[Radiation-induced parotid leiomyosarcoma]

INTRODUCTION

First case of radiation-induced parotid leiomyosarcoma.

ANATOMO-CLINICAL OBSERVATION

A 50-year-old woman with a history of cervical irradiation for Hodgkin's lymphoma presented with a right parotid tumefaction. Examination noted a deep adherent pretragal mass with peripheral facial palsy. A total parotidectomy with intra-operative examination and cervical curage was performed. Histopathological analysis concluded to a grade 3 parotid leiomyosarcoma according to the National Federation of Cancer Centers. Adjuvant radiotherapy was performed. After 24 months of follow-up, the patient presented bone and liver metastases without local recurrence.

DISCUSSION

This is the first case of radiation-induced leiomyosarcoma and the 12th case of parotid leiomyosarcoma described in the literature. The management associates surgery with adjuvant radiotherapy. Follow-up is by clinical examination, parotid MRI, and annual thoracoabdominal CT scan to search for metastases. Recurrences occur during the first year in 40 to 64% of cases, and distant metastases in 40 to 60% of cases. The 5-year survival rate is between 10 and 30%.

Robot-assisted laparoscopic enucleation in the treatment of leiomyosarcoma of urinary bladder: A case report

Leiomyosarcoma of urinary bladder (LMS-UB) is a highly malignant mesenchymal tumor, accounting for less than 0.5% of all bladder malignancies, with a predominant clinical presentation of hematuria. Here we report a case of low-grade LMS-UB. A 44-year-old male patient was admitted to the hospital with urodynia for 2 weeks. The patient's pelvis CT showed a mass on the right part of the bladder. For this reason, he was initially diagnosed with bladder cancer. We performed a robot-assisted laparoscopic enucleation of the bladder tumor and low-grade LMS-UB was diagnosed with the histopathological examination. He underwent 5 cycles of adjuvant chemotherapy after surgery. At 19months postoperative follow-up, the patient had no symptoms, recurrence, or distant metastasis. There is no report on the treatment of LMS-UB with minimally invasive enucleation worldwide. This case provides a new comprehensive treatment method of enucleation combined with adjuvant chemotherapy for early low-grade LMS-UB to reduce complications and improve patients' quality of life after surgery.

Efficacy thresholds for clinical trials with advanced or metastatic leiomyosarcoma patients: A European Organisation for Research and Treatment of Cancer Soft Tissue and Bone Sarcoma Group meta-analysis based on a literature review for soft-tissue sarcomas

BACKGROUND

In 2002, the European Organisation for Research and Treatment of Cancer Soft Tissue and Bone Sarcoma Group reported well-established values for conducting phase II trials for soft-tissue sarcomas. An update is provided for leiomyosarcoma (LMS).

MATERIALS AND METHODS

Clinical trials with advanced or metastatic LMS were identified via literature review in PubMed (published 2003-2018, ≥10 adult LMS patients). End-points were 3- and 6-month progression-free survival rates (PFSR-3m and PFSR-6m). When estimates could not be derived from publications, data requests were sent out. Treatments were classified as recommended (R-T) or non-recommended (NR-T) according to the ESMO 2018 guidelines. A random effects meta-analysis was used to pool trial-specific estimates for first-line (1L) or pre-treated (2L+) patients separately. The ESMO Magnitude of Clinical Benefit Scale was used to guide the treatment effect to target in future trials.

RESULTS

From 47 studies identified, we obtained information on 7 1L and 16 2L+ trials for 1500 LMS patients. Overall, in 1L, PFSR-3m and PFSR-6m were 74% (95% confidence interval [CI] 64-82%) and 58% (95% CI 50-66%), respectively. For 2L+, PFSR-3m was 48% (95% CI 41-54%), and PFSR-6m was 28% (95% CI 22-34%). No difference was observed between R-T and NR-T for first or later lines. Under the alternative that the true benefit amounts to a hazard ratio of 0.65, a PFSR-6m ≥70% can be considered to suggest drug activity in 1L. For 2L+, a PFSR-3m ≥62% or PFSR-6m ≥44% would suggest drug activity. Specific results are also provided for uterine LMS.

CONCLUSIONS

This work provides a new benchmark for designing phase II studies for advanced or metastatic LMS.

Metastases of soft tissue sarcoma to the liver: A Historical Cohort Study from a Hospital-based Cancer Registry

BACKGROUND

Hepatic metastasis of soft tissue sarcoma is rare compared to lung metastasis, and the literature is scarce. We examined the risk of hepatic metastasis according to the site of occurrence and histological type.

METHODS

From a Hospital-based Cancer Registry, 658 patients registered between 2007 and 2017 with soft tissue sarcomas were evaluated. The exclusion criteria were gastrointestinal stromal tumors, tumors of unknown origin, and follow-up periods of less than 1 month. SPSS 25 was used for statistical analysis.

RESULTS

The risk of hepatic metastasis was significantly higher in the retroperitoneum (HR, 5.981; 95% CI, 2.793-12.808) and leiomyosarcoma (HR, 4.303; 95% CI, 1.782-10.390). Multivariate analysis showed that the risk of hepatic metastasis as first distant metastasis was high in leiomyosarcoma (HR, 4.546; 95% CI, 2.275-9.086) and retroperitoneal onset (HR, 4.588; 95% CI, 2.280-9.231). The 2-year survival rate after hepatic metastasis was 21.7%.

