Endolymphatic stromal myosis: a case with positive estrogen and progesterone receptors and good response to progestins

Novel approaches in cancer treatment: preclinical and clinical development of small non-coding RNA therapeutics

Short or small interfering RNAs (siRNAs) and microRNA (miRNAs) are molecules similar in size and function able to inhibit gene expression based on their complementarity with mRNA sequences, inducing the degradation of the transcript or the inhibition of their translation.

siRNAs bind specifically to a single gene location by sequence complementarity and regulate gene expression by specifically targeting transcription units via posttranscriptional gene silencing. miRNAs can regulate the expression of different gene targets through their imperfect base pairing.

This process - known as RNA interference (RNAi) - modulates transcription in order to maintain a correct physiological environment, playing a role in almost the totality of the cellular pathways.

siRNAs have been evolutionary evolved for the protection of genome integrity in response to exogenous and invasive nucleic acids such as transgenes or transposons. Artificial siRNAs are widely used in molecular biology for transient silencing of genes of interest. This strategy allows to inhibit the expression of any target protein of known sequence and is currently used for the treatment of different human diseases including cancer.

Modifications and rearrangements in gene regions encoding for miRNAs have been found in cancer cells, and specific miRNA expression profiles characterize the developmental lineage and the differentiation state of the tumor. miRNAs with different expression patterns in tumors have been reported as oncogenes (oncomirs) or tumor-suppressors (anti-oncomirs). RNA modulation has become important in cancer research not only for development of early and easy diagnosis tools but also as a promising novel therapeutic approach.

Despite the emerging discoveries supporting the role of miRNAs in carcinogenesis and their and siRNAs possible use in therapy, a series of concerns regarding their development, delivery and side effects have arisen.

In this review we report the biology of miRNAs and siRNAs in relation to cancer summarizing the recent methods described to use them as novel therapeutic drugs and methods to specifically deliver them to cancer cells and overcome the limitations in the use of these molecules.

Letrozole as second-line hormonal treatment for recurrent low-grade endometrial stromal sarcoma: A case report and review of the literature

Low-grade endometrial stromal sarcoma (LGESS) is a rare malignancy. The tumor is reportedly responsive to hormonal therapy, most commonly with medroxyprogesterone acetate (MPA), but the effectiveness of aromatase inhibitors for recurrent LGESS remains unclear. The present study reports a case of stage IC LGESS presenting with abnormal uterine bleeding, and also provides a review of the literature. Following a total abdominal hysterectomy and bilateral salpingo-oophorectomy, MPA therapy was initiated; treatment was successful, but discontinued 19 months later due to disruptive side effects. A further 2 months later, the patient presented with recurrent disease and received chemotherapy. MPA treatment was restarted with a partial response. A second recurrence, 4 years later, presented with lung and para-aortic lymph node metastases. The patient responded to treatment with the aromatase inhibitor letrozole. The patient has since exhibited stable disease and remained free of symptoms for 7 years. This case suggests that aromatase-inhibitor treatment may be effective for recurrent LGESS as a second-line treatment.

Endometrial Stromal Sarcoma Presenting as Extrauterine Metastases

A case of endometrial stromal sarcoma that initially presented as an umbilical mass 5 years before and as a lung lesion 8 months before the primary tumor was detected in the uterus is reported. The morphologic features and immunohistochemical profile of the two initial extrauterine lesions suggested metastases from a primary endomerial stromal sarcoma of the uterus, which was confirmed by subsequent endometrial curettage. The tumors in all three locations were characterized histologically by small to medium-sized uniform cells with fewer than 10 mitoses per 10 high-power fields and distinct arterial vasculature that resembled the spiral arteries of the normal enometrium. Both the endometrial and umbilical tumors were immunoreactive for estrogen and progesterone receptors but showed no immunoreactivity for cytokertin. Additionally, the tumor cells of the umbilical mass showed no immunoreactivty for S-100 protein, HMB-45, smooth-muscle actin, or desmin. Endometrial stromal sarcomas are usually confined to the uterus at the time of diagnosis. When they preent initially as an extrauterine metastasis, diagnostic difficulties may arise. A recogition of the morphologic features, together with the immunoreactivity pattern, is needed in evaluating endometrial stromal sarcomas that present as extrauterine metastases.

