Primary leiomyosarcoma of the vagina. Light and electron microscopic observations

Evaluation of Urethra and Anterior Wall Vaginal Leiomyoma by Translabial/Transurethral Sonography

Recent advances in sonography have dramatically improved the evaluation of the female urethra and vaginal canal. Widespread use of sonography for the detection of vaginal masses presents a less expensive way to identify pathology. The author recently encountered a patient with a rare vaginal mass. The following case illustrates translabial and transurethral sonography defining a vaginal mass directly under the urethra with no urethra luminal abnormalities. In general, the identification of a vaginal mass would lead most physicians to consider magnetic resonance imaging for characterization. Sonography presents an opportunity to provide accurate information without increasing medical cost to the patient. To the author’s knowledge, this is the first report describing translabial and transurethral sonography using a 10-MHz linear transducer to determine extension of a tumor from the vaginal wall into the lumen of the urethra.

Primary leiomyosarcoma of the vagina: a case report involving a TVT allograft

INTRODUCTION

Primary malignant lesions of the vagina represent less than 2% of all gynecologic malignancies. Primary vaginal sarcomas account for about 2% of all malignant vaginal lesions, with leiomyosarcoma being the most common vaginal sarcoma found in adult women.

CASE

We report a case of primary vaginal leiomyosarcoma occurring in the field of a prior tension-free vaginal tape (TVT) procedure using a Bard Duraderm allograft.

CONCLUSION

This report represents the first report, to our knowledge, of a vaginal sarcoma arising in the field of a Bard Duraderm TVT allograft. Although the product is no longer available for this use, the ongoing studies of the TVT procedure and outcomes should include this potential complication in their review.

Primary leiomyosarcoma of the vagina. A case report and literature review

Primary vaginal leiomyosarcoma is a rare tumor. We report a unique case of a 27-year-old woman with stage I, high-grade primary leiomyosarcoma of the vagina treated with surgical resection and adjuvant radiation therapy. She returned within 6 months with an abdominal-pelvic recurrence and lung metastases. The patient died of disease 9 months after diagnosis. A comprehensive review of primary vaginal leiomyosarcoma was performed and factors affecting survival were analyzed. A Medline search of the English-language literature revealed 66 previously reported cases. Forty-eight of these had follow-up data. Survival probabilities were calculated using the Kaplan-Meier method, and the effects of age, stage, grade, tumor location, and treatment modality were analyzed. Stage III and IV data were combined. The overall 5-year survival rate was 43%. Patients more than 50 years of age had a 5-year survival rate of 26% compared with 51% for those less than 40 years. Five-year survival for stage I and II tumors was 55% and 44%, respectively. Patients with stage III/IV disease had 25% survival at 18 months. No patient treated primarily with chemotherapy or radiation therapy survived beyond 36 months. In contrast, patients treated primarily with surgery had a 5-year survival rate of 57%. Only stage remained an independent predictor of survival on Cox regression analysis. We continue to recommend surgical resection as primary treatment. Exenteration may be an option for select patients, but ultimately management should continue on a case-by-case basis.

Leiomyosarcoma of the vaginal wall causing difficulty in micturition: a case report

A 52-year-old woman was admitted because of a vaginal-wall tumor adjacent to the external urethral orifice. The tumor had been causing disturbances in micturition for the past year. Magnetic resonance imaging and computed tomography images indicated a 6 x 3 cm solid mass in the anterior vaginal wall. The tumor was enucleated surgically through a median longitudinal incision of the anterior vaginal wall. Micturitional disturbances were rectified after surgery. Histologically, the tumor was a mixture of a high-cellularity area with a mitosis rate of 7 per 30 high-power fields, and a less cellular area without mitosis. Immunohistochemical staining was performed for both areas. The prognostic implications of the tumor are discussed.