CONCLUSIONS

The onset of hepatic metastasis indicates a poor prognosis. However, hepatic metastasis from retroperitoneal sarcoma and leiomyosarcoma may be the first distant metastasis in some cases. For retroperitoneal sarcoma and leiomyosarcoma, additional screening for hepatic metastasis such as contrast CT should be considered during staging and follow-up after treatment.

Recurrent broad ligament leiomyosarcoma with pancreatic and thigh metastasis: a case report

BACKGROUND

Leiomyosarcoma (LMS) is an uncommon mesenchymal neoplasm, which infrequently metastasizes to pancreas and thigh. Clinical presentation and imaging findings of metastatic broad ligament LMS are often nonspecific. Complete excision plays an important role in treatment of patients with localized LMS.

CASE PRESENTATION

Here, we report a case of a 33-year-old woman with recurrent broad ligament LMS metastasizing to pancreas and thigh. Previously, she was diagnosed with broad ligament LMS and underwent hysterectomy, bilateral salpingo-oophorectomy. The disease-free interval was 2.5 years until metastases were found. Computerized tomography (CT) of abdomen and thighs, magnetic resonance imaging (MRI) of thighs and whole-body 18-fluorodeoxyglucose positron emission tomography - computed tomography (PET-CT) performed, revealed pancreatic and thigh metastasis. Ultrasonography-guided biopsy and histological examinations confirmed LMS at both the sites. Pancreatic metastasis was completely resected first. Then the patient underwent surgical resection of thigh metastasis when both chemotherapy and radiotherapy failed. She recovered well and remained free of disease recurrence in the 2 years follow-up.

CONCLUSIONS

Though imaging lacks specificity, it is a valuable asset in assessing the burden of disease and characterizing lesions while histological examination with immunohistochemistry is helpful for the diagnosis of LMS. Complete surgical resection of all metastatic sites where-ever feasible should be strongly considered in a treated case of broad ligament LMS with a durable disease-free interval.

Leiomyosarcoma of the Inferior Vena Cava with Hepatic and Pulmonary Metastases: Case Report

Sarcomas are connective tissue tumors accounting for only 1% of all adult malignancies. Leiomyosarcoma (LMS) is a sarcoma arising from smooth muscle cells, and accounts for 10-20% of all sarcomas. A subtype of LMS are those originating from the smooth muscle of blood vessels. Leiomyosarcoma of the inferior vena cava is a sarcomatous tumor, with less than 350 cases described in the literature. It carries a poor prognosis, with 5- and 10-year survival rates of 31.4% and 7.4%, respectively. We present a case of a 46-year-old female with no significant past medical history presented to the emergency department with mild abdominal pain and distention, early satiety, and weight loss for three weeks, found to have unresectable metastatic leiomyosarcoma of the inferior vena cava.

[Recurrence of a Giant Retroperitoneal Leiomyosarcoma Six Years after the Initial Surgery]

A 51-year-old man came to our department because of a large abdominal mass. CT, MRI, and sonography revealed a large tumor adjacent to the retroperitoneal area. A resection was performed, and histologically we confirmed the diagnosis as a leiomyosarcoma originating from the retroperitoneum. Six years after the initial surgery, the patient came to our outpatient department with a complaint of nausea. A relatively large tumor was seen on a CT scan that was causing obstruction of the duodenum. Another surgery was performed with the final diagnosis as a recurrence of the leiomyosarcoma. After 3 courses of adjuvant chemotherapy with eribulin, the patient presented with abdominal distension. CT revealed a very large tumor with massive invasion to the ileum and colon. This time, we considered the tumor unresectable, and administered chemotherapy with a combination of doxorubicin and ifosfamide. However, after 1 course, the patient's condition worsened and he died of the disease 3 months after the chemotherapy.

Single-port thoracoscopic lung wedge resection using the Endo GIA Radial Reload

The GIA Radial Reload is a surgical stapler with a curved cut line that is perpendicular to the direction of instrument insertion. We used the GIA Radial Reload in three cases of single-port thoracoscopic lung wedge resection. The operations were performed through a 3.0-4.5-cm incision. For the first stapler, we selected the GIA Radial Reload. The orientation of this device's cut line enabled us to easily cut the lung behind the lesion during single-port thoracoscopic surgery.

Vaginal metastasis as the initial presentation of leiomyosarcoma: a case report

BACKGROUND

Uterine leiomyosarcomas are very rare and highly aggressive tumors that have a high rate of recurrence and poor prognosis, even when early diagnosed. Due to their relative rarity, there is limited research on optimal management strategies.

CASE PRESENTATION

A 60-year-old woman with a history of an asymptomatic uterine leiomyoma presented in October 2015 with postmenopausal bleeding and a friable vaginal cyst that bled when palpated. A partial cystectomy was performed, and malignant-like cystic and solid components were identified. Histopathology diagnosed an unclassifiable malignant epithelioid tumor. Subsequent imaging studies identified a malignant uterine tumor, a metabolically active vaginal lesion, and two benign leiomyomas. An anterior pelvic exenteration (colpectomy, hysterectomy, bilateral adnexectomy, total cystectomy, and cutaneous ureteroileostomy ad modum Bricker) were performed by laparotomy in March 2016. Examination of the surgical specimens identified a 75 × 75-mm leiomyoma, an 80 × 30-mm infiltrating mesenchymal uterine lesion with vascular invasion and tumor emboli, and a 60 × 30-mm perivascular vaginal tumor. Immunohistochemistry indicated a phenotypic transition from a uterine leiomyosarcoma to a vaginal epithelioid lesion; marker expression changed from the uterine tumor actin+/desmin+/caldesmon+/CD10- phenotype, through the tumor emboli, to an actin-/desmin-/caldesmon-/CD10+ phenotype in the vaginal lesion. A high-grade uterine mesenchymal tumor and vaginal metastasis were diagnosed. Adjuvant chemotherapy with docetaxel, gemcitabine, and doxorubicin commenced in May 2016 and treatment has been well tolerated.