Ovary and uterus-sparing procedures for low-grade endometrial stromal sarcoma: a retrospective study of 153 cases

OBJECTIVE

To discuss the optimal treatment options for low grade endometrial stromal sarcoma (LG-ESS).

METHODS

Medical records of consecutive patients with LG-ESS in our institute were collected. The pertinent data, including clinicopathological characteristics, treatment and prognostic information were evaluated.

RESULTS

A total of 153 cases of LG-ESS were included. The 5-year relapse free survival (RFS), overall survival (OS) and survival after relapse (SAR) rates were 66.1%, 95.8% and 82.9%, respectively. Ovary-sparing procedures, positive resection-margins, and myomectomy were the independent adverse factors for relapse (P<0.0001, =0.0041, and =0.0075, respectively). Post-menopause, cervical involvement, and positive lymphovascular space involvement were significantly associated with survival (P<0.0001, =0.0020, and =0.0163, respectively). Distance recurrence and macroscopically residual tumors negatively affected SAR (P=0.0137 and =0.0004, respectively). No benefit was found for lymphadenectomy in terms of both RFS and OS (P=0.1187 and =0.5138, respectively). Initial ovary-sparing procedures and myomectomy had no impact on OS (P=0.0810 and =0.8845, respectively). Adjuvant treatment had a slightly beneficial effect both on OS and SAR.

CONCLUSION

Hysterectomy with bilateral salpingo-oophorectomy and complete resection of the macroscopic lesion should be treated as the initial and salvage mainstay treatments for LG-ESS patients. Ovary-sparing procedures could be considered for young women without cervical involvement; however, long-term follow-up should be mandatory. Myomectomy should only be conserved for young patients with a strong desire for future fertility, with fully informed consent; hysterectomy was recommended after the completion of pregnancy and delivery. However, the roles of lymphadenectomy and adjuvant treatment deserve further investigation.

Aromatase inhibitor anastrozole as a second-line hormonal treatment to a recurrent low-grade endometrial stromal sarcoma: a case report

Low-grade endometrial stromal sarcoma (ESS) is a rare neoplasm and is generally an indolent tumor with estrogen and progesterone receptors. Objective responses by hormonal treatment with progestin or aromatase inhibitor have been reported, however, long-term management of this disease could be difficult if it becomes refractory to one of these hormonal therapies. A 34-year-old woman was diagnosed with stage I low-grade ESS at the time of hysterectomy for presumed uterine fibroma. Five years later, she recurred with multiple tumors in the lower abdomen. After an optimal surgery, she was free from progression for 6 years with progestin treatment (medroxyprogesterone acetate: MPA, 200-600 mg daily). Thereafter, she recurred twice during the MPA treatment and received debulking surgery each time. MPA was discontinued at age of 53, because another recurrent tumor grew up to 13 cm in diameter. Aromatase inhibitor anastrozole was then given at a daily dose of 1 mg with partial response (the tumor size decreased to 7 cm in diameter) for a duration of 9 months. After complete resection of the recurrent tumor, she remains progression-free for 16 months. Anastrozole was effective to recurrent low-grade ESS even after being refractory to progestin therapy. Aromatase inhibitor treatment may be a useful option as a second-line hormonal treatment to low-grade ESS.

Low-grade endometrial stromal sarcoma with inferior vena cava tumor thrombus and intracardiac extension: radical resection may improve recurrence free survival

BACKGROUND

Endometrial stromal sarcoma (ESS) represents 0.2% of all uterine malignancies. Based on the mitotic activity, a distinction is made between low and high-grade ESS. Although the overall five-year survival rate for low-grade ESS exceeds 80%, about 50% of the patients show tumor recurrence, mostly after a long latency period. Tumor invasion of the great vessels is extremely rare. We describe a patient with advanced low-grade ESS with tumor invasion of the infrarenal aorta and the inferior vena cava. The patient presented with a large tumor thrombus extending from the inferior vena cava into the right atrium.

