Uterine leiomyosarcoma: A case report

Uterine leiomyosarcoma is a rare uterine malignancy that arises from the smooth muscles of uterine wall. It accounts for only 1-2% of uterine malignancies. We report a case of a 60-year-old female who presented with postmenopausal bleeding and was diagnosed later to be a case of leiomyosarcoma of uterus. The diagnosis of leiomyosarcoma is made by histopathological examination, and surgery is the only treatment. The prognosis for female with uterine sarcoma primarily depends on the extent of disease at the time of diagnosis and the mitotic index.

Leiomyosarcoma of the small bowel: Report of a case and review of the literature

INTRODUCTION

Leiomyosarcoma of the small bowel is an extremely rare form of gastrointestinal malignancy. Small bowel tumours are usually asymptomatic at the early stages, and difficult to visualise by upper and lower endoscopy.

PRESENTATION OF CASE

An 83-year-old gentleman presented in surgical outpatient clinic with chronic anaemia, abdominal discomfort and a single episode of malaena. Initial OGD and colonoscopy were both unremarkable. Subsequent CT revealed a mass in the right iliac fossa of likely small bowel origin, leading to an urgent laparotomy and resection with primary anastomosis. Histopathology showed a high grade leiomyosarcoma with no signs of metastasis and confirmatory immunological staining. Post-surgery follow up remains unremarkable.

DISCUSSION

Leiomyosarcomas of the small bowel are extremely rare entities, particularly following the advent of robust immunohistological diagnostic methods allowing differentiation from GISTs. As small bowel tumours are often not visualised by upper and lower endoscopy, further investigations to visualise the small bowel are crucial, generally in the form of magnetic resonance enterography, CT colonography or wireless capsule endoscopy.

CONCLUSION

The treatment of such tumours remains predominantly centred around surgical resection, and prognosis is dependent on tumour size and histological staging.

Renal leiomyoma: an uncommon differential diagnosis of renal masses with a clinical relevance

Renal leiomyomas are an extremely rare neoplasm which account for 1.5% of the benign lesions and 0.29% of all treated renal tumours, with autopsy evidence of 4.2% to 5.2%. Given their exceptional incidence, they are rarely included in the differential diagnosis of renal masses, despite their capacity to grow to a considerable size. The definitive diagnosis of a leiomyoma is only possible after histopathological examination, most of the times of a nephrectomy specimen. However, due to the rising number of diagnosis resulting from improved medical imaging and interventions, renal leiomyomas should gain importance in the differential diagnosis of renal masses, specialy with respect to kidney sparing surgery. Hereby, we report a case of 60-year-old male patient with a large well circumscribed left renal mass, diagnosed as Renal cell carcinoma on imaging.

Challenging diagnostic and therapeutic modalities for leiomyosarcoma of inferior vena cava

Leiomyosarcoma of the inferior vena cava (IVCL) is a rare malignant tumour originating from the smooth muscle cells of the media with intra- or extra-luminal growth. The type of the lesion is further divided into three levels in relation to hepatic and renal veins respectively. The aim of this review was to evaluate the results of surgical treatment of IVCL with special reference to the extent of its histological spread and to analyse the recent literature in order to provide an update on the current concepts of diagnostic and therapeutic management of this entity. IVCL's patients may present with non-specific complaints such as dyspnoea, malaise, weight loss, nausea, vomiting, fever and abdominal pain. Haematogenous metastasis is frequent. At a later stage, IVCL may also spread through lymphatic. Multiple diagnostic imaging techniques have been proposed for accurate preoperative diagnosis, including Doppler ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI), individually or in combination with cavography echocardiography or CT-guided biopsy. Despite recent research on the therapeutic strategies against IVCL, surgical resection appears the only potentially curative approach. Unfortunately, a mere minority of patients is eligible to undergo surgical intervention. In addition, surgical removal of IVCL does not necessarily guarantee patient's long-term survival. Alternative therapies, such as radio- and chemo-therapy often proved insufficient. Debate continues regarding the optimal management of the IVC after tumour resection, with primary repair, ligation and IVC reconstruction all have been utilized with varying success.

Multiorgan block removal

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Retroperitoneal tumors can have a large size and require complex excisions.

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Surgery with curative intent is not always possible, and we must always evaluate the benefit risk when planning surgery for these tumors.

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Currently only surgery has any chance in curing this disease. Radiotherapy and chemotherapy are complementary to radical surgery.

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Retroperitoneal tumors usually present as large tumors but pathological diagnosis can sometimes be difficult.

INTRODUCTION

Retroperitoneal tumors are rare, mostly malignant. Locally aggressive, and more frequent in women in their 5th decade of life. Its symptoms are nonspecific, including abdominal pain and palpable mass. To diagnosis is helpful computed tomography and biopsy. It needs surgery for absolute healing.

PRESENTATION OF CASE

67 years old man was admitted with back pain and fever. Abdominal imaging tests showed a 15 cm abdominal mass without clear organodependencia. Endoscopy with biopsies evidenced mesenchymal neoplasia of undetermined origin. In surgery we confirm its resecability and was necessary multiorgan resection. Pathologic diagnosis: well differentiated retroperitoneal leiomyosarcoma. Started adjuvant radiotherapy. In subsequent tests showed the presence of liver metastases.

DISCUSSION

Retroperitoneal tumors are developed from nerve, vascular, muscular, connective, supportive and fibroareolar tissue from this space. Its size does not modificate survival or resectability. We used TC and biopsy for its diagnose. Adjuvant therapy does not affect survival or quality of life, surgery remains the only curative option. Locoregional recurrence is the most influential figure in the prognosis. A large percentage of patients required a second surgery (between 45 and 82%).

CONCLUSION

The only curative option of retroperitoneal sarcomas is surgery, which usually requires multiple organ resection. Chemotherapy and radiotherapy are mostly a surgical supplement. Chemotherapy has not shown significant increase in survival.

Lower extremity mass

Key Clinical Message

Soft tissue sarcomas are rare tumors accounting for less than 1% of all malignancies. Multidisciplinary approach is used in the management of these patients.