CONCLUSIONS

Differentiating leiomyosarcoma from leiomyoma is challenging and few tools other than microscopic evaluation are available. Vaginal compromise in leiomyosarcoma usually results from tumor extension, not hematogenous metastasis. A vaginal metastasis is a very rare initial presentation. We have found only two cases like this described on published literature. The atypical clinical and histological presentation in our case complicated diagnosis and delayed treatment. An early diagnosis and complete surgical clearance gives the best chance of survival, and imaging tools should be applied early in instances of new suspicious malignant lesions.

A Case of Uterine Leiomyosarcoma with Long-Term Disease Control by Pazopanib

Uterine leiomyosarcoma (ULMS) is an aggressive tumor associated with high rates of progression, recurrence, and mortality. Pazopanib is the only approved molecular targeted drug for advanced soft tissue sarcoma, and it has been proven to prolong progression-free survival relative to placebo. We herein report a case of ULMS with multiple lung metastases treated with pazopanib, which led to sustained disease control for 44 weeks. A 53-year-old woman was referred to our hospital due to massive uterine bleeding from a uterine corpus tumor mass. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed as emergency surgery. The final histopathological diagnosis was uterine leiomyosarcoma, and computed tomography revealed multiple lung metastases. After chemotherapy with 17 cycles of gemcitabine and docetaxel and two cycles of doxorubicin, the lung metastases had increased in size and new lesions had appeared. Pazopanib administration at 800 mg/day was started as third-line therapy. Ten weeks later, the dose of pazopanib was reduced to 600 mg/day because of hepatic impairment and hypertension. However, lung metastases of ULMS were stabilized by pazopanib administration for about 44 weeks without a decline in the patient's quality of life. After 44 weeks of therapy, pazopanib administration was discontinued because of progressive disease and worsening of the patient's respiratory status. Pazopanib is an oral multityrosine kinase inhibitor of vascular endothelial growth factor receptor-1, -2, and -3; platelet-derived growth factor-α and -β; and c-Kit receptor. The role of pazopanib may be clinically significant in the treatment of advanced ULMS.

Epithelioid Leiomyosarcoma in the Visceral Peritoneum of an American Badger (Taxidea Taxus)

A 12-year-old female American badger was presented to the Taipei city zoo veterinary ward with anorexia and weakness. Treatments were ineffective, and the badger died of chronic interstitial nephritis and uremia. At necropsy, numerous firm white nodules, measuring 0.5–2.0 cm, were present on the surface of the liver, stomach, spleen, small intestine, pancreas, and diaphragm. Most nodules were encapsulated and well demarcated from the organs to which they were attached. A poorly demarcated mass, measuring 0.5 cm in diameter, had invaded the hepatic parenchyma and appeared to be the origin of all the nodules derived by transcavitary implantation. Histologically, the nodules contained primarily oval or spindle-shaped cells, typical of smooth muscle cells, forming alternating bundles attached to the surface of the various organs. In some nodules, aggregates of individual polyhedral to round cells with round to oval centrally located nuclei and abundant eosinophilic cytoplasm, typical of smooth muscle origin, were noted. Zones of subcapsular necrosis and multifocal necrosis were also observed in some nodules. Tumor cells stained positively for α-smooth muscle actin and vimentin and negatively for desmin, cytokeratin, estrogen, and progesterone receptors. This tumor is similar to but distinguishable from the “disseminated peritoneal leiomyomatosis (DPL)” found in women.

[A Case of Severe Hematological Toxicity in Response to Pazopanib]

The patient(woman, approximately 46 years old)began pazopanib (PAZ) treatment (800 mg/day)f ollowing the recurrence of retroperitoneal leiomyosarcoma. Prior to treatment, the patient's platelet count was 18.6×10(4)/µl and her neutrophil count was 1.61×10(3)/µl . The platelet count decreased to 9.2×10(4)/µl on day 7 and to 5.4×10(4)/µl on day 21 after commencement of treatment. The neutrophil count was 0.97×10(3)/µl on day 28 and 0.68×10(3)/µl on day 35 after commencement of treatment. Thus, PAZ treatment was stopped on day 35. The blood sampling results on day 42 after commencement of treatment showed that the platelet count was 13.0×10(4)/µl and that the neutrophil count had recovered to 1.28×10(3)/µl . At that time, PAZ treatment was resumed at a reduced dose of 600 mg/day. By day 84 after commencement of treatment, the platelet count had increased from 12.7 to 13.8×10(4)/µl and the neutrophil count had increased from 1.02 to 1.34×10(3)/µl ; treatment was subsequently continued. The main adverse effects that have been reported for PAZ are hypertension and frequent liver dysfunction; these reports also indicate that the incidence of severe cytopenia(thrombocytopenia, neutropenia)is quite low. However, our patient exhibited cytopenia after commencement of PAZ treatment and her blood cell counts recovered once treatment was ceased, independent of other possible medications. Our findings suggest that cytopenia should be considered as an adverse effect of PAZ.

