Curative resection of leiomyosarcoma of the descending colon with metachronous liver metastasis: A case report

BACKGROUND

Leiomyosarcoma (LMS) has a poor prognosis and rarely originates from the colon. If resection is possible, surgery is the first treatment most commonly considered. Unfortunately, no standard treatment exists for hepatic metastasis of LMS; although, several treatments, such as chemotherapy, radiotherapy, and surgery, have been used. Subsequently, the management of liver metastases remains controversial.

CASE SUMMARY

We present a rare case of metachronous liver metastasis in a patient with LMS originating from the descending colon. A 38-year-old man initially reported abdominal pain and diarrhea over the previous two months. Colonoscopy revealed a 4-cm diameter mass in the descending colon, 40 cm from the anal verge. Computed tomography revealed intussusception of the descending colon due to the 4-cm mass. The patient underwent a left hemicolectomy. Immunohistochemical analysis of the tumor revealed that it was positive for smooth muscle actin and desmin, and negative for cluster of differentiation 34 (CD34), CD117, and discovered on gastrointestinal stromal tumor (GIST)-1, which are characteristic of gastrointestinal LMS. A single liver metastasis developed 11 mo post-operatively; the patient subsequently underwent curative resection thereof. The patient remained disease-free after six cycles of adjuvant chemotherapy (doxorubicin and ifosfamide), and 40 and 52 mo after liver resection and primary surgery, respectively. Similar cases were obtained from a search of Embase, PubMed, MEDLINE, and Google Scholar.

CONCLUSION

Early diagnosis and surgical resection may be the only potential curative options for liver metastasis of gastrointestinal LMS.

Inferior vena cava resection for a leiomyosarcoma: A case report

INTRODUCTION AND IMPORTANCE

Leiomyosarcomas of the inferior vena cava are scarce. Surgery is the only potential curative treatment. Such a surgery is complex and technically demanding, requiring a huge experience in both visceral and vascular surgery. Indeed, enlarged visceral resection may be needed to achieve a free tumor margins as the tumor may invade the duodenum, the head of the pancreas and the liver. Moreover, vascular reconstruction is mandatory which might be complex as both venal reins are usually invaded by the tumor like in our case below.

CASE PRESENTATION

A 53-year-old woman presented with abdominal vague pain. Imaging consisting in abdominal CT-scan with contrast and magnetic resonance angiography were suggestive of the diagnosis of leiomyosarcoma of the inferior vena cava. A surgical complete resection with free margins was conducted. A primary repair of the inferior vena cava and the right renal vein walls. End-to-side anastomosis with a polytetrafluorethylene (PTFE) prosthesis was mandatory to reconstruct the renal left vein to the inferior vena cava. Postoperative outcomes were uneventful. Pathology examination confirmed the diagnosis.

DISCUSSION

The optimal management of leiomyosarcoma of inferior vena cava is controversial. Surgery remains the cornerstone of treatment. However, not all patients are qualified for surgical resection. The prognosis depends on the early diagnosis and histology type.

CONCLUSION

The management of leiomyosarcomas of inferior vena cava requires a multidisciplinary consensus involving experienced surgery and oncology teams.

Primary leiomyosarcoma of the breast: A case report and literature review

INTRODUCTION

Primary leiomyosarcoma is an uncommon form of stromal breast sarcoma. Approximately 73 cases have been documented in English-language literature to date. To our knowledge, this is the first report from Indonesia of an adolescent female with primary leiomyosarcoma of the breast.

CASE PRESENTATION

A 30-year-old Southeast Asian female presented with a tumor in her left breast. Clinical examination revealed a 12 × 8-centimeter tumor. The supraclavicular, subclavicular, and axillary lymphadenopathy were not palpable. An ultrasound revealed a Breast Imaging Reporting and Data System category 5. Abdominal ultrasonography and chest x-ray were normal, as were blood chemistry and routine blood tests. A wide excision with a surgical margin of 2 cm was performed. Pathological investigation identified the mass as a leiomyosarcoma. The pelvis, abdomen, and lung CT scan metastatic workups were negative. The patient is well 8 months post-surgery, with no signs of recurrence.

CLINICAL DISCUSSION

Wide local excision has been the mainstay of treatment for leiomyosarcoma; however, there is no accepted standard of treatment due to the rarity of the disease.

CONCLUSION

Breast leiomyosarcomas have a more favorable prognosis than other breast neoplasms; however, patients must be closely monitored for recurrence or metastases. While there are no known predictors of outcomes, the margins of the initial surgery, mitotic activity, and atypia cellularity are more indicative of malignancy.

A giant primary vaginal sarcoma: A report case and literature review

Primary vaginal sarcoma is a rare disease entity, reported in less than 3% of cases of vaginal cancers. We report the observation of a patient treated at the regional oncology center of Oujda in Morocco who is presented with a non-metastatic primary vaginal leiomyosarcoma of 20 cm. The treatment consisted of neoadjuvant chemotherapy, followed by hemostatic surgery with tumor resection limits, reinforced by radiotherapy and then a surgical resection with a tumor resection taking away the infiltrated part of the anterior face of the lower rectum and the realization of a left iliac colostomy whose resected tumor part limits were healthy. At present, the patient is 4 years of follow-up without locoregional or distant recurrence.

Surgically Treated Brain Metastases from Uterine Origin: A Case Series and Systematic Review

OBJECTIVE

We aimed to describe our institutional case series of 9 surgically treated uterine brain metastases and perform a survival analysis through a systematic review and a pooled individual patient data study.

METHODS

This study was divided into 2 sections: 1) a retrospective, single center patient series assessing outcomes of neurosurgical treatment modalities in patients with malignancy arising in the uterus with brain metastases and 2) a systematic review of the literature between 1980 and 2021 regarding treatment outcomes of individual patients with intracranial metastasis of uterine origin. Pooled cohort survival analysis was done via univariate and Cox regression multivariable analysis and Kaplan-Meier curves.

RESULTS

Final statistical analysis included a total of 124 pooled cohort patients: one hundred fifteen patients from literature review studies plus 9 patients from our institution. Median age at the time of diagnosis was 54 years. Median time from diagnosis of the primary cancer to brain metastasis was 19 months (0-166 months). Surgery and radiotherapy resulted in the highest median OS of 11 months (P < 0.001). Multivariable analyses indicated that the presence of more than one central nervous systemlesion had an increased risk on OS (P = 0.003). Microsurgery, stereotactic radiosurgery, and whole brain radiotherapy remain the evidence-based mainstay applicable to the treatment of multiple brain metastases.

CONCLUSIONS

Brain metastases of cancer arising in the uterus appear to result most often in multiple lesions with dismal prognosis. The seemingly most efficacious treatment modality is surgery and radiotherapy. However, this treatment is often not an option when more than 1 or 2 brain lesions are present.

