The influence of primary site on outcomes in leiomyosarcoma: a review of clinicopathologic differences between uterine and extrauterine disease. Am J Clin Oncol. 2013;36:368-374. [PMID: 22772425 DOI: 10.1097/coc.0b013e318248dbf4]

Primary Tumor Resection in Leiomyosarcoma Patients With Synchronous Isolated Lung Metastases: A National Cancer Database Study

INTRODUCTION

Up to half of patients with leiomyosarcoma (LMS) present with distant metastases, most commonly in the lungs. Despite guidelines around managing metachronous oligometastatic disease, limited evidence exists for synchronous isolated lung metastases (SILMs). Our histology-specific study describes management patterns and outcomes for patients with LMS and SILM across disease sites.

METHODS

We used the National Cancer Database to analyze patients with LMS of the retroperitoneum, extremity, trunk/chest/abdominal wall, and pelvis with SILM. Patients with extra-pulmonary metastases were excluded. We identified factors associated with primary tumor resection and receipt of metastasectomy. Outcomes included median, 1-year, and 5-year overall survival (OS) across treatment approaches using log-rank tests, Kaplan-Meier curves, and Cox proportional hazard models.

RESULTS

We identified 629 LMS patients with SILM from 2004 to 2017. Patients were more likely to have resection of their primary tumor or lung metastases if treated at an academic center compared to a community cancer center. Five year OS for patients undergoing both primary tumor resection and metastasectomy was 20.9% versus 9.2% for primary tumor resection alone, and 2.6% for nonsurgical patients. Median OS for all-comers was 15.5 mo. Community treatment site, comorbidity score, and larger primary tumors were associated with worse survival. Chemotherapy, primary resection, and curative intent surgery predicted improved survival on multivariate Cox regression.

CONCLUSIONS

An aggressive surgical approach to primary LMS with SILM was undertaken for select patients in our population and found to be associated with improved OS. This approach should be considered for suitable patients at high-volume centers.

Prognostic value of mitotic count in leiomyosarcoma: A comprehensive monocentric retrospective study

BACKGROUND

Leiomyosarcomas (LMSs) include heterogeneous entities with different clinical courses not entirely predicted by known prognostic factors. In particular, the value of mitotic count as independent prognostic factor in LMS has been poorly investigated.

METHODS

We retrospectively analyzed all patients with a diagnosis of LMS who accessed to our Institution from June 1999 to May 2022 for which mitotic count was numerically expressed within the pathology report. Univariate and multivariate analyses were conducted to explore the prognostic value of mitotic count along with other clinical and histological variables.

RESULTS

We identified 121 eligible patients, with a median follow-up of 91.03 months (range 0.62-275.2 months). Median progression-free survival (mPFS) was 16.7 months, and median overall survival (mOS) was 105.6 months. In univariate analysis, mitotic count showed a significant impact on PFS and OS, with an hazard ratio per mitotic unit of 1.03 (1.01-1.04, p < 0.001) and 1.03 (1.01-1.04, p = 0.007), respectively. Similar results were found for locally advanced and metastatic patients, separately. Other significant prognostic factors for PFS were stage at diagnosis, performance status, tumor size and Ki-67, while differentiation, necrosis, grade, stage at diagnosis, tumor size, performance status and age at diagnosis were identified for OS. In multivariate analysis, the only significant factors were mitotic count and the presence of metastases at diagnosis for PFS, whereas the same two factors plus age at diagnosis were identified for OS.

CONCLUSION

Mitotic count represented the most important histological prognostic factor for OS and PFS in localized and metastatic LMS.

Pseudoprogression in patients with uterine leiomyosarcoma treated with first-line single-agent doxorubicin

AIM

To evaluate the incidence of pseudoprogression in patients with metastatic or inoperable uterine leiomyosarcoma (LMS) treated with first-line single-agent doxorubicin.

METHODS

The Royal Marsden NHS Foundation Trust Sarcoma Unit database was searched to identify all patients with metastatic or inoperable LMS treated with first-line doxorubicin from January 2006 to January 2022. Patients with available computed tomography scans performed at baseline and during doxorubicin therapy were included. Response evaluation criteria in solid tumours v1.1 and Choi criteria were applied. Any increase in the sum of the longest diameter that decreased on the subsequent scan was labelled as pseudoprogression.