Eribulin versus dacarbazine in previously treated patients with advanced liposarcoma or leiomyosarcoma: a randomised, open-label, multicentre, phase 3 trial

BACKGROUND

A non-randomised, phase 2 study showed activity and tolerability of eribulin in advanced or metastatic soft-tissue sarcoma. In this phase 3 study, we aimed to compare overall survival in patients with advanced or metastatic soft-tissue sarcoma who received eribulin with that in patients who received dacarbazine (an active control).

METHODS

We did this randomised, open-label, phase 3 study across 110 study sites in 22 countries. We enrolled patients aged 18 years or older with intermediate-grade or high-grade advanced liposarcoma or leiomyosarcoma who had received at least two previous systemic regimens for advanced disease (including an anthracycline). Using an interactive voice and web response system, an independent statistician randomly assigned (1:1) patients to receive eribulin mesilate (1·4 mg/m(2) intravenously on days 1 and 8) or dacarbazine (850 mg/m(2), 1000 mg/m(2), or 1200 mg/m(2) [dose dependent on centre and clinician] intravenously on day 1) every 21 days until disease progression. Randomisation was stratified by disease type, geographical region, and number of previous regimens for advanced soft-tissue sarcoma and in blocks of six. Patients and investigators were not masked to treatment assignment. The primary endpoint was overall survival in the intention-to-treat population. The study is registered with ClinicalTrials.gov, number NCT01327885, and is closed to recruitment, but treatment and follow-up continue.

FINDINGS

Between March 10, 2011 and May 22, 2013, we randomly assigned patients to eribulin (n=228) or dacarbazine (n=224). Overall survival was significantly improved in patients assigned to eribulin compared with those assigned to dacarbazine (median 13·5 months [95% CI 10·9-15·6] vs 11·5 months [9·6-13·0]; hazard ratio 0·77 [95% CI 0·62-0·95]; p=0·0169). Treatment-emergent adverse events occurred in 224 (99%) of 226 patients who received eribulin and 218 (97%) of 224 who received dacarbazine. Grade 3 or higher adverse events were more common in patients who received eribulin (152 [67%]) than in those who received dacarbazine (126 [56%]), as were deaths (10 [4%] vs 3 [1%]); one death (in the eribulin group) was considered treatment-related by the investigators.

INTERPRETATION

Overall survival was improved in patients assigned to eribulin compared with those assigned to an active control, suggesting that eribulin could be a treatment option for advanced soft-tissue sarcoma.

FUNDING

Eisai.

[A Case of Bilateral Pneumothorax after Chemotherapy for Uterine Leiomyosarcoma with Multiple Lung Metastases]

We encountered a case of uterine leiomyosarcoma with multiple lung metastases. The patient was a 52-year-old woman who underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy followed by chemotherapy with gemcitabine and docetaxel. After 1 cycle of chemotherapy, the lung metastasis was reduced, but at the same time, she developed bilateral pneumothorax. Chemical pleurodesis using talc was performed. The lungs were expanded and stabilized in 7 days. After 5 cycles of chemotherapy were administered, no recurrence of pneumothorax and adverse effects were observed.

Survival After Resection of Gastrointestinal Stromal Tumor and Sarcoma Liver Metastases in 146 Patients

BACKGROUND

We investigated outcomes by primary tumor type in patients who underwent resection of liver metastases from gastrointestinal stromal tumors (GIST), leiomyosarcomas, and other sarcomas.

METHOD

Our institutional liver database was used to identify patients who underwent resection from 1998 through 2013. Histopathological, clinical, and survival data were analyzed.

RESULTS

One hundred forty-six patients underwent resection of liver metastases from GIST (n = 49), leiomyosarcomas (n = 47), or other sarcomas (n = 50). The 5-year overall survival (OS) rates in patients with GIST, leiomyosarcomas, and other sarcomas were 55.3, 48.4, and 44.9%, respectively, and the 10-year OS rates were 52.5, 9.2, and 23.0%, respectively. The 5-year recurrence-free survival (RFS) rate was better for GIST (35.7%; p = 0.003) than for leiomyosarcomas (3.4%) and other sarcomas (21.4%). Lung recurrence was more common for leiomyosarcomas (36% of patients; p < 0.0001) than for other sarcomas (12%) and GIST (2%). For GIST, the findings support a benefit of imatinib regarding the 5-year RFS rate compared to resection alone (47.1 vs. 9.5%; p = 0.013). For leiomyosarcoma, primary tumor location did not affect the 5-year RFS rate (intraabdominal 14.5%; other location 0%; p = 0.182).

CONCLUSION

Liver metastases from GIST, leiomyosarcomas, and other sarcomas should be assessed separately as their survival and recurrence patterns are different. This is especially important for GIST, for which imatinib is now available.