Leiomyosarcoma of the lower rectum managed by radiotherapy and surgery: A case report and review of literature

Rectal leiomyosarcoma is a very rare entity. Surgery is the main treatment, but the place of radiation therapy remains unclear. A 67-year-old woman was referred for a few-weeks' history of bleeding and anal pain intensified during defecation. Pelvic magnetic resonance imaging (MRI) showed a rectal lesion and biopsies revealed a leiomyosarcoma of the lower rectum. She was free of metastasis on computed tomography imaging. The patient refused radical surgery. After discussion by a multidisciplinary team, the patient received pre-operative long-course radiotherapy followed by surgery. The tumor was treated with 50Gy delivered in 25 fractions, within 5 weeks. The aim of radiotherapy was local control, allowing organ-preservation. Four weeks after radiation therapy, organ-preservation surgery could be performed. She had no adjuvant treatment. At 38-months follow-up, she had no local recurrence. However, distant recurrence (lung, liver, and bone) was detected 38 months after the resection and was managed by intra-venous doxorubicin 60mg/m² and dacarbazine 800mg/m² every 3 weeks. The patient was in a stable condition for nearly 8 months. The patient died 4 years and 3 months after the diagnosis.

Real-world outcomes of pazopanib in metastatic soft tissue sarcoma: a retrospective Turkish oncology group (TOG) study

AIM

Description of patient characteristics, effectiveness and safety in Turkish patients treated with pazopanib for metastatic soft tissue sarcoma (STS).

PATIENTS AND METHODS

This multicenter study is based on retrospective review of hospital medical records of patients (≥ 18 years) treated with pazopanib for non-adipocytic metastatic STS at 37 Oncology clinics across Turkey. Objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS) and overall survival (OS) were evaluated with further analysis of data on the three most common histological subtypes (leiomyosarcoma [LMS], undifferentiated pleomorphic sarcoma [UPS], synovial sarcoma [SS]) in the cohort.

RESULTS

Data of 552 adults (57.6% women, median age: 52 years) were analyzed. DCR and ORR were 43.1% and 30.8%, respectively. Median PFS was 6.7 months and OS was 13.8 months. For LMS, UPS and SS, median PFSs were 6.1, 5.9 and 7.53 months and median OSs were 15.03, 12.87 and 12.27 months, respectively. ECOG ≥ 2 was associated with poor PFS and OS. Liver metastasis was only a factor for progression. Second-line use of pazopanib (vs. front-line) was associated with better PFS, its use beyond third line predicted worse OS. Adverse events (AE) occurred in 82.7% of patients. Most common AEs were fatigue (58.3%) and anorexia (52.3%) which were graded as ≥ 3 in 8.2% and 7.4% of patients, respectively.

CONCLUSION

Pazopanib is effective and well-tolerated in treatment of non-adipocytic metastatic STS. Its earlier use (at second-line), good performance status may result in better outcomes. Worldwide scientific collaborations are important to gain knowledge on rarer STS subtypes by conducting studies in larger patient populations.

Primary leiomyosarcoma of the inferior vena cava in a pediatric case: a case report and literature review

BACKGROUND

Leiomyosarcoma is classified as a soft tissue sarcoma. In adults, leiomyosarcoma is the most common malignancy affecting the vascular system; however, vascular leiomyosarcoma in children is extremely rare as most pediatric soft tissue tumors are rhabdomyosarcomas. The survival rate is very low, and incomplete resection is a poor prognostic factor. There is also a high rate of distant recurrence, with the lungs and liver being the most common sites of metastasis. There is no established effective chemotherapy, and complete surgical resection is the only potentially curative treatment for leiomyosarcoma.

CASE PRESENTATION

A 15-year-old female patient with no significant medical history presented with severe upper abdominal pain and was admitted. Abdominal contrast-enhanced computed tomography and magnetic resonance imaging showed a large retroperitoneal tumor protruding into the lumen of the inferior vena cava behind the liver and multiple small nodules, and metastasis to the liver was suspected. The tumor was 6 × 4 × 5 cm in diameter, located just behind the hepatic hilar structures, and was suspected to infiltrate into the right portal vein. The tumor was diagnosed as a leiomyosarcoma through an open tumor biopsy. As the multiple liver metastases were located only in the right lobe of the liver on imaging, we performed tumor resection with right hepatectomy and replacement of the inferior vena cava (IVC). The postoperative course was uneventful; however, on postoperative day 51, distant metastatic recurrences were found in the remaining liver and right lung. The patient was immediately started on chemotherapy and trabectedin proved to be the most effective drug in the treatment regimen; however, severe side effects, such as hepatotoxicity, prevented timely administration, and the patient passed away 19 months after surgery.

CONCLUSIONS

IVC resection and reconstruction combined with right hepatectomy were able to be safely performed even in a pediatric case. To improve the prognosis of leiomyosarcoma with multiple metastases, an effective treatment strategy combining surgical treatment and chemotherapy, including molecularly targeted drugs, should be established as early as possible.

Surgical resection of primary leiomyosarcoma of retro-hepatic inferior vena cava extending from bilateral renal veins across the diaphragm

Vascular leiomyosarcoma of the inferior vena cava is a rare malignant soft tissue tumor that requires surgical treatment to prevent tumor-related symptoms such as pulmonary embolism and Budd-Chiari syndrome. However, a treatment strategy for surgical resection of advanced cases has not yet been determined. This report describes the case of advanced leiomyosarcoma of the inferior vena cava that was successfully treated with surgery and subsequent chemotherapy. A 44-year-old man was found to have a 12 × 10 cm retroperitoneal tumor on computed tomography. The tumor originated in the inferior vena cava and extended beyond the diaphragm into the renal vein. The surgical plan was determined in joint consultation with the multidisciplinary team. It was safely resected and the inferior vena cava was closed caudal to the porta hepatis without a synthetic graft. The tumor was diagnosed as leiomyosarcoma. Doxorubicin, followed by pazopanib were administered as treatment for metastatic disease. Eighteen months after the surgery, the patient's performance status was maintained.

The biology and treatment of leiomyosarcomas

Leiomyosarcoma (LMS) is a soft tissue sarcoma of smooth muscle origin that can arise in multiple anatomical sites and is broadly classified as extra-uterine LMS or uterine LMS. There is substantial interpatient heterogeneity within this histological subtype, and despite multi-modal therapy, clinical management remains challenging with poor patient prognosis and few new therapies available. Here we discuss the current treatment landscape of LMS in both the localised and advanced disease setting. We further describe the latest advances in our evolving understanding of the genetics and biology of this group of heterogeneous diseases and summarise the key studies delineating the mechanisms of acquired and intrinsic chemotherapy resistance in this histological subtype. We conclude by providing a perspective on how novel targeted agents such as PARP inhibitors may usher in a new paradigm of biomarker-driven therapies that will ultimately impact the outcomes of patients with LMS.

Not All Leiomyosarcomas Are the Same: How to Best Classify LMS

OPINION STATEMENT

Leiomyosarcoma arises from smooth muscle and represents one of the most common soft tissue sarcomas. Despite aggressive multimodality care, over half of the patients will ultimately develop metastatic and incurable disease with a median survival of 12-18 months. At present, there is no standard system to classify leiomyosarcoma, which itself is a heterogeneous disease. Classification by tumor location is the most simplistic approach and is most frequently utilized in clinical practice. Tumor location impacts diagnosis (recognition pre-operatively versus at the time of surgery) as well as treatment (ability to completely resect with clear margins with minimal morbidity). While tumor location can impact prognosis, for example, extremity tumors would generally be considered as lower risk than inferior vena cava tumors, leiomyosarcoma can exhibit a heterogeneous behavior irrespective of tumor location. Specifically, some patients have rapidly progressing disease despite aggressive chemotherapy, while others display a more indolent course even in the metastatic setting. The pathogenic drivers of the heterogeneity observed in tumor behavior are not well understood. As we learn more about the molecular composition of leiomyosarcoma, various classification groups have been proposed as discussed here. Ultimately, it is unlikely that one variable will be adequate for tumor classification, and a combination of location and molecular composition will be necessary to develop appropriate risk stratification nomograms and treatment strategies.