RESULTS

The total number of patients evaluated was 52. In total, 19% (n = 10) of patients treated with doxorubicin showed pseudoprogression. However, pseudoprogression at the time of the second scan was not associated with time to doxorubicin failure. Choi criteria identified 30% (n = 3) of pseudoprogressors as responding.

CONCLUSION

Despite the use of doxorubicin as first-line therapy for soft-tissue sarcomas for over 40 years, pseudoprogression has not been described. This retrospective study shows that pseudoprogression occurs in 19% of patients with metastatic/inoperable uterine LMS treated with first-line doxorubicin. Choi criteria were not consistently able to differentiate pseudoprogression from true progression. It is imperative that oncologists and radiologists are aware of this as symptomatically stable/improving patients may benefit from continued treatment despite initial radiological growth in tumour size.

Metastasectomy in Leiomyosarcoma: A Systematic Review and Pooled Survival Analysis

Simple Summary

Leiomyosarcoma (LMS) is an aggressive soft tissue sarcoma with a poor prognosis. Approximately 40% of patients will develop metastatic disease. The optimal treatment for patients with metastatic LMS is not well established, and there are no randomized controlled trials regarding metastasectomy. This systematic review and pooled survival analysis aims to assess the survival in patients undergoing a metastasectomy for LMS and compare the outcomes based on the site of metastasectomy. We identified that patients with LMS metastases in the lungs, liver, spine, and brain can undergo metastasectomy with acceptable survival. Two studies have compared survival outcomes between patients treated and not treated with metastasectomy; despite their low quality, these studies support a survival benefit associated with metastasectomy.

Abstract

This study assesses the survival in patients undergoing metastasectomy for leiomyosarcoma (LMS) and compares the outcomes by the site of metastasectomy. We conducted a systematic review and pooled survival analysis of patients undergoing metastasectomy for LMS. Survival was compared between sites of metastasectomy. We identified 23 studies including 573 patients undergoing metastasectomy for LMS. The pooled median survival was 59.6 months (95% CI 33.3 to 66.0). The pooled median survival was longest for lung metastasectomy (72.8 months 95% CI 63.0 to 82.5), followed by liver (34.8 months 95% CI 22.3 to 47.2), spine (14.1 months 95% CI 8.6 to 19.7), and brain (14 months 95% CI 6.7 to 21.3). Two studies compared the survival outcomes between patients who did, versus who did not undergo metastasectomy; both demonstrated a significantly improved survival with metastasectomy. We conclude that surgery is currently being utilized for LMS metastases to the lung, liver, spine, and brain with acceptable survival. Although low quality, comparative studies support a survival benefit with metastasectomy. In the absence of randomized studies, it is impossible to determine whether the survival benefit associated with metastasectomy is due to careful patient selection rather than a surgical advantage; limited data were included about patient selection.

Bone Metastases in Patients with Leiomyosarcoma: A Retrospective Analysis of Survival and Surgical Management

Background

Leiomyosarcomas (LMS) are malignancies with smooth muscle differentiation. Metastasis to the bone is not uncommon. The literature on the clinical course and management of such metastases is limited. Our study describes the clinical course of LMS to the bone, including survival rates, prognostic factors, and surgical management.

Methods

We retrospectively reviewed 396 LMS patients presenting at an academic center between 1995 and 2020. We included LMS patients diagnosed with bone metastases and excluded patients with primary LMS of bone. We evaluated survival time with the Kaplan-Meier survival method and used Cox's proportional hazards regression analysis to determine factors associated with survival.

Results

Forty-five patients with LMS (11%) had bone metastases. The most common LMS subtypes with bone metastases were uterine (N = 18, 40%) and retroperitoneal (N = 15, 33%). Bone metastasis was not an independent predictor of mortality by Cox regression analysis (HR 1.0, 95% CI: 0.67-1.5). Patients more frequently metastasized to the axial (N = 29, 64%) than to the appendicular (N = 5, 11%) skeleton. Bone was the first site of metastasis in 13 patients (29%). Patients presented with bone metastases at a median of 32.7 months (IQR: 5.2, 62.6) after initial LMS diagnosis. Twelve patients (27%) sustained a pathologic fracture. Twenty (44%) required surgical management, with 30 surgeries total. Three (15%) had a failure of reconstructive constructs. The median overall survival time was 69.7 months (IQR: 43.2, 124.5). There were no associations between the LMS subtype and survival. Pathologic fracture was an independent predictor of mortality by Cox regression analysis (HR 5.4, 95% CI: 1.8-16).