Superior vena cava syndrome due to a leiomyosarcoma of the anterior mediastinum: A case report and literature overview

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Leiomyosarcomas are rare causes of superior vena cava syndrome.

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Surgery is the treatment of choice.

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Specific approaches depend on the neoplasm's size and invasion of neighbouring tissues.

INTRODUCTION

Leiomyosarcomas are an infrequent cause of malignant superior vena cava syndrome (VCS).

PRESENTATION OF CASE

A 51-year old male patient was admitted for a three-day history of dyspnoea, dysphagia and erythema of the head and neck. Computed tomography and magnetic resonance imaging showed a lesion arising on the anterior mediastinum, which was in close proximity with a thrombus in the superior vena cava. Surgical excision was performed, including open resection of the primary tumour and an atrio-innominate vein bypass with 8-mm polytetrafluoroethylene (PTFE). Histology confirmed a leiomyosarcoma and postoperative radiotherapy sessions were performed. Due to evidence of enlargement of the thrombus, a second intervention was undertaken. In this procedure, a remainder of the primary tumour was resected and the superior vena cava reconstructed with an autologous pericardium patch. The patient recovered satisfactorily and was discharged on the seventh postoperative day, with no evidence for relapse after 10 months of follow-up.

DISCUSSION

Leiomyosarcomas comprise less than 2% of the tumours of the mediastinum and are a rare cause of paraneoplastic VCS. Male patients in their sixties are most commonly affected. Relapses seem to be common, and thus a careful follow-up is often recommended.

CONCLUSION

In spite of the limited data on the management of thoracic leiomyosarcomas, surgery is currently considered the mainstay of treatment.

Primary leiomyosarcoma of the mandible

Leiomyosarcoma (LMS) is a malignant soft tissue tumor that exhibits smoothmuscle differentiation. Its occurrence in the oral cavity is exceedingly rare. This article presents a 67-year-old woman with 9-month history of a painful tumoral lesion on the right side of mandible. Tumor was composed of fascicles of spindle-shaped cells with cigar-shaped nuclei and eosinophilic cytoplasm. Immunohistochemistry showed that tumor cells were positive for smooth muscle actin (SMA) and desmin. The findings were consistent with the diagnosis of LMS.

A role for versican in the development of leiomyosarcoma

Leiomyosarcoma (LMS) is a mesenchymal cancer that occurs throughout the body. Although LMS is easily recognized histopathologically, the cause of the disease remains unknown. Versican, an extracellular matrix proteoglycan, increases in LMS. Microarray analyses of 80 LMSs and 24 leiomyomas showed a significant elevated expression of versican in human LMS versus benign leiomyomas. To explore the importance of versican in this smooth muscle cell tumor, we used versican-directed siRNA to knock down versican expression in a LMS human cell line, SK-LMS-1. Decreased versican expression was accompanied by slower rates of LMS cell proliferation and migration, increased adhesion, and decreased accumulation of the extracellular matrix macromolecule hyaluronan. Addition of purified versican to cells expressing versican siRNA restored cell proliferation to the level of LMS controls, increased the pericellular coat and the retention of hyaluronan, and decreased cell adhesion in a dose-dependent manner. The presence of versican was not only synergistic with hyaluronan in increasing cell proliferation, but the depletion of versican decreased hyaluronan synthase expression and decreased the retention of hyaluronan. When LMS cells stably expressing versican siRNA were injected into nude mice, the resulting tumors displayed significantly less versican and hyaluronan staining, had lower volumes, and had reduced levels of mitosis as compared with controls. Collectively, these results suggest a role for using versican as a point of control in the management and treatment of LMS.

Dasatinib (BMS-35482) potentiates the activity of gemcitabine and docetaxel in uterine leiomyosarcoma cell lines

BACKGROUND

To explore the activity of dasatinib alone and in combination with gemcitabine and docetaxel in uterine leiomyosarcoma (uLMS) cell lines, and determine if dasatinib inhibits the SRC pathway.

METHODS

SK-UT-1 and SK-UT-1B uLMS cells were treated with gemcitabine, docetaxel and dasatinib individually and in combination. SRC and paxcillin protein expression were determined pre- and post-dasatinib treatment using Meso Scale Discovery (MSD) multi-array immunogenicity assay. Dose-response curves were constructed and the coefficient of drug interaction (CDI) and combination index (CI) for drug interaction calculated.

RESULTS

Activated phosphorylated levels of SRC and paxillin were decreased after treatment with dasatinib in both cell lines (p < 0.001). The addition of a minimally active concentration of dasatinib (IC25) decreased the IC50 of each cytotoxic agent by 2-4 fold. The combination of gemcitabine-docetaxel yielded a synergistic effect in SK-UT-1 (CI = 0.59) and an antagonistic effect in SK-UT-1B (CI = 1.36). Dasatinib combined with gemcitabine or docetaxel revealed a synergistic anti-tumor effect (CDI < 1) in both cell lines. The triple drug combination and sequencing revealed conflicting results with a synergistic effect in SK-UT-1B and antagonistic in SK-UT-1.

CONCLUSION

Dasatinib inhibits the SRC pathway and yields a synergistic effect with the two-drug combination with either gemcitabine or docetaxel. The value of adding dasatinib to gemcitabine and docetaxel in a triple drug combination is uncertain, but may be beneficial in select uLMS cell lines. Based on our pre-clinical data and known activity of gemcitabine and docetaxel, further evaluation of dasatinib in combination with these agents for the treatment of uLMS is warranted.

Surgical management of leiomyosarcoma of the inferior vena cava

The optimal surgical management of patients with leiomyosarcoma of inferior vena cava remains a controversy. From 1975 and 2009, five patients with leiomyosarcoma of inferior vena cava were treated at the Chinese PLA General Hospital and Beijing Shijitan Hospital. The age ranged 39-61 years and the duration of symptoms ranged from 18 to 36 months. Abdominal and back pain are the most common complaints. A combination of various imaging modalities is essential for treatment planning. R0, R1, R2, and biopsy only were accomplished in 2, 1, 1, and 1 case, respectively. Combined resections included inferior vena cava, right kidney, adrenal gland, psoas, colon, duodenal, gallbladder, liver, and/or aorta, without inferior vena cava reconstruction. No inferior vena cava-related postoperative complication was seen in our series.