[Mesenteric recurrence of leiomyosarcoma of the kidney seven years after the first operation - a case report]

A 60-year-old woman presented to our hospital with a pelvic tumor detected by using computed tomography at the Department of Urology of another hospital. Her medical history indicated that she had undergone left nephrectomy and left hemicolectomy for a tumor of the left kidney 7 years previously. Leiomyosarcoma of the left kidney was diagnosed on the basis of the histopathological examination at the previous hospital. Recurrence of leiomyosarcoma was suspected, and a second operation was performed. A mesenteric tumor was detected. Leiomyosarcoma recurrence was diagnosed on the basis of another histopathological examination. The patient remains free of disease and recurrence 3 years after the second operation. Primary leiomyosarcoma of the kidney is a rare disease, even among renal tumors. The prognosis of leiomyosarcoma of the kidney is poor because of frequent metastasis and recurrence. Radical resection is the preferred first choice for treatment, but recurrence still occurs frequently. In our case, the mesenteric recurrence was detected 7 years after the first operation. There have been no previous reports of mesenteric recurrence of leiomyosarcoma of the kidney. Although histopathological and immunohistochemical examinations indicated a poor prognosis, the patient is alive and there are no signs of recurrence 3 years after the second operation.

CREPT expression correlates with poor prognosis in patients with retroperitoneal leiomyosarcoma

Retroperitoneal leiomyosarcomas (LMSs) are rare gynecological malignancies that display poor prognosis and high mortality. Cell cycle-related and expression-elevated protein in tumor (CREPT) is an oncogene that is involved in the regulation of many cell cycle-related proteins. However, its distribution and clinical significance in retroperitoneal LMS remains poorly understood. This study assessed the histological classifications of postoperative tumor samples from 71 cases of retroperitoneal LMS that were collected at The General Hospital of the People's Liberation Army from January 1998 to December 2012. We found that more than half of the patients displayed positive expressions of CREPT, Ki-67 and PCNA via immunohistochemical analysis. The expression of CREPT correlated with histological grade (P = 0.044), and the PCNA expression level correlated with the differentiation of tumor cells and histological grade (P < 0.001 and P = 0.009, respectively). Multivariate analysis showed that survival was associated with histological grade and the expression level of CREPT (P = 0.011 and P = 0.012, respectively). Kaplan-Meier analysis showed that the patients lacking CREPT expression exhibited significantly longer overall postoperative survival (median, 60.0 months) than the patients displaying CREPT expression (median, 33.0 months), and CREPT expression correlated with distant recurrence within 5 years after surgery (P = 0.004). Western blot analyses showed that CREPT was more strongly expressed in the retroperitoneal LMS tumor tissue than in paired control tissue. Based on the above data, we concluded that CREPT displays unique immunostaining for retroperitoneal LMS tissue and can be used to supplement other currently available retroperitoneal LMS markers.

Brain and multiorgan metastases from uterine leiomyosarcoma

A 59-year-old woman, diagnosed 7 years ago with uterine leiomyosarcoma (ULMS), developed several intrathoracic, pelvic and lately intra-abdominal and brain metastases. On each occasion, surgical resection was followed by a course of failed chemotherapy. Lately she presented with acute neurological deterioration and focal signs. Magnetic resonance imaging demonstrated two presumed brain parenchymal lesions involving the supratentorial and infratentorial compartments. She underwent surgical resection of the left cerebellar lesion. Histological analysis of the brain specimen confirmed the presence of metastatic ULMS. Leiomyosarcoma of the uterus is an uncommon tumor with a very aggressive course and poor prognosis. Multiple organ metastases from ULMS are an extremely rare condition, and prognostically alarming despite current treatments.

Hormone dependency in metastatic low-grade leiomyosarcoma following uterine smooth muscle tumour of uncertain malignant potential

Uterine leiomyosarcoma (ULMS) usually follows an aggressive clinical course, although a small proportion of ULMS exhibit a more indolent course, which in turn reflects heterogeneity within this disease and the need to identify and characterise this distinct subgroup. The role of hormone therapy in ULMS is yet to be elucidated. We report a patient with well-differentiated metastatic ULMS on hormone replacement therapy (HRT) at the time of the diagnosis. The withdrawal of the HRT led to a significant decrease in the tumour burden and symptomatic improvement. The patient further benefited from aromatase inhibitor treatment once the benefit from the HRT withdrawal reached a plateau. The present case report describes for the first time hormone-dependency for tumour growth in a ULMS. We propose that a subset of ULMS that follow a protracted/indolent course might depend on hormone stimulation for tumour proliferation, and antihormone treatment can therefore be useful in these patients.

Ultrasound elastography of pulmonary lesions - a feasibility study

INTRODUCTION

The potential of sonography in the examination of lung tissue is extremely limited by the air-filled alveoles of the lung. Only in special circumstances like pleural adhesion lesions, atelectasis or pneumonia can lung tissue be visualized by B-mode sonography. Real-time elastography was primarily applied to detect and visualize pulmonary lesions.

METHODS AND PATIENTS

8 patients with a total of 18 histologically proven metastases of the lung were included. All pulmonary lesions were detected by computed tomography. Sonographic examination was performed with a 7.5 MHz linear transducer (Acuson Antares premium edition, Siemens, Erlangen, Germany), including B-mode and real-time elastography (RTE). The mean distance between pleura and the lesions ranged from 0 to 2.5 cm. Two lesions were located in the upper right lobe, eleven lesions in the lower right and five in the lower left lobe.

RESULTS

RTE was able to detect and visualize all 18 pulmonary lesions in contrast to B-mode. The size and distance of the lesions from the pleura correlated with the CT findings.

CONCLUSION

In contrast to B-mode sonography, RTE is able to detect and visualize peripheral, non-pleural adherent pulmonary lesions.