Conclusion

The majority of patients with metastatic LMS to bone survive greater than 5 years and frequently require surgical intervention. Extended survival in this patient population should inform fixation and implant choice. No anatomic subtype was associated with risk for bone metastases. Pathologic fracture was associated with worse survival.

Development, validation, and visualization of a web-based nomogram for predicting the incidence of leiomyosarcoma patients with distant metastasis

BACKGROUND

Leiomyosarcoma (LMS) is one of the most common soft tissue sarcomas. LMS is prone to distant metastasis (DM), and patients with DM have a poor prognosis.

AIM

In this study, we investigated the risk factors of DM in LMS patients and the prognostic factors of LMS patients with DM.

METHODS AND RESULTS

LMS patients diagnosed between 2010 and 2016 were extracted from the Surveillance, Epidemiology, and End Result (SEER) database. Patients were randomly divided into the training set and validation set. Univariate and multivariate logistic regression analyses were performed, and a nomogram was established. The area under the curve (AUC), calibration curve, and decision curve analysis (DCA) were used to evaluate the nomogram. Based on the nomogram, a web-based nomogram is established. The univariate and multivariate Cox regression analyses were used to assess the prognostic risk factors of LMS patients with DM. Eventually, 2184 patients diagnosed with LMS were enrolled, randomly divided into the training set (n = 1532, 70.14%) and validation set (n = 652, 29.86%). Race, primary site, grade, T stage, and tumor size were correlated with DM incidence in LMS patients. The AUC of the nomogram is 0.715 in training and 0.713 in the validation set. The calibration curve and DCA results showed that the nomogram performed well in predicting the DM risk. A web-based nomogram was established to predict DM's risk in LMS patients (https://wenn23.shinyapps.io/riskoflmsdm/). Epithelioid LMS, in uterus, older age, giant tumor, multiple organ metastasis, without surgery, and chemotherapy had a poor prognosis.

CONCLUSIONS

The established web-based nomogram (https://wenn23.shinyapps.io/riskoflmsdm/) is an accurate and personalized tool to predict the risks of LMS developing DM. Advanced age, larger tumor, multiple organ metastasis, epithelioid type, uterine LMS, no surgery, and no chemotherapy were associated with poor prognosis in LMS patients with DM.

Leiomyosarcoma in the extremities and trunk wall: systematic review and meta-analysis of the oncological outcomes

Background

Leiomyosarcomas are aggressive malignancies which can occur on the trunk and extremities whose pathogenesis is poorly understood. We aim to quantify the prognostic impact of various clinical and pathological markers on survival and recurrence of leiomyosarcomas.

Methods

We conducted a systematic review as per PRISMA protocol. Survival, local recurrence, and metastasis were the outcome measures. Data were extracted from the studies for the outcome variables; the resultant odds ratios (OR) and 95% confidence interval (CI) were used for the synthesis of a forest plot.

Results

Our search revealed thirteen studies comprising 1380 patients. Seven of these 13 publications were since 2012. Our analysis showed that tumor size larger than 5 cm adversely affected the outcome with an OR 3.39 (2.26–5.10, p < 0.01). Other factors which reduced the overall survival were positive margins of excision OR 2.12 (1.36–3.32, p < 0.01). A reduced risk of metastasis has strongly associated the use of radiotherapy with OR 10.84 (4.41–26.61, p < 0.01). Only a few studies analyzed the impact of factors on local recurrence.

Conclusions

Size larger than 5 cm and positive margins of excision are associated with poor overall survival. In comparison, the use of adjuvant radiotherapy was associated with a lower metastatic rate. There is a need for methodically high-quality studies with more uniform study design and reporting to evaluate the impact of various risk factors on local recurrence and metastases.