METHODS

Review of literature and identification of 19 patients, including our own case report, with advanced low-grade ESS with invasion of the great vessels and formation of an inferior vena cava tumor thrombus.

RESULTS

All 19 patients presented with an abdominal tumor mass and a tumor thrombus protruding into the inferior vena cava. The tumor thrombus extended into the right heart cavities in nine patients reaching the right atrium in four, the right ventricle in three and the pulmonary artery in two patients. There were 5 patients with an advanced primary tumor and 14 patients with an advanced recurrent tumor. Seven patients presented with synchronous metastatic disease and six patients with a pelvic tumor infiltrating the bladder, the rectosigmoid colon or the infrarenal aorta. Mean age at surgery was 45.9+/-12.3 years (median 47, range 25-65 years). Tumor thrombectomy was accomplished by cavatomy or by right atriotomy after installation of a cardiopulmonary bypass. There was no peri-operative mortality and a very low morbidity. Radical tumor resections were achieved in 10 patients. The follow-up for these 10 patients was 2+/-1.3 years (median 2, range 0.3-4.5 years). Nine patients remained recurrence free whereas one patient suffered an asymptomatic local recurrence.

CONCLUSIONS

Low-grade ESS is a rare angioinvasive tumor with a high recurrence rate. Resection of an inferior vena cava tumor thrombus, even with extension into the right heart cavities, can be performed safely. Extensive radical surgery is therefore justified in the treatment of advanced tumor manifestations of a low-grade ESS potentially improving recurrence free survival.

Low-grade endometrial stromal sarcoma with sex cord-like differentiation metastatic to the thoracic spines

We report a case of monostotic low-grade stromal sarcoma (ESS) with sex cord-like elements metastatic to the thoracic spines, which to the best of our knowledge has not previously been documented. A 48-year-old female who had undergone total abdominal hysterectomy for low-grade endometrial stromal sarcoma 7 years previously presented with insidious onset of severe back pain of 2 months' duration. Magnetic resonance image (MRI) showed involvement of the eleventh and twelfth thoracic vertebral bodies. Decompression at the level of T10-12 was performed. Histologically, the laminae of thoracic vertebrae 11 and 12 were replaced by sheets of ovoid cells with plump nuclei intermixed with anastomosing trabeculae, cords and small nests, reminiscent of a sex-cord stromal tumor pattern. The tumor cells showed diffuse nuclear immunostaining for estrogen receptors (ER) and progesterone receptors (PR), as well as membranous immunostaining for CD10. The immunostaining for smooth muscle actin was focal and sparse. These findings confirmed the diagnosis of metastatic low-grade ESS with sex cord-like differentiation. Low-grade ESS with sex cord-like differentiation is an uncommon tumor which rarely metastasizes to the bone, and use of a panel of ER, PR, CD10, actin, cytokeratin and inhibin immunostains is essential to establish the diagnosis.

A case of c-kit positive high-grade stromal endometrial sarcoma responding to Imatinib Mesylate

BACKGROUND

High-grade endometrial stromal sarcoma (HGES) is an aggressive disease with dismal prognosis. Surgery is the standard treatment, and radiotherapy seems to reduce local relapse. No other treatment has proved to be useful in the case of non-resectable diseases.

CASE

A 41-year-old woman suffering HGES, with positive staining for CD117 (c-kit) and large abdominal and retroperitoneal mass progressing after chemotherapy, was treated with Imatinib Mesylate. After 3 months, objective response was documented and radical surgery performed. Two years after surgical intervention, she is currently free of the disease.

CONCLUSION

The response seen with Imatinib should be further investigated in a larger number of cases.