[Low grade fibromixoid sarcoma: a purpose of 3 cases and review of the bibliography]

BACKGROUND

Low grade fibromyxoid sarcoma or tumor Evans is a variety of soft tissue sarcoma that represents 1% of all malignancies. More common in limbs and trunk (50%), we present 3 new cases of retroperitoneal reviewing their characteristics and performing a literature review.

CLINICAL CASE

In the retroperitoneal location highlights the poor specificity of clinical symptoms, demonstrating, according to their growth and size, as an abdominal tumor, usually painless, or by compression and/or invasion of nearby structures. In cases that present the most important finding was the presence of a palpable abdominal tumor without other symptoms despite remarkable infiltration of other organs that should be included in surgical resection.

CONCLUSIONS

We emphasize the difficulty of correct diagnosis preoperatively because preoperative studies are inconclusive and only the histological and immuno-histo-typing chemistry allow precise identification.

Clinicopathological study of primary superficial leiomyosarcomas

BACKGROUND

Primary superficial leiomyosarcomas (PSL) are rare malignant lesions that are subdivided into cutaneous and subcutaneous tumors. Primary cutaneous and subcutaneous leiomyosarcomas differ not only as to primary site of origins, but also to differences in prognosis. Guidelines for management and follow-up are not clearly defined in the literature.

MATERIAL AND METHOD

Retrospective review was conducted from the patient's chart between January 2000 and December 2009. Histopathology, immunohistochemistry, and clinical and surgical records were reviewed.

RESULTS

The authors found five cases of PSL and divided them into two cases of cutaneous leiomyosarcomas and three cases ofsubcutaneous leiomyosarcomas. Overall, mean age of the patients was 42.4 years, male: female ratio was 4:1. Clinical presentations were painless mass. Wide excisions were performed in three cases with 2 cm margins. No local recurrence was found in the period of follow-up (6 months to 3 years). One case presented with bony metastasis five years after operation.

CONCLUSION

PSL are rare tumors. Surgical resection remains the main option for curative treatment. Wide excision with at least 2 cm peripheral margins and a depth that includes subcutaneous tissue and fascia are recommended. The natural history of these tumors is not clearly defined. All patients should be followed-up for a period of at least five years after treatments. The authors hoped that further study of these tumors would result in better treatments and follow-up guidelines to be a benefit to such patients in the future.

Isolated cutaneous metastasis of uterine leiomyosarcoma: case report and review of literature

A 54 year old lady presented for routine excision of a scalp lesion thought clinically to represent a sebaceous cyst of the right occiput. 4 years earlier she underwent total abdominal hysterectomy and right salpingo-oophorectomy for 3 large uterine fibroids. Histo-pathological examination of the hysterectomy specimen revealed an incidental low-grade leiomyosarcoma. Staging imaging was negative for metastatic disease. She made an uneventful recovery and was treated further by adjuvant pelvic radiotherapy.She noticed an uncomfortable and unsightly cystic swelling on her occiput four years after hysterectomy and was referred for routine excision of what was believed to be a benign lesion. The lesion was excised and sent for histopathological examination. Microscopic analysis including immuno-histochemistry demonstrated an ER and PR positive metastatic deposit of leiomyosarcoma. The margins of excision were histologically clear of disease.At Multi-Disciplinary Team (MDT) discussion a diagnosis of metastatic scalp deposit from previous uterine leiomyosarcoma was made. Re-staging CT brain, thorax, abdomen and pelvis and MRI brain were negative for local recurrence or distant metastases. She is currently undergoing radiotherapy to the scalp and surrounding tissues and will be followed up closely by the involved teams.To the best of our knowledge, this is the first case described in the worldwide literature of isolated cutaneous metastasis to the scalp of uterine leiomyosarcoma without evidence of disseminated disease at other sites.

VIRTUAL SLIDES

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1311834987345566.

Muscular metastasis from mesocolic and duodenal leiomyosarcoma. A case report and a review of the literature

BACKGROUND

Mesenteric and duodenal leiomyosarcomas are very rare malignancies. Muscular metastases from leiomyosarcoma are even more rare. Surgery is the only chance of cure and should be attempted whenever possible. The relief of symptoms and the prevention of recurrences are ultimately the aims of surgery. We present a unique case of mesocolic and duodenal leiomyosarcoma with muscular metastases.

CASE REPORT

A 61 year old woman was treated by radical resection including left neftectomy and left hemicolectomy for a leiomyosarcoma of the left mesocolon. Three years after the first surgery a leiomyosarcoma of the duodenal wall was diagnosed. Following a careful evaluation that ruled out the presence of other secondary locations, she underwent pancreatoduodenectomy. Three months later she observed a small, mildly painful swelling in the left thigh, rapidly growing to a diameter of 4 cm over a month period. The MRI showed a low-signal intensity malignancy in T2-weighted images whereas the lesion was homogeneously enhanced by Gadolinium on T1-weighted imaging. The histological examination after excision confirmed the clinical suspicion of a metastasis from high grade leiomyosarcoma. Successively the patient underwent a palliative chemotherapy treatment with epirubicin and ifosfamide for three cycles. The patient experienced a progression of disease with multiple pulmonary and encephalic metastases five months later.

CONCLUSION

Muscular metastases from leiomyosarcoma are occasionally described in the literature. The apparition of muscular metastases is considered a negative prognostic factor and shortly precedes massive distant diffusion of the malignancy. Denervation syndrome can be a risk factor for muscular metastases. To our knowledge, this is the first report of a skeletal-muscle metastasis following mesenteric and duodenal leiomyosarcoma.