Level of evidence

Level 1 Prognostic

Interrogating the Genomic Landscape of Uterine Leiomyosarcoma: A Potential for Patient Benefit

Uterine leiomyosarcoma (uLMS) is a rare and aggressive gynaecological malignancy. Surgical removal and chemotherapy are commonly used to treat uLMS, but recurrence rates are high. Over the last few decades, clarification of the genomic landscape of uLMS has revealed a number of recurring mutations, including TP53, RB1, ATRX, PTEN, and MED12. Such genomic aberrations are difficult to target therapeutically or are actively targeted in other malignancies, and their potential as targets for the treatment of uLMS remains largely unexplored. Recent identification of deficiencies in homologous recombination in a minority of these tumours, however, has provided a rationale for investigation of PARP inhibitors in this sub-set. Here, we review these mutations and the evidence for therapeutic avenues that may be applied in uLMS. We also provide a comprehensive background on diagnosis and current therapeutic strategies as well as reviewing preclinical models of uLMS, which may be employed not only in testing emerging therapies but also in understanding this challenging and deadly disease.

Gemcitabine Maintenance Therapy in Patients With Metastasized Soft Tissue Sarcomas

Background

Metastasized soft-tissue sarcomas still pose a significant therapeutic challenge given the limited efficacy of currently available multimodal treatment strategies. Recent progress in molecular characterization of sarcoma subtypes has enabled successful personalized therapy approaches in a minority of selected patients with targetable mutations. However, in the majority of patients with refractory soft tissue sarcomas, long-term survival remains poor.

Methods

We report on three adult patients with various soft tissue sarcomas subjected to Gemcitabine maintenance therapy. Tumor entities included leiomyosarcoma of the pancreas (patient 1), undifferentiated pleomorphic sarcoma of the right femur (patient 2), and peri-aortic leiomyosarcoma (patient 3). Metastatic sites encompassed liver, lung, and bones. All patients received Gemcitabine maintenance therapy until disease progression following prior salvage chemotherapy with Docetaxel and Gemcitabine. Patients were treated outside of clinical trials. Response assessment was based on radiological imaging.

Results

In response to salvage chemotherapy with Docetaxel and Gemcitabine, one patient exhibited a partial remission, and two patients showed stable disease. Patient 1 exhibited stable disease for 6 months during Gemcitabine maintenance therapy before suffering rapid progression of hepatic metastases. Patient 2 underwent 21 months of Gemcitabine maintenance therapy, which was discontinued after progressive pulmonary metastases were detected. Patient 3 is still being treated with Gemcitabine maintenance therapy. Remarkably, owing to significant chemotherapy-associated hematotoxicity, the dose of Gemcitabine dose was reduced by two-thirds. Nevertheless, stable disease with constant pulmonary metastases has been maintained in this patient for 14 months.

Conclusions

Gemcitabine maintenance therapy following prior Docetaxel and Gemcitabine chemotherapy is manageable and reveals potential benefits for patients with aggressive metastasized soft tissue sarcomas. Prospective trials evaluating Gemcitabine maintenance therapy are encouraged.

Comparison of clinical features and outcomes of patients with leiomyosarcoma of bone and soft tissue: a population-based cohort study

BACKGROUND

Leiomyosarcoma commonly occurs in soft tissue but rarely in the bone. Whether leiomyosarcoma of bone and soft tissue have similar clinical characteristics and outcomes remains unknown.

METHODS

This retrospective analysis was based on data from the Bone and Soft Tissue Tumor Registry in Japan. Patients with leiomyosarcoma of bone and soft tissue were enrolled. Overall survival and distant metastasis-free survival were estimated using the Kaplan-Meier method, and the Cox regression model was used to identify the prognostic factors.

RESULTS

A total of 888 patients (60 leiomyosarcoma of bone and 828 leiomyosarcoma of soft tissue) were included in the study. Clinical characteristics were similar between the two groups, except for younger age in leiomyosarcoma of bone than in leiomyosarcoma of soft tissue (median 56 years vs. 66 years, P < 0.0001). To evaluate the prognostic factors and efficacy of adjuvant chemotherapy, data of localized and locally curative cases were extracted (total 572: 33 leiomyosarcoma of bone and 539 leiomyosarcoma of soft tissue). The 5-year overall survival rates of leiomyosarcoma of bone and soft tissue patients were similar (63.8% vs. 75.2%, P = 0.43); the 5-year distant metastasis-free survival tended to be worse in leiomyosarcoma of bone than in leiomyosarcoma of soft tissue (37.4% vs. 57.9%, P = 0.28). Larger tumor size (≥5 cm) and older age (≥65 years) correlated with poor overall survival in leiomyosarcoma of soft tissue patients. Adjuvant chemotherapy tended to prolong the overall survival of both leiomyosarcoma of bone (P = 0.11) and leiomyosarcoma of soft tissue patients with tumor size >10 cm (P = 0.06).