Systemic therapy for advanced uterine sarcoma: A systematic review of the literature

OBJECTIVE

To conduct a systematic review of the literature regarding the systemic treatment of advanced uterine sarcoma and provide an evidence-based summary of the available literature.

METHODS

MEDLINE, EMBASE, and the Cochrane Library databases were searched. "Uterine sarcoma," "leiomyosarcoma," "mixed mesodermal tumor," "chemotherapy," and "systemic therapy" were combined with the search terms for study designs.

RESULTS

Three randomized controlled trials and 24 prospective phase II trials were included in the systematic review. In a randomized trial of doxorubicin versus doxorubicin plus cyclophosphamide for advanced or recurrent uterine sarcoma, doxorubicin produced an overall response rate (RR) of 19% and median survival of 11.6 months, which was similar to the response with combination chemotherapy (RR 19%, median survival 10.9 months). A randomized trial comparing ifosfamide plus cisplatin versus ifosfamide alone in mixed mesodermal tumors showed a significant improvement in RR and progression-free survival with the combination compared with ifosfamide alone, however, the combination was associated with increased toxicity including death. A randomized trial comparing doxorubicin to doxorubicin with dacarbazine in women with advanced or recurrent uterine sarcoma demonstrated a significantly higher RR with the combination (P < 0.05), but no significant difference in survival.

CONCLUSIONS

Offering palliative chemotherapy to patients with advanced, unresectable uterine sarcoma who are symptomatic from this disease is a reasonable decision. Doxorubicin is an option for women with advanced uterine sarcoma. The combination of cisplatinum and ifosfamide is also an option for women with metastatic mixed mesodermal tumors; however, this combination is associated with significant toxicity when compared to ifosfamide alone.

Metastatic low-grade endometrial stromal sarcoma of the sigmoid colon three years after hysterectomy

A 49-year-old woman, who had undergone hysterectomy for low-grade endometrial stromal sarcoma (ESS) 3 years ago, presented with a 2-wk history of lower abdominal pain. Barium enema and sigmoidoscopy disclosed a polypoid submucosal tumor. Histopathologic features of biopsy specimens from the lesion were similar to those of the resected uterine ESS. Under the diagnosis of metastatic ESS of the sigmoid colon, sigmoidectomy was performed. Microscopic examination demonstrated dense proliferation of spindle cells with little nuclear atypia, which were sometimes arranged in whorled pattern around abundant arterioles. Mitotic count is below 1 in 10 high-power fields. Immunohistochemically, the neoplastic cells were strongly positive for vimentin, estrogen receptor and progesterone receptor but negative for α-smooth muscle actin, S-100 protein and CD34. Thus, a final diagnosis of low-grade ESS metastasis to the sigmoid colon was made. Her postoperative course was uneventful and hormonal therapy with progestational agents is entertained.

Sarcome du chorion cytogène de bas grade

Endometrial stromal sarcoma is a rare malignant uterine tumor. We report 4 cases of low-grade endometrial stromal sarcoma, corresponding to the form with a mitotic index at less than 10 mitoses per 10 high power fields (HPF), from which we carried out a review of the literature and defined the potential interest of hormone therapy and chemotherapy by etoposide. Generally diagnosed in pre-menopause, the main clinical signs, which are not very specific, are metrorrhagia and pelvic pain. The etiologic diagnosis is established from the pathology analysis. Intravascular extension, which is observed in nearly 50% of patients, should evoke the disease. The initial treatment is mainly based open surgery, generally total hysterectomy with annexectomy. There is no effective adjuvant treatment. The potential of reccurences remains around 50% with a 34-month median. Several therapeutic options are possible after recurrence but no standard treatment has been established. We are mainly interested in three medical options but the surgery remains an alternative of choice. Chemotherapy by oral etoposide offers easy administration, good compliance and acceptable toxicity with median 20-month remission in 3 patients before progression. Hormone therapy with progestogens (hormone receptor expression of the tumor is 71% for estrogens and 95% for progesterone) is widely studied in the literature with a 46% response rate and 46% rate of disease stabilization. Hormone therapy with an anti-aromatase appears to be a promising treatment according to the bibliographic references on this subject. Overall, prognosis of low-grade endometrial sarcoma is relatively good with 100% survival at 5 years. The progression pattern is slow, requiring regular and prolonged surveillance.