Local recurrence and multi-organ metastasis of primary retroperitoneal leiomyosarcoma in unusual locations after surgical resection

We report a case of retroperitoneal leiomyosarcoma in a 52-year-old woman, who developed local recurrence, pulmonary, hepatic, peritoneal, pancreatic, subcutaneous and intramuscular metastases two years after surgical resection of the primary tumor. Metastasis to the pancreas, subcutaneous or muscular tissue is very rare; however, presence of a lesion in these locations in a known case of leiomyosarcoma might indicate a metastatic tumor deposit.

The use of lumbar sympathetic blockade at L4 for management of malignancy-related bladder spasms

BACKGROUND

Cancer-related bladder spasms may be a rare but severe symptom of bladder or metastatic cancer or its related treatments. Various treatments described in the literature include systemic medications, intravesical or epidural medications, or even sacral neurolectomies.

OBJECTIVE

We present 3 patients who have suffered from bladder spasm either from invasion of the bladder wall by tumor (2 patients) or from intravesical chemotherapeutic treatment.

DESIGN

Case Report.

SETTING

Cancer pain management hospital.

METHODS

For each patient, we describe the use of lumbar sympathetic block to successfully treat the bladder spasms. Sympathetic blockade was performed at the left anterolateral border of lumbar vertebra L4. We used 10 mL of local anesthetic (0.25% bupivacaine) delivered in 2 mL aliquots, each given after negative aspiration for heme. Each procedure was performed with fluoroscopic guidance (both AP and lateral views) with the use of iodine contrast (Omnipaque-180) to confirm the location of the medication and its resulting spread.

RESULTS

All 3 patients had a reduction in the frequency and intensity of spasms, with 2 out of 3 patients not having a recurrence of the spasms for up to 2 months post procedure and follow up.

LIMITATIONS

Case Report.

CONCLUSION

Lumbar sympathetic blockade could be a useful treatment for recurrent bladder spasm in the oncologic population. Based on these findings, we feel that the branches of the sympathetic nerve set at L4 may be a good target for neurolytic procedures, such as radiofrequency ablation, for long term treatment of bladder spasms. Further research is necessary to determine the efficacy of this technique for the treatment of bladder spasms in the oncologic population.

Pancreaticoduodenectomy for metastasis of uterine leiomyosarcoma to the pancreas

Metastasis of uterine leiomyosarcoma to the pancreas is rare. A 46-year-old woman was diagnosed with uterine leiomyosarcoma and underwent surgery. Thereafter, recurrences in the lung and subsequently in the pancreas were diagnosed. These lesions were resected and diagnosed as metastasis of uterine leiomyosarcoma. We report a rare case of uterine leiomyosarcoma with metastasis to the lung and pancreas, both of which were resected using aggressive surgery.

Uterine smooth muscle tumors of uncertain malignant potential: a case presentation

A 42-year-old virgin woman was admitted to our clinic with increasing menorrhagia and dysmenorrhea for several months. A pelvic ultrasound scan showed a 9 × 7 cm heterogeneous mass in the uterine cavity. Pelvic magnetic resonance imaging showed a large non-homogeneous tumor mass measuring 97 × 56 mm in the uterine cavity. After intravenous contrast material, cystic necrotic areas with marked contrast enhancement were observed in the solid lesion. Tumor markers were all within normal ranges. The patient underwent laparotomy, and total hysterectomy and bilateral salpingo-oophorectomy were performed. Our case was diagnosed as uterine smooth muscle tumor of uncertain malignant potential (STUMP). The patient was put on a close clinical follow-up schedule, and is doing well without recurrence in 2 years later. Patients with STUMP should be counseled regarding the potential for recurrence as leiomyosarcoma, and may require closer surveillance than a yearly examination and may need a consultation with a gynecologic oncologist.

Rectal leiomyosarcoma: report on two cases and a practical approach to differential diagnosis

Rectal leiomyosarcoma is an uncommon malignancy. Herein, we describe the clinicopathological features and biological behaviour of these tumours, and provide a practical approach to differential diagnosis, particularly with gastrointestinal stromal tumours (GIST). We report two cases in elderly men. In the first, the lesion was 2 cm from the anal sphincter, while it was located in the rectal ampulla in the second case. Histologically, both tumours were characterized by pleiomorphic, large spindle cells, presenting numerous mitoses and marked nuclear atypia. Immunohistochemical analysis showed that tumour cells coexpressed both actin and desmin, whereas CD117 and S100 protein were negative. The final diagnosis was leiomyosarcoma. One of the patients died of pulmonary metastasis within six months. The second patient had bone metastasis, but was lost to follow up. This report underlines the potential diagnostic problems raised by rectal leiomyosarcoma and emphasizes the role of immunohistochemistry in achieving correct diagnosis, which has important clinical, therapeutic and prognostic consequences.

Leiomyosarcoma metastatic to the thyroid diagnosed by fine needle aspiration cytology

The thyroid gland is a known but an unusual site for metastatic tumours from various primary sites. Primary smooth muscle tumours of thyroid are rare. Leiomyosarcoma of the thyroid gland whether of primary or metastatic origin should be distinguished from anaplastic carcinoma. Few cases of leiomyosarcoma metastatic to thyroid, diagnosed by fine needle aspiration cytology (FNAC) have been documented. We are reporting this case to highlight the importance of FNAC as a tool for diagnosing sarcomas and to plan further management accordingly. Ancillary techniques can be applied on FNAC and give comparative results to tissue sections.