Prognostic factors and survival of patients with uterine sarcoma: a German unicenter analysis

PURPOSE

Uterine sarcoma (US) as a histologically heterogeneous group of tumors is rare and associated with poor prognosis. Prognostic factors based on systematic data collection need to be identified to optimize patients' treatment.

METHODS

This unicenter, retrospective cohort study includes 57 patients treated at the University Hospital Freiburg, Germany between 1999 and 2017. Progression-free survival (PFS) and overall survival (OS) were calculated and visualized in Kaplan-Meier curves. Prognostic factors were identified using log-rank test and Cox regression.

RESULTS

44 Leiomyosarcoma (LMS), 7 low-grade endometrial stromal sarcoma (LG-ESS), 4 high-grade ESS and 2 undifferentiated US patients were identified. The median age at time of diagnosis was 51.0 years (range 18-83). The median follow-up time was 35 months. PFS for the total cohort was 14.0 (95%-Confidence-Interval (CI) 9.7-18.3) and OS 36.0 months (95%-CI 22.1-49.9). Tumor pathology was prognostically significant for OS with LG-ESS being the most favorable (mean OS 150.3 months). In the multivariate analysis, patients over 52 years showed a four times higher risk for tumor recurrence (hazard ratio (HR) 4.4; 95%-CI 1.5-12.9). Progesterone receptor negativity was associated with a two times higher risk for death (HR 2.8; 95%-CI 1.0-7.5). For LMS patients age ≥ 52 years (p = 0.04), clear surgical margins (p = 0.01), FIGO stage (p = 0.01) and no application of chemotherapy (p = 0.02) were statistically significant factors for OS.

CONCLUSION

Tumor histology, age at time of diagnosis and progesterone receptor status were prognostic factors for US. Unfavorable OS in LMS patients was associated with advanced FIGO stage, suboptimal cytoreduction and application of chemotherapy.

[Uterine leiomyosarcoma - French guidelines from the GSF/NETSARC and TMRG groups]

Uterine leiomyosarcomas represent the most common uterine sarcomas. The prognosis is poor with metastatic recurrence in more than half of the cases. The purpose of this review is to make French recommendations for the management of uterine leiomyosarcomas within the framework of the French Sarcoma Group - Bone Tumor Study Group (GSF-GETO)/NETSARC+ and Malignant Rare Gynecological Tumors (TMRG) networks in order to optimize their therapeutic management. The initial assessment includes a MRI with diffusion perfusion sequence. The diagnosis is histological with a review in an expert center (Reference Network in Sarcoma Pathology (RRePS)). Total hysterectomy with bilateral salpingectomy, en bloc without morcellation, is performed when complete resection is possible, whatever the stage. There is no indication of systematic lymph node dissection. Bilateral oophorectomy is indicated in peri-menopausal or menopausal women. Adjuvant external radiotherapy is not a standard. Adjuvant chemotherapy is not a standard. It can be an option and consists in doxorobucin based protocols. In the event of local recurrence, the therapeutic options are based on revision surgery and/or radiotherapy. Systemic treatment with chemotherapy is most often indicated. In case of metastatic disease, surgical treatment remains indicated when resecable. In cases of oligo-metastatic disease, focal treatment of metastases should be considered. In the case of stage IV, chemotherapy is indicated, and is based on first-line doxorubicin-based protocols. In the event of excessive deterioration in general condition, management by exclusive supportive care is recommended. External palliative radiotherapy can be proposed for symptomatic purposes.

Association of chondroadherin with leiomyosarcoma

The leiomyosarcoma (LMS) subtype of uterine sarcoma accounts for 1-2 % of uterine neoplasia cases. The present study aimed to demonstrate that the gene and protein chondroadherin (CHAD) levels may serve as novel biomarkers for predicting prognosis and devising novel treatment models for LMS. A total of 12 patients diagnosed with LMS and 13 patients diagnosed with myomas were included in the study. The extent of tumour cell necrosis, cellularity and atypia and the mitotic index of each patient with LMS were determined. CHAD gene expression was significantly increased in cancerous tissues compared with that in fibroid tissues (2.17 ± 0.88 vs 3.19 ± 1.61; P = 0.047). The mean CHAD protein expression in tissues was higher in LMS cases but this was not statistically significant (217.38 ± 93.9 vs 177.13 ± 66.67;P = 0.226). Positive significant correlations were obtained between CHAD gene expression and mitotic index (r = 0.476; P = 0.008), tumour size (r = 0.385; P = 0.029) and necrosis (r = 0.455; P = 0.011). Furthermore, there were significant positive correlations between CHAD protein expression levels and tumour size (r = 0.360; P = 0.039) and necrosis (r = 0.377; P = 0.032). The present study was the first to demonstrate the significance of CHAD in LMS. The results suggested that, due to its association with LMS, CHAD has predictive value in determining the prognosis of patients with LMS.

Eribulin in Patients with Liposarcoma and Leiomyosarcoma: A Retrospective Single-Center Experience

INTRODUCTION

Soft tissue sarcomas are rare and heterogenous malignancies with a poor prognosis in advanced disease stages. Eribulin is used in metastatic liposarcoma (LPS) patients, who have failed first-line chemotherapy and has been approved for use in patients with LPS in the USA and Europe due to its efficacy in this histological subtype in a phase 3 trial. We have evaluated efficacy and tolerability of eribulin in LPS and leiomyosarcoma (LMS) patients in the routine clinical setting at our department.

METHODS

In this retrospective single-center analysis, efficacy and safety of eribulin were retrospectively evaluated in advanced LPS and LMS patients at the Division of Oncology, Medical University of Vienna.

RESULTS

A total of 32 adult patients treated with eribulin were identified and included in this analysis. Overall response rate was 9.4% for all patients, with one patient with LPS and two patients with LMS showing a partial response. Disease control rate (partial response plus stable disease) for all patients was 50% (LPS: 47.1%; LMS 53.3%). No statistically significant difference in median progression-free survival and overall survival was detected between patients with LPS and LMS (p = 0.807 and p = 0.519, respectively). Patients with LMS (n = 2) had received fewer previous therapy lines than patients with LPS (n = 14) (≤ previous treatment lines, p < 0.001). Toxicity was generally manageable, and grade 3 + 4 events were rare.

CONCLUSION

The activity and tolerability of eribulin in LPS as in well in LMS patients in the routine clinical setting is comparable to outcomes reported in published phase 3 trials.

Oesophageal carcinosarcoma: a rare neoplasm of the oesophagus

Oesophageal carcinosarcoma (OCS) is a rare oesophageal cancer, expressing both carcinomatous and sarcomatous elements. Although believed to have a better prognosis, no standard guidelines exist for its diagnosis and management. We report a case of a 60-year male presenting with progressive dysphagia and weight loss. Endoscopy and contrast-enhanced computed tomography of the chest revealed a large polypoidal intraluminal growth at the mid-oesophagus. Endoscopic biopsy revealed a sarcoma of the oesophagus. The patient underwent McKeown minimally invasive oesophagectomy. Final histopathology was suggestive of OCS. Postoperatively, the patient received adjuvant chemoradiation. At 20-month follow-up, he was asymptomatic with no radiological evidence of recurrence.