Radiation-induced leiomyosarcoma of the prostate after brachytherapy for prostatic adenocarcinoma

Radiation therapy (RTx) has been employed as a curative therapy for prostatic adenocarcinoma. RTx-induced sarcomas (RISs) are rare, late adverse events, representing less than 0.2% of all irradiated patients. RISs are more aggressive tumors than prostatic adenocarcinomas. Herein, we present a case with RTx-induced prostatic leiomyosarcoma after permanent brachytherapy for prostatic adenocarcinoma. A 69-year-old male presented with dysuria and gross hematuria. Six years previously, he had been diagnosed with localized prostate cancer and was treated by permanent brachytherapy. Urethroscopy showed stenosis by a tumor at the prostate. Transurethral prostatectomy was performed for a diagnosis. Based on pathological findings, the diagnosis was leiomyosarcoma of the prostate. He was treated with three cycles of neoadjuvant chemotherapy (CTx) that consisted of doxorubicin and ifosfamide (AI), followed by a prostatocystectomy with intrapelvic lymphadenectomy. The tumor extended from the prostate and infiltrated the bladder wall and serosa with lymphatic and venous invasion. The surgical margin was negative, and no residual prostatic adenocarcinoma was observed. The proportion of necrotic tumor cells by neoadjuvant CTx was around 50%. Subsequently, adjuvant CTx was offered, but the patient chose a follow-up without CTx. Local recurrence and lung metastasis were detected by computed tomography 3 months after the surgery. He was treated again with AI. However, CTx was not effective and he died 6 months after the operation. In conclusion, an effective treatment strategy for prostatic sarcoma should be developed in the near future, although the clinical feature of prostatic sarcoma remains unclear due to its rare incidence.

Inferior vena cava leiomyosarcoma confirmed by catheter suction biopsy during digital subtraction angiography

Leiomyosarcoma of vascular origin is a rare disease and most cases arise in the inferior vena cava. Inferior vena cava leiomyosarcoma (IVCLMS) usually presents in females in their sixth decade of life. The clinical symptoms are often non-specific and the diagnosis is often delayed. Current imaging techniques can accurately differentiate inferior vena cava neoplasms from other non-neoplastic lesions. However, definitive diagnosis of IVCLMS needs histologic evidence. We report a case of IVCLMS in a 61-year old Chinese woman. This is the first IVCLMS case confirmed by catheter suction biopsy during digital subtraction angiography.

Metastatic pattern of uterine leiomyosarcoma: retrospective analysis of the predictors and outcome in 113 patients

Objective

To describe metastatic pattern of uterine leiomyosarcomas (ULMS) and correlate it with clinical and histopathologic parameters.

Methods

We included 113 women (mean age, 53 years; range, 29 to 72 years) with histopathology-confirmed ULMS from 2000 to 2012. Distribution of metastases was noted from imaging by two radiologists in consensus. Predictors of development of metastases were analyzed with univariate and multivariate analysis. Impact of various clinical and histopathologic parameters on survival was compared using Log-rank test and Cox proportional hazard regression model.

Results

Distant metastases were seen in 81.4% (92/113) of the patients after median interval of 7 months (interquartile range, 1 to 21). Lung was most common site of metastases (74%) followed by peritoneum (41%), bones (33%), and liver (27%). Local tumor recurrence was noted in 57 patients (50%), 51 of whom had distant metastases. Statistically significant correlation was noted between local recurrence and peritoneal metastases (p<0.001) and between lung and other common sites of hematogeneous metastases (p<0.05). Age, serosal involvement, local recurrence, and the International Federation of Gynecology and Obstetrics (FIGO) stage were predictive factors for metastases. At the time of reporting, 65% (74/113) of the patients have died; median survival was 45 months. Stage, local recurrence, and age were poor prognostic factors.

Conclusion

ULMS metastasizes most frequently to lung, peritoneum, bone, and liver. Local recurrence was associated with peritoneal spread and lung metastases with other sites of hematogeneous metastases. Age, FIGO stage and local recurrence predicted metastatic disease and advanced stage, older age and local recurrence predicted poor outcome.

Primary malignant tumors of peritoneal and retroperitoneal origin: clinical and imaging features

Peritoneal carcinomatosis and metastatic involvement of the retroperitoneum are manifestations of many organ-based malignancies and lymphoproliferative disorders. Primary malignancies of peritoneal and retroperitoneal origin occur much less frequently, and are difficult to distinguish from metastatic disease on imaging alone. However, the imaging features of these primary tumors, taken in concert with the clinical data, can be helpful in narrowing the scope of the differential diagnosis. This review presents the clinical and imaging features of primary peritoneal and retroperitoneal tumors arising from the various tissue components that comprise the ligaments, mesenteries, and connective tissues of the peritoneal and retroperitoneal spaces.

Leiomyosarcoma of the inferior vena cava

Inferior vena cava leiomyosarcoma is a rare tumor with a variety of symptoms. A 41-year-old woman was admitted with nonspecific epigastric pain. Computed tomography revealed a dense mass between the inferior vena cava and the liver. The patient underwent successful resection of the mass. The pathologic study confirmed leiomyosarcoma. Adjuvant radiation therapy was completed, and after 12 months of follow-up, the patient had no problems.

Urinary Bladder Leiomyosarcoma: Primary Surgical Treatment

Cases of bladder leiomyosarcoma represent 0.1% of all nonurothelial tumors. We present a case report of a 73-year-old man who underwent a radical cystoprostatectomy for a high-grade bladder leiomyosarcoma with an ileal diversion. The patient recovered uneventfully and no surgical margins were verified in final pathology. Early follow-up at 3 months shows no signs of computed tomography recurrence and adequate adaptation to ileal diversion. Although bladder sarcomas were once thought to have a grim prognosis, recent studies suggest that adequate surgical treatment is able to achieve optimal cancer control outcomes.