Establishment and characterization of human uterine leiomyosarcoma heterotransplanted into nude mice

Human uterine leiomyosarcoma is a rare gynecological malignancy with a generally poor prognosis. We have established a human uterine leiomyosarcoma tumor line in nude mice, designated UTS-1, and describe the characteristics of this tumor. The UTS-1 tumor doubled in 12.1 days and retained the histological characteristics of leiomyosarcoma, even after 14 serial generations. Ultrastructurally, the tumor is characterized by nuclear pleomorphism typical of smooth muscle, intracytoplasmic filaments with dense bodies, a relative paucity of micropinocytotic vesicles, and an incomplete external lamina. Immunohistochemically, the UTS-1 cells reacted with antibodies against vimentin, desmin, smooth-muscle actin and myosin, but not with antibodies against keratin, CEA and S-100 protein. Serum levels of AFP, CA125, CEA and SCC ranged within normal limits in tumor-bearing mice. The serum level of immunosuppressive acidic protein correlated well with an activity of the tumor. Estrogen and progesterone receptors were not detected in the tumor. Chromosomal analysis showed a human karyotype with some marker chromosomes and a modal number of 85 chromosomes. The UTS-1 tumor should prove a useful model to explore the biological characteristics and treatment of human uterine leiomyosarcoma.

Leiomyosarcoma of the skin and subcutaneous tissue of the hand and wrist

Leiomyosarcoma of the skin and subcutaneous tissues is a rare tumor of smooth muscle origin. A case report of leiomyosarcoma of the hand is presented. The lesion was treated with wide local excision and has shown no recurrence in 2 years of follow-up.

Nonsquamous cancer of the vagina

This report retrospectively analyzes 48 cases of primary vaginal cancer treated at Walter Reed Army Medical Center and the Naval Hospital, Bethesda, from 1962 through 1983. There was an unusually high number of uncommon histologic types. Nine patients had an adenocarcinoma, 5 had a sarcoma, 3 had a melanoma, 2 had an adenosquamous carcinoma, 1 had a lymphoma, and 1 had a carcinoid tumor. The remaining 27 patients had a squamous cell carcinoma. This represents a 43% prevalence of nonsquamous lesions. Nonsquamous cancer of the vagina occurred in patients at an earlier age than squamous cell carcinoma. Presenting symptoms, the location of the tumor within the vagina, and survival rates were similar for both groups. The clinical characteristics and treatment of the patients with nonsquamous tumors are discussed.

Benign periurethral mass lesions: the female prostate

Bladder outflow obstruction in the female is usually a functional complaint, but rarely may be of organic aetiology, due to peri-urethral mass lesions. These lesions are usually midline in location and present clinical and roentgenological features comparable with those of prostate in the male. Two such patients, one of pure fibroma and another of hyperplastic glandular tissue are presented and their management is discussed.

A transmission electron microscopic study of two cases of oral smooth muscle neoplasm

Two cases of smooth muscle tumors that had appeared in the oral regions were examined by means of histopathology and electron microscopy. One was a case of angiomyoma that appeared in the lip of a 33-year-old man, and the other was a case of leiomyosarcoma in the maxilla of a 63-year-old woman. The results of the examination of both cases were as follows: the benign tumor (angiomyoma) was composed of mainly mature smooth muscle cells having dark cytoplasm, and the malignant tumor (leiomyosarcoma) consisted mainly of two types of cells, undifferentiated mesenchymal cells or fibroblast-like cells (type I) and myofibroblast-like cells (type II). Based upon these results, the relationship between the myogenous differentiation and the component cell types, and biological behavior of these smooth muscle tumors was discussed.

Ultrastructural observations on smooth muscle tumors

The ultrastructure of a series of primary and metastatic smooth muscle tumors is reviewed. Myofilaments and other smooth muscle features were present in all primary leiomyosarcomas of the soft tissues and uterus. They were also present but were less plentiful in most of the metastatic leiomyosarcomas. Electron microscopy is therefore a useful method to establish the diagnosis of a suspected leiomyosarcoma. Stromal tumors of the gastro-intestinal tract may require correlated immunocytochemical and ultrastructural studies for their identification: 9 of the 50 cases examined were positive with immunostaining for S-100 protein, and 16 tumors with epithelioid transformation did not show evidence of smooth muscle differentiation by electron microscopy.