Low-grade endometrial stromal sarcoma recurring with multiple bone and lung metastases: report of a case

BACKGROUND

Approximately 50% of patients with low-grade endometrial stromal sarcoma (ESS) develop recurrent disease, mainly in lung or pelvis. Bone metastasis of low-grade ESS is an extremely rare phenomenon.

CASE

A 63-year-old Japanese female developed multiple bone and lung metastases 18 years after initial treatment for low-grade ESS. Bone scintigram showed a high uptake area at thoracic spine (Th6, Th8-9 and Th12), right 9th rib, iliac bone, and sacrum. Radiation therapy with Liniac of 4500cGy to the Th6 vertebra and Liniac of 4200cGy to sacrum was performed for the palliation of the pain. Radiotherapy was effective for the pain relief, although the size of recurrent tumor was unchanged.

CONCLUSION

This is the first detailed reported case of multiple bone recurrence in a patient with low-grade ESS. The long-term follow-up after treatment is recommended.

Low-grade endometrial stromal sarcoma: hormonal aspects

OBJECTIVE

The goal of this work was to determine whether exposure to estrogen following treatment of low-grade endometrial stromal sarcomas affects clinical outcome.

METHODS

Twenty-two patients with low-grade endometrial stromal sarcomas were reviewed to determine whether they were exposed to exogenous or endogenous estrogen and/or progestins following their diagnosis and whether exposure to these hormones might have influenced their prognosis. Estrogen receptor (ER) alpha and beta and progestin receptor (PR) status were analyzed from paraffin-embedded tissue by immunohistochemistry and ER mRNA was measured in fresh tissue by reverse transcription polymerase chain reaction (RT-PCR).

RESULTS

Ten of the twenty-two patients with low-grade endometrial stromal sarcomas developed recurrent disease. Four of five patients (80%) who received estrogen replacement therapy (ERT) recurred. Four of eight patients (50%) with retained ovaries recurred. Eight of the ten specimens available for analysis were positive for ERalpha, none were positive for ERbeta, and 9 of 10 were positive for PR. Four of thirteen patients who received progestins as adjuvant therapy recurred, compared with 6 of 9 patients who did not receive progestins (31% vs 67%). Eight recurrences were treated with progestin therapy and 7 (88%) of them had either stable disease (3/8, 38%) or complete response (4/8, 50%).

CONCLUSIONS

Our results suggest that ERT may be detrimental in patients with low-grade endometrial stromal sarcoma. Retention of normally functioning ovaries, on the other hand, may not significantly affect the recurrence rate following hysterectomy alone in Stage I patients. The lack of ERbeta expression in endometrial stromal sarcomas compared with normal endometrial stromal cells suggests that loss of ERbeta may be a marker for malignancy. Progestin therapy should be routinely considered for adjuvant therapy and for the treatment of recurrent endometrial stromal sarcomas.

Mesodermal (müllerian) adenosarcoma of the ovary: a clinicopathologic analysis of 40 cases and a review of the literature