Confusing combination of thrombocytopenia and thrombosis after heparin therapy in a patient with cardiac leiomyosarcoma; a nephrologist viewpoint

We represent here a 30-year-old woman with cardiac leiomyosarcoma who developed thrombocytopenia and deep vein thrombosis a few days after the start of low molecular weight heparin. Thrombocytopenia improved after replacement of low molecular weight heparin with hirudine. We speculated that cardiac leiomyosarcoma is a predisposing factor for development of heparin induced thrombocytopenia.

Recurrent chromosomal aberrations in intravenous leiomyomatosis of the uterus: high-resolution array comparative genomic hybridization study

Uterine intravenous leiomyomatosis (IVL) is a distinct smooth muscle neoplasm with a potential of clinical aggressiveness due to its ability to extend into intrauterine and extrauterine vasculature. In this study, chromosomal alterations analyzed by oligonucleotide array comparative genomic hybridization were performed in 9 cases of IVL. The analysis was informative in all cases with multiple copy number losses and/or gains observed in each tumor. The most frequent recurrent loss of 22q12.3-q13.1 was observed in 6 tumors (66.7%), followed by losses of 22q11.23-q13.31, 1p36.13-p33, 2p25.3-p23.3, and 2q24.2-q32.2 and gains of 6p22.2, 2q37.3 and 10q22.2-q22.3, in decreasing order of frequency. Copy number variants were identified at 14q11.2, 15q11.1-q11.2, and 15q26.2. Genes mapping to the regions of loss include CHEK2, EWS, NF2, PDGFB, and MAP3K7IP1 on chromosome 22q, HEI10 on chromosome 14q, and succinate dehydrogenase subunit B, E2F2, ARID1A KPNA6, EIF3S2 , PTCH2, and PIK3R3 on chromosome 1p. Regional losses on chromosomes 22q and 1p and gains on chromosomes 12q showed overlaps with those previously observed in uterine leiomyosarcomas. In addition, presence of multiple chromosomal aberrations implies a higher level of genetic instability. Follow-up polymerase chain reaction (PCR) sequencing analysis of MED12 gene revealed absence of G> A transition at nucleotides c.130 or c.131 in all 9 cases, a frequent mutation found in uterine leiomyoma and its variants. In conclusion, this is the first report of high-resolution, genome-wide investigation of IVL by oligonucleotide array comparative genomic hybridization. The presence of high frequencies of recurrent regional loss involving several chromosomes is an important finding and likely related to the pathogenesis of the disease.

Myxoid leiomyosarcoma of ovary-a rare case report

Primary pure myxoid leiomyosarcoma of the ovary is extremely rare, comprising of only 1% of the ovarian tumours. Patient presented with a mass in the right iliac fossa since three months. Radiological diagnosis of broad ligament fibroid was given. Right salphingo-oophorectomy with enucleation of ischial fossa and wedge biopsy of left ovary was carried out. Based on gross, microscopy and immunohistochemistry a diagnosis of primary myxoid leiomyosarcoma of ovary was made. We report a rare case of primary pure myxoid leiomyosarcoma of the ovary with metastasis to ischial fossa emphasising on reliable prognostic markers. Ovarian leiomyosarcomas are highly aggressive tumours with poor prognosis.

Primary pancreatic leiomyosarcoma

Primary pancreatic leiomyosarcomas are rare malignant neoplasms with an aggressive course and a large size. A 56-year-old woman presented with an 8-year history of abdominal pain. Multislice computed tomography revealed a large heterogeneous mass with necrotic, calcified and macroscopic fatty areas. The tumor was excised. Histopathological evaluation revealed leiomyosarcoma of the pancreas. If a patient has a large size mass with a cystic-necrotic component, pancreatic leiomyosarcoma should be considered in the differential diagnosis list after excluding other common differential diagnoses.

Isolated metastasis of uterine leiomyosarcoma to the pancreas: Report of a case and review of the literature

INTRODUCTION

Metastatic tumors of the pancreas are uncommon and rarely detectable clinically. Metastases to the pancreas are rare. We present a patient with pancreatic metastases from a leiomyosarcoma of the uterus and review the literature about the clinical features of pancreatic metastasis and its surgical management.

PRESENTATION OF CASE

A 40-year-old woman, who underwent hysterectomy, left oophorectomy, omentectomy and lymp node dissection for leiomyosarcoma of the uterus. At the follow up, the patient complained of non-specific abdominal discomfort. Preoperative diagnosis were pancreatic pseudocyst, cystadenoma or cystadenocarcinoma. At laparotomy, a cystic mass was found in the tail of the pancreas which was invased to the transverse colon mesenterium and the spleen. Distal pancreatectomy with splenectomy and transverse colon resection was performed. Histologically, the tumor was evaluated as poorly differentiated leiomyosarcoma.

DISCUSSION

Metastatic lesions of the pancreas are uncommon and less than 2% of all pancreatic malignancies. However a few cases of leiomyosarcoma with metastases to the pancreas have been reported in the literature. Before deciding that the lesion in the pancreas was metastasis, primary leiomyosarcoma of the pancreas had to be ruled out. Histologically, leiomyosarcoma of the pancreas contains interlacing spindle cells with varying degrees of atypia and pleomorphism. The surgical approach to the pancreatic metastases must be aimed complete excision of the tumor with a wide negative margin of clear tissue and maximum preservation of pancreatic remnant if possible.

CONCLUSION

In the absence of widespread metastatic disease, aggressive surgical approach with negative margins must be aimed.

Leiomyosarcoma of the Face

Leiomyosarcoma is a rare form of soft tissue neoplasm, with only 1% to 5% occurring in the head and neck region. Current recommended treatment suggests surgical excision with a wide lateral margin, but no definite guidelines regarding excisional margin have been established yet. Recently, complete excision with a narrow surgical margin has been recommended, and the authors present a case of cutaneous leiomyosarcoma on the face that was successfully managed by complete removal with a narrow excisional margin. A 74-year-old woman presented with a 3 cm sized, rapidly growing cutaneous mass on her right preauricular area. Preoperative biopsy of the skin lesion suggested a cutaneous leiomyosarcoma. The authors performed complete surgical excision with a 1 cm lateral margin, and the resulting skin defect was repaired with bilateral V-Y advancement local flaps. Histopathology and immunohistochemistry evaluation confirmed a moderately differentiated cutaneous leiomyosarcoma, with negative margin involvement. The patient refused of any additional treatment, but showed no locoregional recurrence during the 1.5 years of postoperative follow-up period. With a regular postoperative follow-up, cutaneous leiomyosarcomas may be successfully treated with a narrow surgical margin.