Leiomyosarcoma of the vagina

A 46-year-old woman, who had very interesting tumor of the vagina microscopically, was presented. The removed tumor (40 g) in the upper lateral wall of the vagina was composed of two nodules. The cut surface of one nodule (20 g) was separated into two parts and they were diagnosed as necrosis and borderline case of leiomyomata microscopically. The other nodule (20 g) was diagnosed as leiomyosarcoma with interlacing bundles of spindle-shaped cells with large hyperchromatic, irregularly shaped nuclei and abundant mutases. These bindings suggest a possibility that leiomyoma of the vagina may undergo malignant change to become leiomyosarcoma.

Primary leiomyosarcoma of the vagina

A case of primary leiomyosarcoma of the vagina is described and discussed. The tumor recurred and the patient died 8.5 years after the diagnosis and primary treatment. This is the longest survival time reported in the literature for a primary vaginal leiomyosarcoma.

Primary leiomyosarcoma of the vagina: a study of five cases

The clinical and light and electron microscopic features of five cases of primary vaginal leiomyosarcoma, representing 2.9% of all vaginal malignancies registered at the Swedish Cancer Registry, are presented. The ages of the patients ranged from 31 to 69 years. The most common clinical presentation was an increasing mass and/or local tenderness. The tumor was located in the anterior wall in three cases and in the lateral wall in two. The size of the tumors ranged from 2 to over 10 cm. Four patients had tumors of high histologic malignancy grade and were all dead within 36 months. One patient had a tumor of low grade and is still alive 10 years after the initial excision. The ultrastructural observations of abundant myofilaments with focal elongated densities in primary paraffin-embedded material conform with the light microscopic diagnoses in all cases and indicate the usefulness and value of such material for electron microscopy in order to arrive at the diagnosis of leiomyosarcoma. The therapeutic and diagnostic aspects are discussed.

A comparative electron microscopic study of leiomyosarcoma and leiomyoma of the duodenum

Comparison of ultrastructural features between leiomyosarcoma and leiomyoma of the duodenum was made. There was no absolute difference between the two, but the following ultrastructural features of leiomyosarcoma were different from leiomyoma: (1) occasional conglomerations of mitochondria surrounded by granular endoplasmic reticulum; (2) quite rare presence of single cilia; (3) frequent occurrence of intranuclear inclusion bodies; (4) variability in nuclear size and shape; and (5) wide interstitial space with scanty collagen fibrils. Although both tumors were considered to be of smooth muscle origin, their ultrastructural features were distinctively different from the normal smooth muscle in some points. In addition to the light microscopic findings, ultrastructural features were considered to be valuable for distinguishing the malignant from the benign smooth muscle tumors in the gastrointestinal tract.

Primary sarcoma of the gallbladder. A light and electronmicroscopical study

Six Swedish cases of primary sarcoma of the gallbladder from the period 1958-1973 and 1 case from 1975 were studied by light and electron microscopy. the literature was reviewed for the period after 1970. Ultrastructural features of sarcoma were investigated in order to exclude poorly differentiated carcinoma. One case was considered to be an embryonal rhabdomyosarcoma, three cases leiomyosarcoma and two were diagnosed as fibrosarcoma. One case, diagnosed as sarcoma of the gallbladder by light microscopy, was omitted because electron microscopical examination revealed a squamous cell carcinoma.

Monophasic synovial sarcoma, epithelioid sarcoma and chordoid sarcoma: ultrastructural evidence for a common histogenesis, despite light microscopic diversity

Ultrastructural examination of six rare sarcomas--four monophasic spindle cell tumours, one epithelioid sarcoma, one chordoid sarcoma--has revealed marked similarities at the electron microscopic level despite widely divergent light microscopic appearances. These features consisted of: 1 the presence of two cell types, viz. a clear cell and a cell resembling the fibroblast; 2 pseudoglandular spaces with projecting microvilli or filopodia, and with related tight junctions; 3 an amorphous intercellular ground substance with focal condensation into recognizable basement membrane. The findings suggest a common maturation of these diverse tumours to synovial-like tissue, and support the proposal of Hajdu Shiu & Fortner (1977) that these be considered variants of synovial sarcoma. Published ultrastructural studies of synovial, epithelioid and chordoid sarcoma are reviewed in the light of these findings. The ultrastructural differentiation of synovial sarcoma from extraskeletal myxoid chondrosarcoma, chordoma and the spectrum of malignant spindle cell tumours is discussed.