Spontaneous transient size reduction of a solitary pulmonary metastasis from a leiomyosarcoma

BACKGROUND

A solitary pulmonary nodule (SPN) poses a diagnostic challenge, which includes both a benign and malignant etiology. A size enlargement often indicates malignancy. We herein describe a case of a solitary pulmonary metastasis from a leiomyosarcoma that regressed transiently during follow-up.

CASE PRESENTATION

A 47-year-old woman presented with an SPN detected by follow-up computed tomography 7 years after surgery for a left forearm high-grade leiomyosarcoma. The nodule regressed spontaneously after an additional 6 months, and therefore, an inflammatory change was the most likely diagnosis at that time. However, the nodule enlarged again over the next 5 years. The growth rate led us to suspect a malignancy. A trans-bronchial biopsy was undiagnostic and a video-assisted thoracic surgery was planned. She underwent a wedge resection of the right lung, and a histopathological examination found it was a metastatic leiomyosarcoma.

CONCLUSIONS

A pulmonary metastasis from a leiomyosarcoma could emerge as an SPN and reveal a subsequent transient size reduction. An SPN in patients even with a remote history of a soft tissue tumor should raise the possibility of metastasis, and periodic follow-up is essential even after the size reduction.

Pulmonary vein thrombosis associated with metastatic uterine leiomyosarcoma: a case report

BACKGROUND

Pulmonary vein thrombosis (PVT) is rarely associated with malignancies. Leiomyosarcoma, a malignant tumor originating from smooth muscles, has never been reported as the etiology of PVT.

CASE PRESENTATION

In this case report, we described a 43-year-old Kurdish woman with a known case of leiomyosarcoma who presented with hemoptysis, dyspnea, and pleuritic chest pain. Chest computed tomography (CT) angiography revealed a thrombus in the left infero-posterior pulmonary vein. She was successfully treated with unfractionated heparin administered intravenously followed by orally administered warfarin. At the end of the article, we describe and compare other reports of malignancy-related PVT.

CONCLUSIONS

While malignancies are not a common cause of PVT, both primary lung tumors and metastatic cancers could be associated with PVT. Delay in diagnosis may lead to serious complications and even death. Therefore, clinicians should be aware of the possibility of the development of PVT in different malignancies for appropriate diagnosis and treatment.

[Rectal leiomyosarcoma, a rare malignant tumor diagnosed in ulcerative colitis]

Patients with chronic inflammatory diseases (IBD) of the digestive tract are known to have an increased risk of colorectal cancer. These are usually adenocarcinomas, and the occurrence of malignant mesenchymal tumours, particularly leiomyosarcomas, is exceptional. We report one case in a 40-year-old woman, followed for 9 years for ulcerative colitis. The tumour measured 2cm in length and infiltrated the entire rectal wall as far as the subserosa. It was composed of fusiform cells, with 5 mitoses for 10 fields at ×400 magnification, and expressing actin, desmin and caldesmone under immunohistochemical study. We review the 2 cases of leiomyosarcomas associated with Crohn's disease and 3 cases developed during ulcerative colitis published in the literature.

Primary retropharyngeal leiomyosarcoma in a young cat

Case summary

An Oriental Shorthair cat, aged 1 year and 6 months, developed progressive stridor and a palpable right ventral cervical mass. Fine-needle aspiration of the mass was inconclusive, while thoracic radiography and CT showed no evidence of metastasis. There was initial improvement in stridor with oral doxycycline and prednisolone treatment, but it recurred 4 weeks later and excisional biopsy was performed. Histopathology with immunohistochemistry diagnosed leiomyosarcoma with incomplete surgical margins. Adjunctive radiation therapy was declined. Repeated physical examination and CT 7 months postoperatively documented no evidence of mass recurrence.

Relevance and novel information

This is the first reported case of retropharyngeal leiomyosarcoma in a young cat with no evidence of local reoccurrence 7 months following an excisional biopsy.

Long-Time Progression-Free Survival with Trabectedin in Chemorefractory Metastatic Leiomyosarcoma of the Retroperitoneum: A Case Report

We present the case of a 46-year-old mother of a young child who was diagnosed with metastatic leiomyosarcoma. At diagnosis, the tumor had already infiltrated the vena cava, infiltration of the pancreas was suspected, and pulmonary metastases had been histologically confirmed. The goal of treatment was to prolong survival and gain quality time for the family. When the patient had not responded to 4 cycles of doxorubicin, trabectedin was initiated. After an initial partial remission with a reduction in the size of the primary leiomyosarcoma as well as some pulmonary metastases, the disease remained stable for a total of 10 months. Upon progression, the patient did not further respond to subsequent treatment lines. The presented case shows that second-line trabectedin may represent a promising option for patients with chemotherapy-resistant leiomyosarcoma to prolong survival while preserving quality of life.

Venous Thromboembolism in Metastatic Uterine Leiomyosarcoma: A Case Report and Review of the Literature

We report an unusual case of extensive deep vein thrombosis (DVT) and pulmonary embolism (PE) in the setting of metastatic uterine leiomyosarcoma. Recognition of the associated sequelae of this condition may improve short- and long-term outcomes. A 56-year-old black female with a history of uterine leiomyosarcoma diagnosed incidentally after total abdominal hysterectomy for fibroid uterus without initiation of chemoradiation treatment presented to the emergency department complaining of generalized weakness and progressively worsening stridor for 2 weeks. The patient was experiencing shortness of breath, dysphagia, and hoarseness. Physical exam was remarkable for rhonchi but was otherwise normal. Diagnostic imaging via CT of the abdomen, pelvis, and chest revealed DVTs of the left common and external iliac veins, the superior mesenteric artery, multiple pulmonary emboli of the right pulmonary artery, several nodular lesions within the lungs, and scattered peritoneal necrotic lesions, which were suspicious for metastatic disease. Additionally, CT of the neck showed an exophytic mass protruding into the airway from the subglottic region and thyromegaly with bilateral thyroid lobe nodules. The patient was subsequently started on Eliquis and chemotherapy. The rarity of this case is rooted in the extent of the patient's DVTs and PEs secondary to hypercoagulability in metastatic cancer. This presentation should be further evaluated to exclude thrombophilias or underlying malignancies. Drawing from the lessons of this case will help guide future clinical management regarding the care of metastatic uterine leiomyosarcoma.

Neglected case of a huge leiomyoma in an elderly postmenopausal woman: a case report

BACKGROUND

Fibroids are benign tumors of the female reproductive tract originating from the myometrial smooth muscle cells. They are a frequent occurrence in women of childbearing age but their incidence is rare after menopause. In addition, there is a remote possibility of malignant transformation to leiomyosarcoma in less than 1% of cases.

CASE PRESENTATION

We hereby report a case of large fibroid in a postmenopausal Indian female with rapid growth, raising the suspicion of malignant transformation into leiomyosarcoma. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Histopathology report confirmed it to be benign leiomyoma without any evidence of neoplasia.

CONCLUSION

Sudden enlargement of leiomyoma in postmenopausal women should not be ignored due to possible malignant transformation and is to be dealt immediately with hysterectomy followed by histopathology.