Forty cases of mesodermal adenosarcoma of the ovary occurred in women 30-84 years of age (mean 54 years). Abdominal discomfort and distension were the usual complaints. All the patients were treated with an oophorectomy, which was accompanied by a hysterectomy in 85%, a contralateral oophorectomy in 65%, and nonsurgical therapy in 28%. Tumor rupture occurred at or before the operation in 67% of the cases. Twenty-six tumors were stage I, 11 stage II, and 3 stage III. The tumors were unilateral in 97.5% of the cases and 5.5-50 cm (mean 14 cm) in greatest dimension; most of the tumors were predominantly solid but contained numerous small cysts. Microscopic examination revealed sarcomatous overgrowth in 12 tumors. Sex cord-like elements were present in six tumors (including four with sarcomatous overgrowth) and heterologous elements in five (including two with sarcomatous overgrowth). The highest mitotic index of the sarcomatous component was 1-25 (mean 6) mitotic figures per 10 high power fields. Only 6 of 26 women (23%) who were followed postoperatively for > or=5 years were free of tumor. In the other 20 patients recurrent tumor appeared at 0.4-6.6 years (mean 2.6 years) after operation as pure sarcoma (low grade or high grade) or adenosarcoma (with or without sarcomatous overgrowth). Eight women had additional recurrences, and four women had blood-borne metastases. One patient was alive at 15.7 years after the excision of pulmonary metastases. The 5-, 10-, and 15-year survival rates were 64%, 46%, and 30%, respectively. Age <53 years, tumor rupture, a high grade, and the presence of high-grade sarcomatous overgrowth appeared to be associated with recurrence or extraovarian spread. Ovarian adenosarcomas have a worse prognosis than uterine adenosarcomas, presumably because of the greater ease of peritoneal spread. Many of the tumors caused problems in differential diagnosis.

Endometrial stromal sarcoma: objective response to letrozole

BACKGROUND

Low-grade endometrial stromal sarcoma is generally an indolent tumor rich in estrogen and progesterone receptors. Objective responses to hormonal therapy, most commonly with megestrol acetate, have been reported.

CASE

The patient is a 51-year-old woman who presented with low-grade endometrial stromal sarcoma confined to the uterus in 1991 and was treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy. Approximately 5 years later, the patient had recurrent pelvic disease treated with radiation therapy, followed by an attempt at resection. She was treated with megestrol acetate during the period she received radiation therapy with poor tolerance. Tamoxifen was then given with no tumor response. Megestrol acetate was restarted with progression of disease in the pelvis and abdomen. Letrozole was then given at a daily dose of 2.5 mg with partial response for a duration of 9 months.

CONCLUSION

Letrozole at a daily dose of 2.5 mg may be effective in low-grade endometrial stromal sarcoma with positive estrogen receptors.

Thrombectomy of the inferior vena cava from recurrent low-grade endometrial stromal sarcoma: case report and review of the literature

We report a rare case in which a patient successfully underwent surgical removal from the inferior vena cava of a neoplastic thrombus induced by a recurrent low-grade endometrial stromal sarcoma. The patient was admitted with severe acute renal failure and a large edema on the right lower extremity. One year previously she had undergone hysterectomy and adnexectomy due to an endometrial stromal sarcoma with involvement of the tuba. Because of complete thrombosis of the right internal and common iliac veins and the inferior vena cava, she underwent thrombectomy of the inferior vena cava. The postoperative course was complicated by hydruric renal failure induced by a acute tubular necrosis. At 6-month follow-up, the patient was asymptomatic with normal renal function. The ileocaval axis was patent on magnetic resonance imaging. Only 5 cases of intracaval extension of endometrial stromal sarcoma have been reported. Surgical treatment is viable due to excellent prognosis of the low-grade endometrial stromal sarcoma (80-100% 5-year survival) and likely fatal heart failure in untreated cases.

Expression of oestrogen and progesterone receptors in low-grade endometrial stromal sarcomas

We analysed oestrogen receptor (ER) and progesterone receptor (PR) expression in a retrospective series of 21 low-grade endometrial stromal sarcomas (LGSSs). Archival formalin-fixed and paraffin-embedded material was analysed by immunohistochemistry. ER and PR were measured with monoclonal antibodies and the peroxidase-antiperoxidase method and a score was calculated as for breast carcinoma based on both the percentage of positive tumour cell nuclei and the staining intensity. ER were seen in 15 (71%) and PR in 20 (95%) of tumours respectively. ER expression was scored as high in three (14%), moderate in four (19%), and low in eight (38%) tumours. Six (29%) tumours did not stain for ER and all of these were positive for PR. PR expression was scored as high in eight (38%), moderate in ten (47%) and weak in two (10%) LGSSs. Only one (5%) LGSS did not stain for PR (this tumour was positive for ER). ER and PR expression in LGSS is heterogeneous. This may have implications for hormone therapy in the management of these tumours. These results suggest that ER and PR should be routinely quantified in LGSSs by immunohistochemical methods.