Primary leiomyosarcoma of bone: a study of five cases

Five cases of leiomyosarcoma of bone are described. The patients, 3 men and 2 women, ranged in age from 24 to 74 years. Four of the five tumors were located in the distal half of the femur. Radiographically, all tumors presented as purely osteolytic lesions. Angiography, performed in 3 cases, revealed hypervascularity and the presence of irregular, tortuous vessels at the site of the lesion in 1, but not in 2 others. Histologically, the five tumors showed features characteristic of leiomyosarcomas. The most prominent features were blunt-ended, cigar-like, chromatin-rich nuclei in elongated acidophilic cells arranged in bundles which intersected each other at wide angles. The importance of trichrome stains, such as van Gieson stain, for th recognition of leiomyosarcomas is emphasized. Electron microscopic examination, performed in 3 cases, showed as the most prominent features spindle-shaped cells in parallel arrangement containing abundant myofilaments which elongated densities, pinocytotic vesicles, and basal lamina structures.

Malignant schwannoma: a light microscopic and ultrastructural study

The light microscopic and ultrastructural features of 3 cases of malignant schwannoma were studied and compared with those of other types of soft-tissue sarcoma. The tumor in 1 of these cases originated in an intercostal nerve and was composed of compactly arranged spindle-shaped tumor cells. The other 2 cases showed osteogenic areas in addition to exhibiting prominent nuclear palisading, focal myxoid changes, and a rosette-like arrangement of tumor cells. The tumor in 1 of these latter cases occurred at the site of a preexisting neurofibroma. The Schwann cell origin of these tumors is strongly supported by the ultrastructural findings of basement membranes and conspicuous intercellular junctions in all 3 cases and dense-core granules in 1.

Plexiform tumors of the uterus: ultrastructural study

Two cases of plexiform tumor of the uterus are presented. Both were incidental microscopic findings in leiomyomatous uteri and had the typical branching cords of small, polygonal cells with scanty cytoplasm and vesicular nuclei. Ultrastructurally the cells had features of smooth muscle differentiation such as actin-like filaments, dense bodies, peripheral dense plaques, pinocytotic vesicles, and incomplete basal lamina. Their close relationship to capillaries resembled the structure of glomus tumor and vascular leiomyoma and suggested histogenetic kinship among these neoplasms.

Primary leiomyosarcoma of the bone and its comparison with fibrosarcoma

Two cases of primary leiomyosarcoma of the bone are recorded, one in the distal fibula of a 66-year-old man, the other in the proximal tibia of a 61-year-old woman. The cytological, histological, and ultrastructural features of leiomyosarcoma of bone are described and compared with those of fibrosarcoma. These features are sufficiently characteristic to enable a confident diagnostic distinction between leiomyosarcoma and fibrosarcoma. Nevertheless, certain basic similarities exist between these two tumors, manifested at the ultrastructural level by the presence of myofilaments in fibrosarcoma; it would seem that the observed differences relate to the degree of development of the myofilamentous structures. It is postulated that primary leiomyosarcoma of the bone need not necessarily always arise from the media of blood vessels; it might also conceivably develop through advanced myogenic metaplasia of a sarcoma originating from fibroblastic tissue.

[Electron microscopic investigation on cutaneous leiomyosarcoma (author's transl)]

A 61-year old woman developed a tumourous nodule in her left leg. Fifteen years ago a similar tumour had been removed in the same localization. Histological examination performed on biopsy material showed bundles of predominantly fusiform tumour cells with nuclear pleomorphism and many mitotic figures. Electron microscopic examination confirmed the diagnosis of leiomyosarcoma by demonstration of the ultrastructural characteristics of smooth muscle cells. Cellular differentiation showed various degree ranging from smooth muscle cell type to dedifferentiated edematous tumour cells with scanty myofilaments. An important finding was the demonstration of multiple accumulated centrioles.