CONCLUSIONS

The clinical characteristics and outcomes of leiomyosarcoma of bone and soft tissue patients were similar. In localized cases, adjuvant chemotherapy may improve the survival of leiomyosarcoma of bone and soft tissue patients with large-size tumor.

Epigenetic signatures differentiate uterine and soft tissue leiomyosarcoma

Leiomyosarcomas (LMS) are diverse, rare, and aggressive mesenchymal soft tissue sarcomas. Epigenetic alterations influence multiple aspects of cancer, however epigenetic profiling of LMS has been limited. The goal of this study was to delineate the molecular landscape of LMS for subtype-specific differences (uterine LMS (ULMS) vs soft tissue LMS (STLMS)) based on integrated analysis of DNA methylation and gene expression to identify potential targets for therapeutic intervention and diagnosis. We identified differentially methylated and differentially expressed genes associated with ULMS and STLMS using DNA methylation and RNA-seq data from primary tumors. Two main clusters were identified through unsupervised hierarchical clustering: ULMS-enriched cluster and STLMS-enriched cluster. The integrated analysis demonstrated 34 genes associated with hypermethylation of the promoter CpG islands and downregulation of gene expression in ULMS or STLMS. In summary, these results indicate that differential DNA methylation and gene expression patterns are associated with ULMS and STLMS. Further studies are needed to delineate the contribution of epigenetic regulation to LMS subtype-specific gene expression and determine the roles of the differentially methylated and differentially expressed genes as potential therapeutic targets or biomarkers.

Leiomyosarcoma of the urinary bladder: A SEER database study and comparison to leiomyosarcomas of the uterus and extremities/trunk

No well-established staging system exists for bladder leiomyosarcoma (LMS), and the current staging system does not include tumor size, a thoroughly validated prognostic parameter for sarcomas. Uterine and extremity/trunk LMS are more common than those in the bladder and have well-established staging systems incorporating tumor size. We aim to improve the understanding of LMS of the urinary bladder by assessing cancer-specific survival (CSS) and comparing LMS at this unusual anatomic site to those arising at other sites using the Surveillance, Epidemiology, and End Results (SEER) database. The SEER database (1973-2013) was queried for bladder, uterus, and trunk/extremity LMS. Multivariable Cox proportional hazard regression was performed to identify predictors of CSS for each anatomic location and used to compare outcomes at different sites. We identified 165 bladder, 4987 uterus, and 2536 extremity/trunk LMS cases. Five-year CSS was 52% for uterus, 73% for bladder, and 82% for extremity/trunk LMS. For LMS at all sites, uterine location (HR = 2.14, P < 0.001) and increasing tumor size (HR = 1.05, P < 0.001) were significant predictors of worse CSS on multivariate analysis. For bladder LMS, increasing tumor size (HR = 1.18, P = 0.003) was an independent prognostic factor and the conventional staging cut-off threshold of 5 cm for sarcomas outside the head/neck showed statistical significance in stratifying patient risk of cancer-related death. Bladder LMS appears to have clinical behavior intermediate between those of the extremities/trunk and uterus. We suggest that the conventional sarcoma staging protocols based on tumor size be applied to LMS of the urinary bladder.

Leiomyosarcoma: a rare presentation as multifocal lesion

Leiomyosarcoma is a rare type of connective tissue cancer, accounting for 5–10% of all soft tissue sarcomas. We present a case of leiomyosarcoma as unusual multifocal presentation. Retroperitoneal, mediastinal, pulmonary, uterine and bony regions were all involved at the time of presentation. The liver was normal without detected lesions.

Outcomes of patients with pelvic leiomyosarcoma treated by surgery and relevant auxiliary diagnosis

BACKGROUND

Leiomyosarcoma is a subtype of soft tissue sarcoma with adverse outcomes. Leiomyosarcoma accounts for nearly 70% of all uterine sarcomas and is responsible for a considerable proportion of deaths because of uterine cancer. Clinical characteristics and relevant diagnosis of pelvic leiomyosarcoma should be further explored.