Pulmonary hypertension due to a pulmonary artery leiomyosarcoma: A case report

BACKGROUND

Primary pulmonary artery sarcomas are very rare and their histologic type called leiomyosarcoma is even rarer. These tumors are frequently misdiagnosed as pulmonary thromboembolism in clinical settings. Many patients receive anticoagulant therapy without response, and many are diagnosed postmortem only. Most of the tumors reported in the literature have involved the right ventricular outflow tract and the main pulmonary trunk, often extending into the main pulmonary artery (MPA) branches.

CASE REPORT

A 64-year-old woman presented with weakness, fatigue, malaise, dyspnea, and marked elevation of pulmonary artery pressure was admitted to our hospital. She was initially diagnosed with chronic pulmonary thromboembolism, and chest computed tomography (CT) scan revealed lobulated heterogeneous left hilar mass extended to precarinal and subcarinal space. Magnetic resonance imaging (MRI) demonstrated a polypoid lesion at the trunk with extension to left MPA and its first branch. The patient was operated, and a yellowish-shiny solid mass in pulmonary trunk was seen intra-operation and pulmonary endarterectomy was performed. Her tumor was pathologically diagnosed as pulmonary artery leiomyosarcoma.

CONCLUSION

Clinicians must consider pulmonary artery sarcoma when making the differential diagnosis for patients with pulmonary artery masses. The clinical prediction scores and the CT and MRI findings can help identifying patients with pulmonary artery sarcoma.

Clitoris metastasis from a retroperitoneal leiomyosarcoma: A case report

Leiomyosarcoma is a rare form of cancer commonly found in the retroperitoneum, uterus, stomach, small intestine and vascular tissue. Surgery with a wide margin of resection is the most effective treatment. Nevertheless, metastasis is common and generally occurs within the first 3 years. The liver and lungs are the most common sites of metastasis in leiomyosarcoma. Other sites of metastasis include bone, spleen, soft tissues and brain. Metastatic tumours of the clitoris are extremely rare. As cited in the literature, the most common cancers that metastasize to the clitoris are breast, bladder, renal and gastric. Here, we report a case of a clitoral mass in a 64-year-old woman who received an operation for retroperitoneal leiomyosarcoma 4 years prior. Mass resection was performed. The pathological diagnosis was a leiomyosarcoma metastasis. The patient also presented with brain and lung metastases at the time of the clitoral metastasis. This is the first case of clitoral and brain metastases originating from a retroperitoneal leiomyosarcoma.

Unusual presentation of retroperitoneal leiomyosarcoma mimicking an adnexal tumor with highly elevated serum CA-19-9

When retroperitoneal leiomyosarcoma develops in pelvic cavity, it often presents similar symptoms and radiological findings to adnexal tumor, therefore obscures diagnostic approaches until an exploratory laparotomy is performed. We report an unusual presentation of retroperitoneal leiomyosarcoma mimicking an adnexal tumor with extremely elevated serum CA-19-9. Though the most of the prominent mass was removed during surgery, there was massive bleeding due to tearing of internal iliac vein while dissecting the ureter close to vessels. This case focuses on the significance of considering retroperitoneal tumor even if the mass is located in ovarian fossa and has highly elevated serum level of CA-19-9. And in attempt of tumor removal, the excision needs to be clean-cut without damaging nerves or vessels around the mass and avoid causing any prospective complications.

Leiomyosarcoma of the female breast: report of a case

Sarcomas of the breast account for less than 1% of breast tumors. Leiomyosarcoma is an extremely rare form of primary breast sarcoma. We presented here a case of primary leiomyosarcoma of the breast in a 44-year-old woman. We present a case of primary leiomyosarcoma of the breast in a middle-aged female in whom fine-needle aspiration cytologic features uneventful.

Primary leiomyosarcoma of the penis: a case report

Primary leiomyosarcoma of the penis is a very rare tumour. Only 46 cases have been reported in the English medical literature. We are presenting this case of a 59-year-old patient with a ulceroproliferative growth in his penis. Histopathology was a high grade spindle cell sarcoma, which was proved by immunohistochemistry to be a leiomyosarcoma.

Adjuvant treatment of proper endobronchial management in leiomyosarcoma

Endobronchial metastasis of leiomyosarcoma is rare, but it can cause life-threatening complications, such as massive hemoptysis, respiratory failure or even death. The development of new endoscopic modalities allows for effective endobronchial management. We report three patients with endobronchial metastases from advanced leiomyosarcomas which caused bronchial obstruction. The bronchoscopic examinations revealed masses obstructing the left main bronchus in all three patients. After removing the endobronchial tumor via interventional bronchoscopy, there was symptomatic and radiologic improvement. Moreover, the patients were able to undergo additional palliative chemotherapy. Therefore, endobronchial management of endobronchial tumors should be considered in the treatment of endobronchial metastasis, even in patients with advanced malignancies.

Leiomyosarcoma of the middle ear and temporal bone

Leiomyosarcoma is a malignant tumor of smooth muscle cells that is exceedingly rare in the middle ear and temporal bone. Wide surgical resection is treatment of choice and adjuvant treatment has not proven to be of benefit. This is a report on a patient with otorrhea and rapidly growing mass on postauricualr area. A tumor that was mainly located in the middle ear and temporal bone was surgically removed and proved to be a leiomyosarcoma. The optimal surgical technique and other treatment strategy are discussed.