Ultrastructure of gastric leiomyosarcoma

Samples of gastric leiomyosarcomas from two male patients (69 years and 57 years of age) were studied by electron microscopy. The tumour cells contained abundant 50--90 A thick microfilaments and microtubules. Another cell type, regarded as immature leiomyosarcoma cell, contained numerous profiles of granular endoplasmic reticulum, free ribosomes and a well developed Golgi apparatus. There were intercellular junctions of zonula adherens-type between adjacent tumour cells. It was concluded that electron microscopy offers a valuable aid in the diagnosis of gastric neoplasms of smooth muscle origin.

An unusual multifocal leiomyosarcoma of the stomach: a light and electron microscopic study

A multifocal leiomyosarcoma of the stomach originating from the muscularis mucosae with lymph node and distant metastases is described in a 66 year old man. The electron microscopic features of a representative tumor mass and a metastasis confirmed the smooth muscle histogenesis. The light microscopic appearance consistently suggested malignant fibrous histocytoma. The pathological features of gasttric leiomyosarcomas are reviewed with special emphasis on the problem of practical diagnosis. This case also indicates that not all sarcomas with storiform features are necessarily histiocytic in origin.

Meningioma and intracranial hemangiopericytoma. A comparative electron microscopic study

Electron microscopic study of 2 intracranial hemangiopericytomas and 7 meningiomas revealed fundamental morphologic differences between the 2 neoplasms. The most significant finding in hemangiopericytoma was the presence of ultrastructure features suggesting leiomyoblastic differentiation. These included characteristic fusiform intracytoplasmic and submembranous dense bodies, abundant cytoplasmic filaments, elongated cells with blunt-ended nuclei and juxtanuclear polarization of organelles. This observation is considered highly significant as an indicator of the pericytic nature of this tumor. In addition, hemangiopericytoma cells sometimes were arranged in spirals around pools of basement membrane-like material, perhaps a manifestation of the biologic capability of the cells to synthetize such material. Meningioma cells displayed as their main feature an ability to produce surface membrane specializations including interdigitations, desmosomes, zonulae adhaerentes and gap functions. Sometimes the last 3 elements were linearly juxtaposed forming junctional complexes similar to those seen in certain epithelia. It is suggested that the characteristic whorls of meningioma are the result of cell interconnections arising from the specialized junctional attachments. Thus the distinctive morphology of the 2 neoplasms appears to derive from basic biologic properties of their elements.

Primary leiomyosarcoma of bone

A case of primary leiomyosarcoma of bone in the femur of an 18-year-old girl is described. Light and electron microscopy showed characteristic changes with cytoplasmic myofilaments, dense bodies, pinocytic vesicles and basal lamina fragments. Clinically, the patient is well and without evidence of tumor 9 months after the femur amputation without further treatment.

Central leiomyoma of the mandible

A case of central leiomyoma of the mandible is reported, along with ultrastructural confirmation of the diagnosis. The pertinent literature is reviewed. It is probable that this lesion arose from the smooth muscle in the walls of blood vessels. To the best of our knowledge, this is only the second report of a leiomyoma central in bone.

Giant cell tumor of soft parts. An ultrastructural study

The light-microscopic and ultrastructural findings in a case of so-called giant cell tumor of soft parts, localized at the dorsal side of the left foot of a 23-years-old male are described. An amputation of the lower extremity was performed and subsequently chemotherapy with adriamycin was given for 3 months. Despite the histology and cytologic malignant appearance and the evident vascular invasion, already present at the time of the first excision, the last known status 2 years later seems favorable. There are no pathologic lymph nodes in the groins and no signs of metastases on chest X-rays. From the electron-microscope study no definite conclusion can be drawn as regards the histogenesis of this tumor. we feel, as do others, that many of the principal mononuclear tumor cells are poorly differentiated mesenchymal cells. Some of the neoplastic cells, however, show ultrastructural features suggestive of chondro- or osteoblasts (a well-developed r.e.r. containing electron-dense material; multiple Golgi complexes; masses of glycogen; interdigitating cell membrane villi; cytoplasmic filaments; an extracellular amorphous matrix). Some of the larger tumor cells have the submicroscopic aspects of histiocytes as described in osseous, cutaneous, or pulmonary lesions of the histiocytosis X group. As yet undetermined cytoplasmic inclusion bodies constitute another rare observation in our material.