Rectal leiomyosarcoma as the initial phenotypic manifestation of Li-Fraumeni-like syndrome: a case report and review of the literature

BACKGROUND

Leiomyosarcoma is a rare malignant tumor of smooth muscle origin and represents 10-20% of all soft tissue sarcomas. Primary colon and rectal sarcomas constitute < 0.1% of all large bowel malignancies. In Li-Fraumeni syndrome, sarcomas are the second most frequent cancer (25%). Li-Fraumeni syndrome is a genetic disease with a familial predisposition to multiple malignant neoplasms. This syndrome has an autosomal dominant pattern of inheritance and high penetrance characterized by germline TP53 mutations. Patients with a history of cancer who do not meet all the "classic" criteria for Li-Fraumeni syndrome are considered to have Li-Fraumeni-like syndrome. To the best of our knowledge, this article is the first report of a patient with rectal leiomyosarcoma as the initial phenotypic manifestation of Li-Fraumeni-like syndrome. The authors also present a literature review.

CASE PRESENTATION

A 67-year-old Brazilian woman underwent anterior rectosigmoidectomy and panhysterectomy secondary to rectal leiomyosarcoma. She subsequently developed carcinomatosis and died 2 years after the operation. Her family medical history consisted of a daughter who died at 32 years of age from breast cancer, a granddaughter diagnosed with adrenocortical carcinoma at 6 years of age and two siblings who died from prostate cancer. A genetic study was carried out to identify a pathogenic variant of Li-Fraumeni syndrome. In the DNA extracted from the peripheral blood leukocyte, restriction fragment length polymorphism was analyzed to search for mutations in the TP53 gene. The DNA sequencing identified the germline pathogenic variant p. R337H heterozygous in exon 10 of TP53. The patient was classified as having Li-Fraumeni-like syndrome.

CONCLUSION

In patients with rectal leiomyosarcoma, it is advisable to investigate the family history of cancer and perform genetic studies to screen for Li-Fraumeni syndrome.

Primary adrenal leiomyosarcoma

Primary adrenal leiomyosarcoma is a very rare mesenchymal tumor that arises from smooth muscle cells in the wall of the central adrenal vein or its branches (1). Less than 50 cases have been published in the English literature (2). The tumors are aggressive and often metastasize. This report describes a case of primary adrenal leiomyosarcoma that presented as intermittent left flank pain of 6 months duration in an otherwise healthy 58-year-old Caucasian female. The patient was initially imaged with an abdominal ultrasound, which revealed a left suprarenal mass. A follow-up CT of the abdomen and pelvis confirmed a malignant appearing left adrenal mass. A subsequent PET-CT demonstrated increased metabolic activity within the adrenal mass without evidence of metastasis. Biopsy proven metastasis eventually was detected on surveillance CT studies over the course of 2.5 years. Since this is such a rare malignancy, documenting its imaging findings with multiple modalities is of importance to add to the medical literature and help further characterize its imaging features.

Uterine sarcomas and rare uterine mesenchymal tumors with malignant potential. Diagnostic guidelines of the French Sarcoma Group and the Rare Gynecological Tumors Group

The landscape of uterine sarcomas is becoming increasingly complex with the description of new entities associated with recurrent molecular alterations. Uterine sarcomas, as well as soft tissue sarcomas, can be distinguished into complex genomic sarcomas and simple genomic sarcomas. Leiomyosarcoma and pleomorphic type undifferentiated uterine sarcoma belong to the first group. Low-grade and high-grade endometrial stromal sarcomas, NTRK, COL1A1::PDGFB, ALK, RET, ROS1 associated sarcomas, and SMARCA4 deficient uterine sarcoma belong to the second group. Leiomyosarcoma is the most common uterine sarcoma followed by endometrial stromal sarcomas. Three different histologic subtypes of leiomyosarcomas are recognized with distinct diagnostic criteria and different clinical outcomes, the myxoid and epithelioid leiomyosarcomas being even more aggressive than the fusiform type. The distinction between low-grade and high-grade endometrial stromal sarcoma is based first on morphology and immunohistochemistry. The detection of fusion transcripts helps in the diagnosis. Definitely recognized as a separate entity, uterine PEComa is a rare tumor whose diagnostic criteria are being recently defined. Uterine PEComa has a specific algorithm stratifying the tumors into uncertain malignant potential and malignant tumors. Embryonal rhabdomyosarcomas of the uterine cervix are not restricted to children but can also be observed in adult women and are almost always DICER1 mutated, unlike embryonal rhabdomyosarcoma of the vagina which are DICER1wild-type, and adenosarcoma which can be DICER1 mutated but with less frequency. As sarcomas associated with fusion transcripts involving the NTRK, ALK, COL1A1::PDGFB genes can benefit from targeted therapy, systematic detection are now relevant especially for patients with high risk of relapse or in recurrent setting. The integration of molecular data with dedicated expert pathology review for histology and clinical data allows better identification of uterine sarcomas in order to better treat them.

PET/MR: primary inferior vena cava leiomyosarcoma

Positron emission tomography (PET) combined with a magnetic resonance (MR) scanner (PET/MR) with 18F-fluorodeoxyglucose (FDG) tracer is being used in quite a few nuclear medicine centers. The aim of this study is to illustrate two uncommon cases of primary inferior vena cava leiomyosarcoma which were formerly evaluated with anatomical images such as computed tomography and ultrasound. These techniques were inferior in the definition of the tumor and its characteristics. F-18 FDG PET/MR was essential and provided all the necessary information: its origin, local extension, anatomo-metabolic behavior, form of presentation, and distant metastasis in one single diagnostic technique. PET/MR accurately contributed to the diagnosis in a shortened period of time and, therefore, in the prognosis of this disease with greater benefits.

Primary hepatic leiomyosarcoma: A case report and literature review

BACKGROUND

Primary hepatic leiomyosarcoma (PHL) is a rare tumor with a very low incidence of about 0.2%.

CASE SUMMARY

A 48-year-old diabetic, hypertensive, and morbidly obese female patient presented with a history of abdominal pain and weight loss for 2 mo. She had no history of fever, jaundice, or other liver disease(s). Clinical examination revealed a palpable mass in the epigastrium. Imaging evaluation with a contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis revealed an ill-defined enhancing hyper vascular hepatic mass of 9.9 cm × 7.8 cm occupying the left hepatic lobe with evidence of central necrosis, compression effect on the left hepatic vein, and partial wash-out on delayed images. On further workup, the maximum standardized uptake value on positron emission computed tomography scan was 6.4, which was suggestive of malignancy. The remaining part of the liver was normal without any evidence of cirrhosis. Ultrasound-guided biopsy of the mass showed smooth muscle neoplasm suggestive of leiomyosarcoma. After optimization for co-morbidities, an extended left hepatectomy was planned in a multidisciplinary team meeting. On intraoperative ultrasound, the left hepatic lobe was entirely replaced by a large tumor extending to the caudate lobe with a compression effect on the middle and left hepatic veins. Final histopathology showed nodular and whorled white tumor comprised of spindled/fascicular cells with moderate to severe pleomorphism and focal necrosis. The mitotic index was greater than 20 mitoses per 10 high-power fields. The resection margins were free of tumor. Immunohistochemistry (IHC) depicted a desmin-positive/ caldesmon-negative/discovered on gastrointestinal stromal tumor 1-negative/ cluster of differentiation 117-negative profile, confirming the definitive diagnosis as PHL.