MED12 exon 2 mutations in uterine and extrauterine smooth muscle tumors

Mutations in exon 2 of the MED12 gene have been reported in 50% to 70% of uterine leiomyomas. To determine the frequency of MED12 mutations in various types of smooth muscle tumors as well as normal uterine myometrium adjacent to a leiomyoma, we selected a total of 143 cases for analysis of MED12 exon 2 mutations by polymerase chain reaction and Sanger sequencing. MED12 mutations were detected in 54% of classical uterine leiomyomas (15/28) and in 15% of cases in myometrium adjacent to leiomyomas (2/13); 34% of leiomyoma/leiomyomatosis in pelvic/retroperitoneal sites (10/29); 0% of extrauterine leiomyomas (0/29); 8% of smooth muscle tumor of uncertain malignant potential (1/12); 30% of uterine leiomyosarcomas (6/20); and 4% of extrauterine leiomyosarcomas (1/25). Mutations were clustered around codons 44, 40, 41, and 36, and consisted primarily of single nucleotide substitutions and small in-frame deletions. Our results confirm the findings of similar recent studies and further show that pelvic and retroperitoneal leiomyomas harbor an increased frequency of MED12 mutations (34%) as compared with other extrauterine sites (0%; P = 0.0006), and that histologically unremarkable adjacent myometrium can harbor similar MED12 mutations. These findings suggest that smooth muscle tumors in pelvic/retroperitoneal sites are subject to the same mutational changes as those of uterine myometrium, and that these mutations may precede the gross or histological development of a leiomyoma.

Leiomyosarcoma: Principles of management

The term soft-tissue sarcomas (STS) embraces more than 50 different sub-types that are often associated with poor prognosis. Only a very limited number of agents are active against STS. Doxorubicin and ifosfamide are widely accepted as the most effective compounds. However, their low response rates and poor impact on the overall survival of the patients illustrate the need for new treatment options. Among them, leiomyosarcomas are one of the most frequently occurring subtypes. In spite of the relatively high incidence of leiomyosarcomas, the overall effectiveness of the currently available systemic treatments is still poor. The heterogeneity of its biological origin, clinical behavior and responsiveness to chemotherapy, together with the scarcity of successful clinical trials, makes the treatment of leiomyosarcoma especially challenging. In addition, the evidence-based treatment for leiomyosarcoma comes from trials in which, in the majority of cases, no distinctions have been made among the different STS sub-types. As a result, every therapeutic decision should be made on an individual basis in collaboration with the patient. The results of new specific histology-designed clinical trials should aid decision making in this complex field.

Laryngeal leiomyosarcoma, a case report and review of articles

INTRODUCTION

Laryngeal leiomysarcoma is an extremely rare malignancy originating from smooth muscle cells. Its rarity is due to the fact that only less than 50 cases of pure laryngeal leiomyosarcoma and less than 10 cases of hypopharyngeal leiomyosarcaoma have been reported in modern medical literature. Even though the clinical presentation mimics that of a laryngeal carcinoma forming the major bulk of the laryngeal malignancies, the difference in management, warrants an accurate diagnosis.

CASE REPORT

We reported a case of this very rare malignancy presenting in the supraglottic region by highlighting the clinical features, histological and radiological diagnosis and management of this extremely rare malignant entity.

CONCLUSION

An accurate histological diagnosis may be difficult; but supplementing by electron microscopy and immunohistochemical staining, the diagnosis can be reached certainly.

A case of rapidly progressing leiomyosarcoma combined with squamous cell carcinoma in the esophagus

Esophageal leiomyosarcoma is a rare tumor that accounts for less than 1% of all malignant esophageal tumors. Esophageal leiomyosarcoma combined with squamous cell carcinoma is even rarer than solitary leiomyosarcoma. We experienced a case of leiomyosarcoma combined with squamous cell carcinoma that progressed very rapidly.

An open-label, phase 2 study evaluating the efficacy and safety of the anti-IGF-1R antibody cixutumumab in patients with previously treated advanced or metastatic soft-tissue sarcoma or Ewing family of tumours

BACKGROUND

Cixutumumab (IMC-A12), a fully human immunoglobulin G1 (IgG1) monoclonal antibody, exerts preclinical activity in several sarcoma models and may be effective for the treatment of these tumours.

METHODS

In this open-label, multicentre, phase 2 study, patients with previously treated advanced or metastatic rhabdomyosarcoma, leiomyosarcoma, adipocytic sarcoma, synovial sarcoma or Ewing family of tumours received intravenous cixutumumab (10mg/kg) for 1h every other week until disease progression or discontinuation. The primary end-point was the progression-free survival rate (PFR), defined as stable disease or better at 12 weeks. In each tier of disease histology, Simon's optimum 2-stage design was applied (PFR at 12 weeks P0=20%, P1=40%, α=0.10, β=0.10). Stage 1 enrolled 17 patients in each disease group/tier, with at least four patients with stable disease or better required at 12 weeks to proceed to stage 2.

RESULTS

A total of 113 patients were enrolled; all tiers except adipocytic sarcoma were closed after stage 1 due to futility. The 12-week PFR was 12% for rhabdomyosarcoma (n=17), 14% for leiomyosarcoma (n=22), 32% for adipocytic sarcoma (n=37), 18% for synovial sarcoma (n=17) and 11% for Ewing family of tumours (n=18). Median progression-free survival (weeks) was 6.1 for rhabdomyosarcoma, 6.0 for leiomyosarcoma, 12.1 for adipocytic sarcoma, 6.4 for synovial sarcoma and 6.4 for Ewing family of tumours. Among all patients, the most frequent treatment-emergent adverse events (AEs) were nausea (26%), fatigue (23%), diarrhoea (23%) and hyperglycaemia (20%).

CONCLUSIONS

Patients with adipocytic sarcoma may benefit from treatment with cixutumumab. Cixutumumab treatment was well tolerated, with limited gastrointestinal AEs, fatigue and hyperglycaemia.

Gemcitabine with paclitaxel therapy against mesocolic leiomyosarcoma: a case report

A 65-year-old man complained of lower right abdominal pain, and an intra-abdominal mass was identified. An intra-abdominal hemorrhage was discovered during a thorough examination and emergency surgery was performed. The tumor was ruptured and was fragile, making it difficult to perform extirpation; thus, an ileocecal resection was performed. The histopathological diagnosis of the tumor was leiomyosarcoma, and recurrence was observed during the early postoperative period. The patient underwent surgery twice; each time there was a recurrence, but complete resection could not be obtained, and paclitaxel and gemcitabine chemotherapy was performed. A temporary effect was observed, and control of disease progression lasted approximately five months. Standard chemotherapy for leiomyosarcoma has not been established, but this method could become a therapeutic strategy for leiomyosarcoma.