The ultrastructural morphology of gynecologic neoplasms

Our knowledge of the morphology and pathogenesis of malignant neoplasms of the female genital tract has traditionally depended heavily on their light microscopic characteristics. The introduction of transmission, and most recently, scanning electron microscopy, into the field of gynecologic pathology has resulted in a considerable improvement in the diagnosis of genital cancers that are difficult to classify and has provided valuable information for a better understanding of their subcellular dynamics and pathogenetic development. This paper describes and illustrates the ultrastructural alterations that are considered specific for the most common malignant and potentially malignant neoplasms of the genital system in this context. The value of electron microscopy in the morphologic study of genital cancers warrants its increased use in routine diagnostic pathology, as well as further evaluation of it in basic research in this challenging area of investigation.

Intracranial hemangiopericytoma: ultrastructural evidence of its leiomyoblastic differentiation

Two intracranial hemangiopericytomas revealed subcellular features of the neoplastic elements comparable to those observed in normal and neoplastic smooth muscle. These included intracytoplasmic and submembranous fusiform dense bodies associated with bundles of filaments, tapered configuration of cells with grouping of cytoplasmic organelles at nuclear poles and deposition of intercellular basal lamina-like material. These observations are consistent with the pericytic origin but opposed to the ofttimes postulated meningothelial derivation of the neoplasm.

Microfilaments in human epithelial cancer cells

The occurence, distribution, and ultrastructural morphology of microfilaments in malignant epithelial cells of invasive squamous cell carcinoma of human oral cavity were studied by electron microscopy. The findings are compared with those in malignant oral epithelial cells of carcinoma-in-situ. In the malignant cells of invasive carcinoma, microfilaments 50-70 A in diameter are prominent in the cortical cytoplasm of the lateral and basal cell surfaces, adjacent and parallel to the plasma membrane, and extending into cell processes and microvillous extensions. Additional microfilaments are found to run from the peripheral cytoplasm to the perinuclear region. The microfilaments are aggregated into bundles aligned parallel to the long axis of the cell and display foci of increased electron density. They also tend to be aggregated into complex polygonal arrays. These microfilaments are similar in organization, concentration and ultrastructural architecture to those of various other nonmuscle cells, where they are thought to be capable of contraction and associated with cell motility. The presence of a microfilament system believed to be associated with contractile and motile cell processes may be an important characteristic of malignant cells of invasive tumors. The lack of abundant organized microfilaments in malignant cells in the absence of tumor invasion, and the presence of a prominent microfilament system in cells of invasive tumors, suggest that the microfilaments are related to the invasive properties of malignant tumor cells.

An unusual leiomyosarcoma of the uterus containing osteoclast-like giant cells

An unusual variant of a poorly differentiated leiomyosarcoma of the uterus, containing osteoclast-like giant cells, is described. Areas of the resected tumor bore a close resemblance to giant cell tumor of bone. It is postulated that these giant cells, as well as the osteoclast-like giant cells reported in a number of tumors of other tissues, originate from the monocyte/histiocyte group of cells. The diagnosis of leiomyosarcoma was possible only after the tumor had been examined in the electron microscope. The ultrastructural features are consistent with a smooth muscle origin of the neoplasm; the final assessment is based on the relative proportions and frequency of such structures as: bundles of myofilaments with focal densities, marginal densities, pinocytotic vesicles, and an external lamina.

Bladder outlet obstruction caused by vaginal fibromyoma: the female prostate

Three patients with urinary difficulty were cured by surgical removal of a viaginal fibromyoma. The appearance of this benign tumor on an intravenous cystogram and cystoscopy as well as the clinical response to surgical removal bears similarity to the hypertrophied prostate in men. The best surgical technique for its removal is enucleation via a vaginal incision.