Endometrial low-grade stromal sarcoma with ovarian sex cord-like differentiation: report of two cases with an immunohistochemical and flow cytometric study

Two cases of endometrial low-grade stromal sarcoma with ovarian sex cord-like differentiation occurring in a 39-year-old woman and a 42-year-old woman are presented. Both tumors, which were intramyometrial and measured 7.5 cm and 7.0 cm in greatest diameter, respectively, showed a multinodular, ill-demarcated, and yellowish white cut-surface. Histologically, most parts of the tumors were composed of trabecular, cord-like, or plexiform arrangements that were reminiscent of the growth pattern seen in ovarian sex cord tumors. Features of conventional endometrial low-grade stromal sarcoma were only focally observed. The tumors showed infiltrative margins and lymphatic invasion. The tumor cells were positive for vimentin, desmin, alpha-smooth muscle actin, and muscle actin (HHF35). The tumors were also positive for both estrogen and progesterone receptors. Both tumors were DNA diploid as determined by flow cytometry. One patient had recurrences, including osteolytic lesions in the pelvic bones, but had no evidence of recurrence or metastasis 11 months after the last surgery. The other patient had no evidence of tumor in a limited follow-up. Familiarity with the neoplasm and other uterine mesenchymal tumors with ovarian sex cord-like differentiation by gynecologists and pathologists is essential in avoiding misdiagnosis because adjuvant hormonal therapy may be effective in treating low-grade stromal sarcomas.

High-grade pelvic sarcoma after radiation therapy for low-grade endometrial stromal sarcoma

A high-grade heterologous pelvic sarcoma arose in a 60-year-old woman 15 years after she received whole-pelvic radiation for a low-grade endometrial stromal sarcoma. This complication must be considered in determining therapy for low-grade endometrial sarcomas, which are usually inherently of indolent biological behavior.

Endolymphatic stromal myosis (endometrial low-grade stromal sarcoma) presenting with hematuria: a diagnostic challenge

In this case of a 41-year-old white woman who presented with hematuria, the diagnosis of metastatic endolymphatic stromal myosis (ESM) in the urinary bladder was reached on the basis of the histologic pattern and with the aid of intermediate filament typing. In the hysterectomy specimen the tumor foci of ESM were of minute size. To the best of our knowledge, this is the first report of such an unusual clinical presentation of this lesion.

Low-grade endometrial stromal sarcoma recurring over three decades

Endometrial stromal sarcoma (ESS) is an uncommon uterine malignancy with a variety of histologic characteristics and clinical courses. We describe a patient who recently underwent her third resection of a locally recurring low-grade ESS 29 years after original diagnosis. Tissue from her recurrent tumor contained high levels of estrogen and progesterone receptors and had a diploid DNA content. In addition to multiple resections, she has previously been treated with vincristine chemotherapy and is now receiving megestrol acetate therapy. Mitotic activity is the most important prognostic feature distinguishing high- and low-grade ESS. The mainstay of therapy for both high- and low-grade tumors is surgical excision. A beneficial adjuvant role for cytotoxic chemotherapy or radiotherapy is yet to be clearly established for low-grade ESS; however, recent reports suggest that progestational agents may produce significant responses in recurrent or persistent disease patients whose tumors produce steroid hormone receptors. Indolent tumors may require years of close observation and multiple treatment approaches to maintain a patient in a functional capacity.

Endolymphatic stromal myosis: surgical and hormonal therapy for extensive venous recurrence

The surgical management for recurrent endolymphatic stromal myosis metastatic to the inferior vena cava is described. Positive estrogen and progesterone receptors in the resected tumor are reported. A plan of therapy is suggested for patients with endolymphatic stromal myosis, including a rationale for adjuvant progestin therapy.