CONCLUSION

This case report highlights the rare malignant mesenchymal hepatic tumor. To confirm PHL diagnosis, one requires peculiar histopathological findings with ancillary IHC confirmation. Management options include adequate/complete surgical resection followed by chemotherapy and/or radiotherapy.

Inferior Vena Cava (IVC) Resection Without Reconstruction for a Large IVC Leiomyosarcoma

BACKGROUND

Retroperitoneal tumours arising from the inferior vena cava (IVC) are rare tumours often requiring large vessel resection for complete surgical excision. Limited exposure to such tumours often discourages surgeons from offering surgical resection to these patients, depriving them of the only potentially curative modality. We present here the surgical technique for resection of a large IVC sarcoma without IVC reconstruction.

METHODS

A 53-year-old lady presented with a large retroperitoneal sarcoma encasing the infra-hepatic IVC with tumour thrombus extension into the hepatic cloaca as well as the left renal vein. Surgical resection was planned as the disease remained stable after 2 cycles of neoadjuvant chemotherapy with adriamycin and ifosfamide.

RESULTS

Complete surgical excision of the tumour was achieved by performing a resection of the entire length of infra-hepatic IVC and right kidney, without IVC reconstruction. Left renal vein was divided after careful preservation of a draining collateral. Tumour thrombus was extracted from the hepatic cloaca, and proximal IVC stump closure was achieved with preservation of right hepatic vein insertion. Total blood loss during the procedure was 2300 mL, and the patient recovered without compromise of renal function or development of lower limb oedema.

CONCLUSION

IVC resection without reconstruction can be safely performed for large retroperitoneal sarcomas involving major vascular structures. Familiarity with the retroperitoneal, retro-hepatic and supra-hepatic anatomy is paramount to achieving good surgical outcomes.

Surgical treatment of vena cava leiomyosarcomas: Series of cases in a referral center and literature review

BACKGROUND

Primary tumors of the inferior vena cava are rare tumors of mesenchymal origin. They arise from the smooth muscles of the vena cava wall. Due to its low prevalence, there are few definitive data on its treatment and prognosis. Its treatment is based on general oncological principles.

METHODS

A series of 6 cases operated from 2010 to 2020 were analyzed. Different parameters related to the demographic characteristics, the tumor, the treatment received, and the results obtained in survival and morbidity were analyzed. In addition, a bibliographical review of the currently available evidence was carried out.

RESULTS

Optimal surgical resection was accomplished in all patients with R0 in 4/6 and R1 in 2/6. The greatest morbidity occurred in a patient who died in the intraoperative period. Cavorraphy was performed in one patient and cavoplasty in 5/6 using cryopreserved graft in 3/6 and prothesis in 2/6. The 50% were still alive at the end of the follow-up (with a mean follow-up of 10.7 months). The mean survival was 11.3 ± 9.07 months. 3/6 patients presented hematogenous recurrences with a disease-free interval of 9 ± 2 months.

CONCLUSION

The diagnosis and treatment of inferior vena cava leiomyosarcoma is still a challenge. Due to its low prevalence, it will be difficult to establish a totally standardized treatment and its approach is recommended in specialized centers. On the other hand, a multicentric study should be made to collect the most cases as possible in order to advance in the understanding of the approach to this disease.

Leiomyosarcoma of the small bowel: A case report and literature review

INTRODUCTION

Malignant tumors of the small bowel are rare. The jejunum, ileum, and duodenum represent the most common sites of intestinal leiomyosarcoma (LMS). Herein, we present a case of a 65-year-old patient having ileal LMS successfully treated with surgical resection.

PRESENTATION OF CASE

A 65-year-old patient, with no comorbidities, presented with chronic and paroxysmal abdominal pain. Upper endoscopy and colonoscopy showed no abnormalities. Thoracoabdominal computed tomography (CT) revealed an ileal lobulated, heterogeneously enhancing solid mass measuring 6 cm. Laparotomy was performed. Findings showed a lobulated ileal mass. We made an enlarged ileal resection with end-to-end anastomosis. The postoperative course was uneventful. Histology and IHC stains concluded into ileal LMS. No relapse of the disease was noted during the 4-month follow-up.

CLINICAL DISCUSSION

Ileal LMS is a rare tumor originating from the smooth muscle cells within the muscularis mucosa or muscularis propria. CT colonography (CTC) and magnetic resonance enterography (MRE) represent good options to aid the diagnosis. Histologically, LMS often has a comparable morphological appearance to GISTs. IHC is essential to differentiate those tumors. Surgery is the only curative treatment. The prognosis is poor knowing that those tumors are discovered at advanced stages.

CONCLUSION

Ileal LMS is a rare tumor originating from the smooth muscle cells. It has a comparable morphological appearance to GISTs. Immunohistochemistry is essential to confirm the diagnosis. Surgery is the only curative treatment. The prognosis is poor.

Treatment for local control of retroperitoneal and pelvis sarcomas: A review of the literature

Retroperitoneal and pelvis sarcomas are uncommon tumors for which complete surgical resection is the mainstay of treatment. However, achieving complete gross resection with microscopically negative margins is challenging, and local recurrence rates can be high. Patients often succumb to uncontrolled local disease. Radiation therapy offers a potential means for sterilizing microscopic residual disease, although its use continues to be controversial. Chemotherapy alone or in combination with radiation continues to be investigated as an adjunct to surgery, along with immunotherapy and targeted therapies. In this review, we discuss the current management of retroperitoneal and pelvis sarcomas, focusing on studies of surgery and radiation therapy to maximize local control.

A case report]

A 54-year-old female patient presented with a left nasal obstruction. On physical examination a pink delimited mass in the left nostril was observed. A cranial computed tomography scan revealed an expansive mass in the upper anterior third of the left nasal fossa, partially obstructing it. Endoscopic resection of the mass was performed. Histopathology revealed an atypical mesenchymal proliferation formed by cells disposed in disorganized and interconnected long bundles. Tumor cells had abundant eosinophilic cytoplasm and an oval, vesicular and hyperchromatic nucleus. Frequent mitotic figures were observed, many of them atypical. Necrosis was not observed. Immunohistochemistry showed tumor cells to be positive for calponin, muscle specific actin, caldesmon and smooth muscle specific myosin. Ki-67 index proliferation was 30%. A diagnosis of leiomyosarcoma of the nasal fossa was established.

Leiomyosarcoma: Current Clinical Management and Future Horizons

Leiomyosarcomas are soft tissue tumors that are derived from smooth muscle mainly in the pelvis and retroperitoneum. Percutaneous biopsy is paramount to confirm diagnosis. Imaging is necessary to complete clinical staging. Multimodal treatment should be directed by expert sarcoma multidisciplinary teams that see a critical volume of these rare tumors. Surgery is the mainstay of curative intent treatment; however due to its high metastatic progression, there may be a benefit for neoadjuvant systemic treatment. Adjuvant systemic treatment has no proven disease-free survival, and its main role is in the palliative setting to potentially prolong overall survival.