AIM

To identify the outcome and relevant perioperative evaluation of patients with pelvic leiomyosarcoma.

METHODS

The Kaplan-Meier method was used to determine progression-free survival and overall survival rates. Factors predictive of outcomes were identified using univariate and multivariate Cox proportional hazards models.

RESULTS

Fifty-one patients with pelvic leiomyosarcoma were enrolled and divided into two groups including uterine leiomyosarcoma and non-uterine leiomyosarcoma. Overall, 28.6% and 45.5% of uterine leiomyosarcoma and non-uterine leiomyosarcoma patients, respectively, had elevated carbohydrate antigen 125 levels, whereas 45.7% and 68.8%, respectively, underwent ultrasonography. Although 68.8% of uterine leiomyosarcoma patients were initially diagnosed with hysteromyoma, 72.7% of non-uterine leiomyosarcoma patients had pelvic and abdominal masses. Moreover, 93.3% of the recurrent lesions were detected using ultrasonography. Patients with International Federation of Gynaecology and Obstetrics (FIGO) stages III–IV disease had poorer progression-free survival values than those with FIGO stages I–II (P = 0.027) disease. FIGO stage was significantly associated with poor progression-free survival in the univariate (hazard ratio = 2.64, P = 0.03) and multivariate (hazard ratio = 2.49, P = 0.048) analyses.

CONCLUSION

Serum tumour biomarkers cannot be used for pelvic leiomyosarcoma diagnosis. FIGO stage is critical to predict the outcome of uterine leiomyosarcoma. Ultrasonography is more reliable for postoperative follow-up than preoperative diagnosis.

Medicolegal Issues in Power Morcellation: Cautionary Rules for Gynecologists to Avoid Unfavorable Outcomes

Power morcellation in laparoscopic surgery enables specialists to carry out minimally invasive procedures such as hysterectomies and myomectomies by cutting specimens into smaller pieces using a rotating blade and removing pieces through a laparoscope. Unexpected uterine sarcoma treated by surgery involving tumor disruption could be associated with poor prognosis. The current study aims to shed light on power morcellation from a medicolegal perspective: the procedure has resulted in adverse outcomes and litigation, and compensation for plaintiffs, as published in various journals cited in PubMed and MEDLINE, Cochrane Library, EMBASE, and GyneWeb. Considering the claims after the US Food and Drug Administration warnings on morcellation, the current study broadens the scope of research by including search engines, legal databases, and court filings (DeJure, Lexis Nexis, Justia, superior court of New Jersey, and US district court of Minnesota) between 1995 and 2019. Legal records show that courts determine professional responsibility regarding complications, making it essential to document adherence to safety protocols and specific guidelines, when available. Sound medical practices and clearly stated institute best practices result in better patient outcomes and are important when unfavorable clinical outcomes occur; adverse legal decisions can be avoided if there are grounds to prove professional conformity with specific guidelines and the unpredictability of an event.

Leiomyosarcoma: Prognostic outline of a rare head and neck malignancy

Soft tissue sarcomas (STS) are mesenchymal malignant neoplasms with a broad spectrum of biologic behaviour. Most STS show predilection for extremities with rarity in head and neck. Leiomyosarcoma (LMS) is an extremely rare STS in head and neck due to the paucity of smooth muscles in this anatomical region. Owing to its rarity, diagnosis of LMS is often delayed or is often misdiagnosed. Our study aimed to evaluate clinico-demographic factors determining clinical course of primary head-neck LMS. Further, we also assessed cases of secondary head-neck LMS and LMS due to other causes to compare their clinical outcome with primary head-neck LMS. In primary LMS cases, intraoral LMS showed slightly better prognosis than extraoral LMS. Survival analysis revealed that prognosis of primary LMS was significantly better than secondary LMS. No significant difference in survival was seen between primary LMS and LMS due to other causes. These observations indicate that site of origin appears to determine the clinical behaviour of LMS. Results showed that size, recurrence and metastasis are important prognostic variables. Though large tumor size was associated with poor prognosis, tumor aggressiveness may not be directly proportional to its size. Surgical management with or without adjuvant therapy was associated with favourable outcome. As several factors are associated with prognostic outcome of head-neck LMS, multimodality therapy approach after careful analysis of various prognostic variables in each case on an individual basis is essential.