Partial vaginal expulsion of a leiomyosarcoma

Uterine sarcomas are an uncommon and heterogeneous group of tumors that account for 3-7% of the malignant neoplasms of the uterus and approximately 1% of all malignant tumors of the female genital system. The main clinical manifestations are abnormal uterine bleeding in pre- or postmenopausal women. Pelvic pain, abdominal distension, urinary urgency, and profuse and fetid leukorrhea are other frequent complaints. The authors present a case of a 48-year-old patient that was in amenorrhea for 2 years, who sought treatment for vaginal bleeding. On physical examination, the abdomen was distended, painful in the hypogastrium and upon examination of the external genitalia, it was observed the exteriorization of an amorphous "mass". The patient was submitted to uterine curettage. The results of the histological examination revealed leiomyosarcoma. Staging workup showed an enlarged uterus with endometrial lesion, and non-calcified pulmonary nodules. The patient underwent a pan-hysterectomy and chemotherapy, and is under oncologic treatment. The authors call attention for the unusual form of presentation of this entity.

Primary leiomyosarcoma of the thyroid

A 56-year-old male with primary leiomyosarcoma of the thyroid is presented. The paucity of diagnostic maneuvers, including tumor markers, fine needle aspiration, and frozen section biopsy, are stressed, in addition to the fulminate course of the disease.

Leiomyosarcoma, a nonurothelial bladder tumor: a rare entity with therapeutic diversity

A 22-year-old young woman presented with dysuria and lower urinary tract symptoms that had persisted for 6 months. She was diagnosed with a tumor near the bladder neck. Transurethral resection was done under anaesthesia. The histopathological examination with immunohistochemical staining showed the tumor to be a low-grade leiomyosarcoma. Adjuvant chemoradiation was given, and the patient has been doing well for 12 months of follow-up. Nonurothelial tumors of the bladder are rare and consensus is lacking regarding their definitive treatment. Furthermore, little is known about the natural history and prognosis of this type of bladder sarcoma. We present a minimally invasive treatment for this relatively rare tumor in which bladder preservation was achieved with no evidence of local or distant recurrences during the follow-up to date.

Intraosseous leiomyosarcoma arising in the epiphysis of the distal femur

Herein, we present a rare case of intraosseous leiomyosarcoma arising in the epiphysis of the distal femur and showing unusual radiographic features. A 44-year-old man presented with a pain in the left knee joint. Computed tomography revealed an intraosseous lesion with slightly increased attenuation and a thin marginal sclerotic rim in the femoral medial condyle. The signal of the lesion was hypointense on T1-weighted magnetic resonance (MR) images and hyperintense on fat-suppressed T2-weighted MR images. After gadolinium administration, the signal of the lesion was moderately and diffusely enhanced. The histological diagnosis of leiomyosarcoma was made based on a preoperative core biopsy specimen. Microscopic examination of the resected specimen revealed an ill-defined intraosseous tumor composed of proliferated atypical and mildly pleomorphic smooth muscle cells permeating among the bone trabeculae with only focal destruction of the bone trabeculae and low mitotic activity, indicating low grade leiomyosarcoma. The bone trabeculae at the periphery of the tumor were mildly thickened and anastomosed with a rim of an increased number of osteoblasts. Systemic examination showed no tumorous lesions in other anatomical sites. Leiomyosarcomas rarely present in the bone as a diffuse intertrabecular growth, even in low grade tumors.

Leiomyosarcoma of the urinary bladder: A review and a report of two further cases

OBJECTIVES

To review the published cases of leiomyosarcoma of the urinary bladder and to report two further cases.

METHODS

The databases Pubmed and Hinari were searched using the keywords 'bladder', 'leiomyosarcoma' and 'smooth muscle neoplasm'. The 14 articles identified were reviewed, and we present a further two cases.

RESULTS

Of more than 100 cases reported, 77 were reviewed. There is a lack of consensus about the standard treatment, and little is known about the natural history and prognosis of the tumour, due to its very low incidence. These tumours occur in older adults of either sex and are characterised by an aggressive behaviour. There is usually an unfavourable outcome, with the lungs being the most common site of metastasis. The two further cases we report had a different presentation and outcome.

CONCLUSIONS

Because of the limited experience with this rare tumour, there are insufficient data to suggest the optimum management strategy and prognosis.

Cardiac leiomyosarcoma, a case report

In this case report we present the history of a patient admitted with recurrent pulmonary edema. Transesophageal echocardiography showed a tumour in the left atrium, occluding the ostium of the mitral valve and mimicking intermittent mitral stenosis. Cardiac surgery followed by pathological examination revealed that the tumour was a leiomyosarcoma. Images from the echocardiography as well as the pathological findings are shown and discussed. The present case report illustrates that atrial tumors comprise also sarcomas, suggesting the use of careful, rapid diagnostic procedures and treatment to prevent dissemination of malignancy.

Rapid growing superficial cutaneous leiomyosarcoma of the face

Leiomyosarcomas are uncommon malignant smooth muscle tumors, mainly derived from vessels or viscera. Superficial leiomyosarcomas are a rare soft tissue sarcoma arising from the dermis or subcutaneous tissue in the skin. According to tumor origin and location, they are divided into cutaneous and subcutaneous leiomyosarcoma. They have distinctly different histologic and prognostic features from each other. Superficial leiomyosarcomas show a predilection for the proximal extremities and tend to be slow growing. We report one rare case of superficial cutaneous leiomyosarcoma on the right temporal area of face, which showed an extremely rapid growing mass within 3 months.