Inferior vena cava leiomyosarcoma with liver metastasis at presentation in a young male: A challenging diagnostic quandary

Leiomyosarcomas of vascular origin are very rare tumors, predominantly affecting the inferior vena cava (IVC). Although vascular leiomyosarcomas are slow-growing, their non-specific and late presentation results in delayed diagnosis which portends a very poor prognosis. Here we report a case of a 24-year-old man who presented with abdominal pain since 15 days and was found to have unresectable metastatic leiomyosarcoma of the inferior vena cava at initial diagnosis.

Primary leiomyosarcoma of cervical spine invading the vertebra without obvious osteoclasia: Case report and literature review

Context: Primary leiomyosarcomas are malignant tumors of smooth muscles, with few reported cases occurring in the cervical spine. The authors report a case involving a 29-year-old man with primary leiomyosarcoma in the spinal canal posterior to the C3-C5 vertebrae.Findings: No obvious osteolytic lesions could be found in neither X-ray nor computed tomography scan. Because of the confusion of nontypical imaging findings, a decompressive surgery of anterior cervical corpectomy of C4 and reconstruction with a mesh cage filled with allogenic bone grafts were performed. The patient refused a second operation and then was advised to receive the radiotherapy. No recurrence of the symptoms was evident 6 months after surgery.Conclusion: When a patient suffers from upper cervical tumor, the leiomyosarcoma should be kept in mind as possible diagnoses despite its low occurring ratio. Early detection, early diagnosis, and early treatment must be the goal of the strategy.

Incidentally Diagnosed Extraluminal Leiomyosarcoma of Infrarenal Inferior Vena Cava: A Case Report and Literature Review from a Radiologist's Perspective

Background

Vascular leiomyosarcoma is a rare but most common vascular tumor of the inferior vena cava.

Case presentation

We present the case of an incidentally diagnosed extraluminal leiomyosarcoma of the inferior vena cava in a 62 year old patient who presented with abdominal pain following blunt trauma. Ultrasonography showed a lobulated hypoechoic lesion in the upper abdomen. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a circumscribed lobulated near homogeneously enhancing retroperitoneal lesion in anterior relation to the infrarenal inferior vena cava, right paramedian in location with imperceptible vena caval lumen at the site of maximum contact. In positron emission tomography (PET) CT the lesion showed mild fluorodeoxyglucose (FDG) uptake with no distant metastases. CT guided biopsy with immunohistochemical analysis showed leiomyosarcoma. Patient underwent surgical resection with inferior vena cava reconstruction.

Conclusions

Leiomyosarcoma of the inferior vena cava is a rare tumor of vascular origin. Imaging plays an imperative role in the diagnosis and preoperative evaluation. This article also provides a comprehensive literature review of the radiological features of inferior vena caval leiomyosarcoma that would aid in optimal preoperative characterization and evaluation.

Utilization and outcomes of adjuvant therapy for stage II and III uterine leiomyosarcoma

OBJECTIVES

The optimal adjuvant therapy for uterine leiomyosarcoma (uLMS) remains uncertain. We analyzed the utilization of adjuvant chemotherapy and radiation therapy for stage II and III uLMS and explored the association between use of adjuvant therapy and survival.

METHODS

Patients with stage II or III uLMS treated from 2004 to 2016 and recorded in the National Cancer Database were identified. Multivariable regression models were fit to estimate predictors of use of either adjuvant radiation therapy or chemotherapy. To analyze the impact of chemotherapy on all-cause mortality, an inverse probability of treatment weighted (IPTW) propensity score method was used to account for measured confounders, and the receipt of radiation therapy was adjusted in the outcome model. The process was repeated to analyze the impact of radiation therapy on all-cause mortality by using an IPTW propensity score method and adjusting for the receipt of adjuvant chemotherapy.

RESULTS

A total of 890 patients were identified. Adjuvant chemotherapy use increased from 62.2% in 2010 to 70.4% in 2016, whereas radiation usage decreased from 26.7% in 2010 to 10.4% in 2016. Patients with stage III (vs. stage II) disease were less likely to receive radiation therapy. After propensity score weighting, chemotherapy was associated with a 30% decreased risk of all-cause mortality in stage III patients (HR 0.70, 95% CI 0.45-0.98) but had no effect on mortality for stage II patients (HR 0.93, 95% CI 0.70-1.20). Radiation therapy was associated with a 26% decreased risk of mortality for stage II tumors (HR 0.74; 95% CI, 0.53-0.99) and a 57% decrease in mortality for stage III disease (HR 0.43, 95% CI 0.18-0.99).

CONCLUSIONS

Among women with stage II-III uLMS, use of chemotherapy is increasing while use of radiation therapy is decreasing. Radiation therapy is associated with improved survival in both stage II and III disease, while there was no association between use of adjuvant chemotherapy and survival in stage II patients.

Mesenchymal tumors of the stomach: radiologic and pathologic correlation

Mesenchymal tumors of the stomach are uncommon, with gastrointestinal stromal tumor (GIST) being the most common among them. Majority of the tumors may arise from cells of Cajal, smooth muscle cells, neural cells, totipotent stem cells, adipocytes or fibroblasts. Imaging plays an important role not only in staging but also in characterizing these tumors. Many of these tumors have characteristic imaging features. GISTs usually present as large cavitating and necrotic tumors with exophytic component. Presence of fat tissue within the tumor suggests a lipoma or a teratoma, early phase hyperenhancement indicates glomus tumor and hemangioma, and delayed contrast enhancement is seen in schwannoma. Their differentiation from epithelial tumors like carcinoma and neuroendocrine tumors is often possible based on the location (mesenchymal tumors are intramural), spread, morphological appearance and enhancement patterns. However, overlapping features exist between these tumors with imaging often being only suggestive. A biopsy is necessary for a definitive diagnosis in many cases.

Update on Uterine Mesenchymal Neoplasms

This review focuses on recent advances in epithelioid and myxoid uterine mesenchymal neoplasms, a category of tumors whereby diagnostic criteria have been rapidly evolving due to advances in molecular testing. Pertinent clinicopathological and molecular features are highlighted for perivascular epithelioid cell tumors, uterine tumors resembling ovarian sex cord tumors, BCOR/BCORL1-altered high-grade endometrial stromal sarcomas, and inflammatory myofibroblastic tumors. Novel developments in epithelioid and myxoid leiomyosarcomas are briefly discussed, and differential diagnoses with key diagnostic criteria are provided for morphologic mimickers.

Phase II study of niraparib in recurrent or persistent rare fraction of gynecologic malignancies with homologous recombination deficiency (JGOG2052)

Background

Poly (adenosine diphosphate)-ribose polymerase (PARP) inhibitors for tumors with homologous recombination deficiency (HRD), including pathogenic mutations in BRCA1/2, have been developed. Genomic analysis revealed that about 20% of uterine leiomyosarcoma (uLMS) have HRD, including 7.5%–10% of BRCA1/2 alterations and 4%–6% of carcinomas of the uterine corpus, and 2.5%–4% of the uterine cervix have alterations of BRCA1/2. Preclinical and clinical case reports suggest that PARP inhibitors may be effective against those targets. The Japanese Gynecologic Oncology Group (JGOG) is now planning to conduct a new investigator-initiated clinical trial, JGOG2052.