Efficacy of the progesterone receptor antagonist mifepristone for palliative therapy of patients with a variety of advanced cancer types

BACKGROUND

Mifepristone has been demonstrated to improve longevity and quality of life in mice with spontaneous murine cancer without progesterone receptors and in human colon cancer. The present study evaluated the palliative effect of mifepristone in a variety of different types of human cancer.

PATIENTS AND METHODS

Mifepristone was given at 200 mg daily orally with permission from the Food and Drug Administration to people with widely metastatic human cancer no longer responsive to other chemotherapy regimens.

RESULTS

Improvement in pain and energy and/or length of life was found in thymic epithelial cell carcinoma, transitional cell carcinoma of the renal pelvis, leiomyosarcoma, pancreatic carcinoma, malignant fibrous histiocytoma and another case of adenocarcinoma of the colon.

CONCLUSION

Our data demonstrate a palliative role for the use of mifepristone in cancer therapy. Progesterone receptor antagonists should be given a therapeutic trial in larger controlled studies of various malignancies in humans.

Whipple's procedure for an oligometastasis to the pancreas from a leiomyosarcoma of the thigh

BACKGROUND

Pancreatic tumours are most frequently primary, with lesions secondary to metastasis uncommon.

METHODS

This report describes the case of a 61-year-old man who underwent resection of a right thigh leiomyosarcoma 2 years prior to presentation with obstructive jaundice. Subsequent CT and endoscopic ultrasound (EUS) diagnosed metastatic leiomyosarcoma to the pancreatic head for which he underwent a Whipple's pancreaticoduodenectomy.

CONCLUSION

Metastasis from an extremity leiomyosarcoma to the pancreas is an extremely rare entity, which can be diagnosed by EUS and treated successfully by pancreaticoduodenectomy.

[Case of primary leiomyosarcoma of the seminal vesicle]

A 72-year-old male visited our hospital with a complaint of perineal and voiding pain. An elastic hard mass was palpated by rectal examination in the cranial lesion of prostate. On CT scan and MRI it was located at the site of the right seminal vesicle. Trans-rectal needle biopsy specimen showed leiomyosarcoma. Radical cystoprostatectomy with pelvic lymph node dissection was performed at Hokkaido University Hospital. Microscopic examination of the resected specimen revealed the tumor arose from the right seminal vesicle without involvement of the bladder and the prostate gland. Three months after the operation the tumor recurred at lung and pelvic lymph node. He died 10 month postoperatively. Autopsy finding showed many visceral organs metastases without local recurrence. In the past, nine cases of leiomyosarcoma of seminal vesicle were published in the literature. Including our case, pathological diagnosis by core needle biopsy was attempted in five cases, though accurate diagnosis was made in only two cases. In our case, Immunohistological study by SMA and desmin was useful for histological diagnosis preoperatively.

Cyclooxygenase 2 expression in soft tissue leiomyosarcoma

BACKGROUND

Cyclooxygenase 2 (COX2) expression is up-regulated and associated with adverse prognosis in select types of carcinoma. Although not extensively studied in skeletal or soft tissue sarcoma, expression of COX2 has been described in a variable number of gynecological and non-gynecological leiomyosarcomas. In this study, the prevalence and prognostic implications of COX2 expression in leiomyosarcoma were evaluated further.

MATERIALS AND METHODS

Immunohistochemical stains for COX2 were performed on 33 samples of soft tissue leiomyosarcoma and tested for their association with clinicopathological parameters and patient outcome.

RESULTS

COX2 staining was limited to tumor cells surrounding areas of tumor necrosis in 6 cases. There were no statistically significant correlations with the clinicopathological parameters studied, including local recurrence, distant metastasis, or disease-specific death.

CONCLUSION

The low frequency, restricted distribution and absence of prognostic implications of COX2 expression soft tissue leiomyosarcoma suggest that this enzyme may not be a useful pharmacological target in this clinical setting.

Extensive cardiac metastases secondary to uterine leiomyosarcoma

Uterine leiomyosarcoma metastatic to multiple cardiac chambers occurs infrequently. Over the past 4 decades, there have been only 11 reported cases of cardiac metastasis secondary to uterine leiomyosarcoma. Metastatic cardiac tumors are commonly diagnosed postmortem, although it may be possible to diagnose them during life. The authors report a rare case of a 48-year-old woman with uterine leiomyosarcoma who was diagnosed with extensive cardiac metastases (in the left atrium, right and left ventricles, pulmonary artery, and pulmonary vein). Although extensive cardiac metastases are suggestive of imminent death, aggressive treatment resulted in survival for >1 year for this patient, which underscores the importance of treatment in select patients.

The diagnostic hurdle of an elderly male with bone pain: how 18F-FDG-PET led to diagnosis of a leiomyosarcoma of the adrenal gland

It is uncommon for patients to present with bone metastases while the primary tumor is still unknown. The case of a patient with bone metastases as primary presentation of leiomyosarcoma, who was diagnosed after a 18F-FDG PET-CT and a CT-guided biopsy of the adrenal gland is described. If after routine physical, laboratory and radiological investigations no diagnosis can be made, 18F-FDG PET should be added to the conventional work-up of patients with unknown primary cancer. In this way, unnecessary and enduring suffering of symptomatic patients may be prevented.