clinical symptoms and sonographic assessment of tumor size may be helpful in early diagnosis of an underlying malignant tumor.

Multiple cutaneous leiomyomas. Report of a case

Multiple cutaneous leiomyomas usually appear as painful nodules of the skin. Historically these have been treated by surgical excision, however, because they are often numerous, surgery may be an impractical approach. This article reports on a patient with multiple leiomyomas of the face treated by excision as well as a discussion of alternative treatments such as pharmacologic agents that may be used when surgical excision is not feasible.