Methods

JGOG2052 is a single-arm, open-label, multi-center, phase 2 clinical trial to evaluate the efficacy and safety of niraparib monotherapy for a recurrent or persistent rare fraction of gynecologic malignancies with BRCA1/2 mutations except for ovarian cancers. We will independently consider the effect of niraparib for uLMS or other gynecologic malignancies with BRCA1/2 mutations (cohort A, C) and HRD positive uLMS without BRCA1/2 mutations (cohort B). Participants must have 1–3 lines of previous chemotherapy and at least one measurable lesion according to RECIST (v.1.1). Niraparib will be orally administered once a day until lesion exacerbation or unacceptable adverse events occur. Efficacy will be evaluated by imaging through an additional computed tomography scan every 8 weeks. Safety will be measured weekly in cycle 1 and every 4 weeks after cycle 2 by blood tests and physical examinations. The sample size is 16–20 in each of cohort A and B, and 31 in cohort C. Primary endpoint is the objective response rate.

Trial Registration

Japan Primary Registries Network (JPRN) Identifier: jRCT2031210264

Recurrent hematuria: A rare presentation of leiomyosarcoma of the prostate

Introduction and Importance

Prostatic leiomyosarcoma is a rare aggressive tumor. The presentation came with non-specific signs and symptoms likewise other forms of prostatic pathology like benign prostatic hyperplasia.

Case presentation

A 64 years old man presented to the emergency with a recurrent macroscopic hematuria, he was a heavy smoker and has reported lower urinary tract symptoms. On the physical examination, the patient was hemodynamically stable and afebrile. However, the digital rectal exam revealed an enlarged homogeneous prostate without any palpable nodule. Pelvic transabdominal ultrasound showed an enlarged prostate and a thickening of the bladder's left lateral wall. The CT-scan showed a large and heterogeneous mass arising from the left bladder wall measuring 100 mm, which extends through almost the entire bladder wall. Furthermore, the patient performed cystoscopy, performed by a Urology Professor, showing a normal urethra, a normal prostate gland, and a large solid bladder mass with multiple clots. Subsequently, multiple masses' biopsies were performed. The diagnosis of a primary protatic leomyosarcoma was based on the clinical findings and on the histopathological exam. The patient was prepared for a radical cystoprostatectomy, which would be performed by a Urology Professor, but he died of cardiac arrest before undergoing surgery.

Clinical discussion

There are no specific clinical presentations of prostatic sarcoma, patients normally complain of urinary frequency and urinary urgency. Due to the lack of typical clinical symptoms, the tumor is easily overlooked or misdiagnosed as benign prostatic hyperplasia. In this case, the first symptom was a recurrent hematuria in a 64 years-old heavy smoker, which is a relatively rare obvious symptom according to literature. As showed in this case, recurrent hematuria may delay the diagnosis. Concerning the management of prostatic leiomyosarcoma, there are no standard recommendations. Multimodality combination treatments including surgery, pre or postoperative radiotherapy and neo or adjuvant chemotherapy have been used in the management of leiomyosarcoma of prostate.

Conclusion

Prostatic leiomyosarcoma poses a unique diagnostic challenge, as clinical presentation alone may not always be suggestive, an unsual clinical presentation as recurrent hematuria must suggest a prostatic leimyosarcoma when associated with urinary frequency and urinary urgency. Histopathological examination and the FNCLCC grading system are essential for the definitive diagnosis. Multimodality treatment regimens including surgery, radiotherapy and chemotherapy are recommended.

Early recurrence of aggressive leiomyosarcoma of the vagina

Malignant mesenchymal tumors of the female genital tract are uncommon gynecological cancers, particularly in the vagina. They are typically aggressive and often relapse, both locally and at distant sites. The treatment of choice for primary tumors is surgical excision as they are generally refractory to chemotherapy and radiotherapy. We describe the case of a vaginal leiomyosarcoma in a 43-year-old woman who presented with abnormal genital bleeding and discharge. The tumor was excised but recurred locally after just 11 months. It was removed by hysterectomy with double adnexectomy and partial vaginal excision.

Primary perimenarcheal ovarian leiomyosarcoma: A case report and review of the literature

INTRODUCTION AND IMPORTANCE

Leiomyosarcomas of the ovary are extremely rare neoplasia usually occurring in perimenopausal patients.

CASE PRESENTATION

A 16-year-old female patient, with no particular pathological history, who presented with chronic pelvic pain. On imaging; presence of a suprauterine solid cystic formation of 12 cm long axis. Tumor markers were normal. On exploration, solid cystic formation of 15 cm long axis. A total hysterectomy with bilateral salpingo-oophorectomy associated with bilateral pelvic and para-aortic lymphadenectomy and a total omentectomy were performed. Anatomical pathology; an ovarian leiomyosarcoma.

CLINICAL DISCUSSION

Leiomyosarcomas of the ovary are extremely rare, representing less than 1% of all ovarian malignancies. They probably derive from the smooth muscle component. No definitive diagnostic criteria for ovarian leiomyosarcomas have been adopted to date, however the histological criteria adopted are those for uterine leiomyosarcomas. The differential diagnosis of these tumors includes fibrosarcomas, rhabdomyosarcomas, thecomas and extradigestive stromal tumors. The prognosis of ovarian leiomyosarcomas is generally poor. Complete surgical resection remains for all authors the cornerstone of treatment. The benefit of adjuvant therapies, namely chemotherapy or radiotherapy, remains to be proven.

CONCLUSION

Leiomyosarcoma of the ovary, although exceptional, should always be included among the diagnostic possibilities when an ovarian cyst of organic appearance is discovered in a perimenarcheal patient.

U2 small nuclear RNA auxiliary factor 2, transcriptionally activated by the transcription factor Dp-1/E2F transcription factor 1 complex, enhances the growth and aerobic glycolysis of leiomyosarcoma cells

The dysregulation of U2 Small Nuclear RNA Auxiliary Factor 2 (U2AF2) is associated with malignant behaviors of multiple types of tumors. In this study, we explored the association between U2AF2 dysregulation and the survival of patients with primary leiomyosarcoma, the regulatory effect of U2AF2 on cell growth/aerobic glycolysis, and the mechanisms of U2AF2 dysregulation at the transcriptional level. Gene expression and survival time of patients with primary leiomyosarcoma were extracted from TCGA-Sarcoma (SARC). Leiomyosarcoma cell lines SK-LMS-1 and SK-UT-1 were utilized to construct in vitro and in vivo models. Results showed that the higher U2AF2 expression group had significantly shorter progression-free survival (HR: 2.049, 95%CI: 1.136-3.697, p = 0.011) and disease-specific survival (4.656, 95%CI: 2.141-10.13, p < 0.001) compared to the lower U2AF2 expression group. U2AF2 knockdown suppressed leiomyosarcoma cell growth and aerobic glycolysis (decreased glucose uptake, lactate production, and extracellular acidification rate) in vitro. Tumors derived from SK-LMS-1 cells with U2AF2 knockdown grew significantly slower, with lower GLUT1, PGK1, and PGAM1 protein expression than the control groups. TFDP1 and E2F1 could interact with each other in leiomyosarcoma cells. Both TFDP1 and E2F1 could bind to the promoter of U2AF2 and exert a synergistic activating effect on U2AF2 transcription. In conclusion, this study revealed that U2AF2 upregulation is associated with poor survival of leiomyosarcoma. Its upregulation enhances proliferation and aerobic glycolysis of leiomyosarcoma cells in vitro and in vivo. TFDP1 and E2F1 can form a complex, which binds to the U2AF2 gene promoter and synergistically activates its transcription.