Leiomyosarcoma of the Inferior Vena Cava - Radical Resection, Vascular Reconstruction and Challenges: A Case Report and Review of Relevant Literature

Leiomyosarcomas of the inferior Vena Cava (IVC) are rare soft tissue sarcomas accounting for only 0.5% of all soft tissue sarcomas in adults with fewer than 300 cases reported. Extraluminal tumor growth along the adventitia of the IVC seems to be the common presentation. Intraluminal tumor growth is rare. The origin of the tumor is divided into three levels in relation to the hepatic and renal veins. The presentations and surgical modalities vary accordingly. Retroperitoneal tumors are often not diagnosed until the disease is at an advanced stage with large tumor growth and involvement of surrounding structures. This is partly because of the nonspecific clinical presentation as well as absence of early symptoms. Most patients present with abdominal or flank pain. Symptoms vary according to the dimensions of the tumor, growth pattern and localization of the tumor. Radical en bloc resection of the affected venous segment remains the only therapeutic option associated with prolonged survival. The goals of surgical management of these tumors include the achievement of local tumor control, maintenance of caval flow, and the prevention of recurrence. The involvement of renal or hepatic veins determines the strategy for vascular reconstruction. Reconstruction of the IVC is not always required, because gradual occlusion of the IVC allows the development of venous collaterals. However, when pararenal leiomyosarcoma of the IVC is present, reconstruction of the IVC and the renal vein is necessary to prevent transient or permanent renal dysfunction. Recent study has shown that radical surgery combined with adjuvant multimodal therapy has improved the cumulative survival rate. We report a case of IVC leiomyosarcoma in a young healthy woman along with details of its diagnostic workup and discussion of the surgical options and reconstruction of caval continuity.

Recurrent subcutaneous trunk leiomyosarcoma: Management and review of the literature

Superficial leiomyosarcomas are rare malignant smooth-muscle tumors accounting for 4-6.5% of all soft-tissue sarcomas, less than 2-3% of cutaneous soft-tissue neoplasms and 0.04% of all cancers. They are divided into cutaneous or dermal and subcutaneous leiomyosarcomas. Subcutaneous tumors have been reported to be associated with an increased risk of local recurrences and distant metastases, compared to their cutaneous counterparts. In this study, we describe a rare case of a recurrent subcutaneous trunk leiomyosarcoma in a 68-year-old male patient. Local recurrence developed two years after the complete surgical resection with wide margins and adjuvant postoperative radiotherapy. The management of the patient is discussed along with a review of the literature. We conclude that subcutaneous leiomyosarcoma is a rare clinical entity which may be associated with an atypical clinical presentation. Physicians should be aware of the misleading features of this tumor in order to avoid delay in diagnosis and treatment. Early complete surgical resection with wide margins of at least 2 cm is the cornerstone of treatment and has been reported to mostly influence the prognosis. However, the tumor has a high tendency to recur locally and metastasize. Recurrence may develop despite wide resection and radiotherapy. Long-term follow-up is mandatory.

A rare intramedullary spinal cord metastasis from uterine leiomyosarcoma

Leiomyosarcoma is a rare smooth-muscle-derived malignancy with a significant malignant potential. Systemic metastases are a common late complication of leiomyosarcoma typically to lungs, liver, brain and bones. We report a 44-year-old woman with a prior history of uterine leiomyosarcoma who presented to us with a cervicothoracic intramedullary lesion and recent onset of neurological deficits. She underwent surgery with histological confirmation of a diagnosis of metastatic leiomyosarcoma, which was followed by adjuvant radiation and chemotherapy. To our knowledge there is no prior report of intramedullary spinal cord metastases (ISCM) from a leiomyosarcoma in the English literature. We report the present patient in view of the rarity of ISCM and its clinical significance. Even though ISCM are unusual, they should be suspected in any patient with primary malignancy irrespective of the histology. The overall prognosis remains grim irrespective of the treatment modality chosen and recognition of the same is important in preoperative counseling and overall treatment approach.

Mediator complex subunit 12 exon 2 mutation analysis in different subtypes of smooth muscle tumors confirms genetic heterogeneity

Recently, heterozygous mutations in exon 2 of the mediator complex subunit 12 gene have been described in 50% to 70% of uterine leiomyomas; the recurrent nature of these mutations suggests an important role in their pathogenesis. Mediator complex subunit 12 is involved in regulation of transcription and Wnt signaling. So far, little is known about the pathogenesis of the different subtypes of extrauterine leiomyomas and leiomyosarcomas. We performed mutation analysis of mediator complex subunit 12 and immunohistochemistry for β-catenin, using 69 tumors of 64 patients including 19 uterine leiomyomas, 6 abdominal leiomyomas, 9 angioleiomyomas, 5 piloleiomyomas, and 7 uterine and 23 soft tissue leiomyosarcomas. In line with previous observations, 58% of uterine leiomyomas carried a mediator complex subunit 12 mutation. However, all other extrauterine leiomyomas were negative with the exception of 1 abdominal leiomyoma with a likely primary uterine origin. Of the 30 leiomyosarcomas, only 1 uterine tumor harbored a mutation. A new observation is the identification of 3 tumors with a homozygous mutation; a monosomy X or interstitial deletion was excluded. β-Catenin immunohistochemistry showed nuclear positivity in only 55% of the mediator complex subunit 12-mutated uterine leiomyomas, suggesting the involvement of pathways other than canonical Wnt signaling in tumorigenesis. Interestingly, 80% of mediator complex subunit 12 wild-type sporadic piloleiomyomas displayed nuclear β-catenin positivity, indicating its involvement in this leiomyoma subtype. The lack of mediator complex subunit 12 mutations in extrauterine leiomyomas and leiomyosarcomas indicates that these tumors arise through a different pathway, emphasizing the genetic heterogeneity of smooth muscle tumors.

Uterine leiomyosarcoma manifesting as a tricuspid valve mass

Uterine leiomyosarcoma is a rare malignancy and carries a poorer prognosis when compared to endometrial carcinoma. It has been observed to metastasize to all the major organs. It presents with symptoms of abdominal distension, vaginal bleeding and may pass unnoticed until an advanced stage in patients with leiomyomas. Surgery is a viable option in patients with disease limited to the uterus, but metastasis to the heart may require surgery to prevent acute and catastrophic complications. The case described here involves metastasis to the tricuspid valve, which caused severe tricuspid regurgitation in the setting of acute pulmonary embolism. Surgical resection restored cardiac function and stabilized the patient. This case illustrates a rare site of metastasis of leiomyosarcoma which required immediate intervention and resulted in a favorable outcome.