Analysis of the CDK4/6 Cell Cycle Pathway in Leiomyosarcomas as a Potential Target for Inhibition by Palbociclib

Leiomyosarcoma (LMS) is characterized by high genomic complexity, and to date, no specific targeted therapy is available. In a genome-wide approach, we profiled genomic aberrations in a small cohort of eight primary tumours, two relapses, and eight metastases across nine different patients. We identified CDK4 amplification as a recurrent alteration in 5 out of 18 samples (27.8%). It has been previously shown that the LMS cell line SK-LMS-1 has a defect in the p16 pathway and that this cell line can be inhibited by the CDK4 and CDK6 inhibitor palbociclib. For SK-LMS-1 we confirm and for SK-UT-1 we show that both LMS cell lines express CDK4 and that, in addition, strong CDK6 expression is seen in SK-LMS-1, whereas Rb was expressed in SK-LMS-1 but not in SK-UT-1. We confirm that inhibition of SK-LMS-1 with palbociclib led to a strong decrease in protein levels of Phospho-Rb (Ser780), a decreased cell proliferation, and G₀/G₁-phase arrest with decreased S/G₂ fractions. SK-UT-1 did not respond to palbociclib inhibition. To compare these in vitro findings with patient tissue samples, a p16, CDK4, CDK6, and p-Rb immunohistochemical staining assay of a large LMS cohort (n=99 patients with 159 samples) was performed assigning a potential responder phenotype to each patient, which we identified in 29 out of 99 (29.3%) patients. Taken together, these data show that CDK4/6 inhibitors may offer a new option for targeted therapy in a subset of LMS patients.

Retroperitoneal Leiomyosarcoma From the Radiologic Pathology Archives

Leiomyosarcoma is a malignant neoplasm that shows smooth muscle differentiation. It is the second most common sarcoma to affect the retroperitoneum. Retroperitoneal leiomyosarcomas may grow to large sizes before detection and may be an incidental finding at imaging. When symptomatic, retroperitoneal leiomyosarcoma may cause compressive symptoms, including pain. Retroperitoneal leiomyosarcoma most commonly manifests as a large soft-tissue mass, with areas of necrosis. The most frequent pattern of growth is an entirely extravascular mass. Less commonly, leiomyosarcoma may demonstrate both extravascular and intravascular components. Rarely, retroperitoneal leiomyosarcomas are completely intravascular, typically arising from the inferior vena cava. Given its variable imaging features, a large variety of neoplastic and nonneoplastic conditions are included in the differential diagnosis of retroperitoneal leiomyosarcoma. In this review, the authors discuss retroperitoneal leiomyosarcoma, with emphasis on the pathologic basis of disease, and illustrate the multimodality imaging appearances of retroperitoneal leiomyosarcoma using cases from the Radiologic Pathology Archives of the American Institute for Radiologic Pathology. The authors review important differential considerations of retroperitoneal leiomyosarcoma, focusing on the extravascular pattern of growth, and emphasize clinical and imaging features that help radiologists differentiate leiomyosarcoma from the most frequent mimics. The information presented in this review will aid radiologists in fulfilling their key roles in the diagnosis, operative planning, and follow-up of patients with retroperitoneal leiomyosarcoma.

Treatment with epigenetic agents profoundly inhibits tumor growth in leiomyosarcoma

Leiomyosarcomas are rare mesenchymal neoplasms characterized by a smooth muscle differentiation pattern. Due to the extremely poor prognosis in patients, the development of novel chemotherapeutic regimens remains critically important. In this study, multiple leiomyosarcoma cell lines, SK-UT1, SK-LMS1, and MES-SA were treated with varying doses of the DNA Methyltransferase Inhibitors (DNMTi) 5-azacitidine (Aza), 5-aza-2-deoxycytidine (DAC), and guadecitabine (SGI-110). The effect of these epigenetic modulators was measured using both in-vitro and in-vivo models.

Of the three epigenetic modulators, Guadecitabine was the most effective at decreasing cell survival in LMS cell lines. SK-UT1 was found to be the more sensitive to all three epigenetic modulators, while SK-LMS1 and MES-SA were more resistant. The contrast in sensitivity seen was also represented by the increase in apoptosis in Aza and guadecitabine. In parallel with Aza, guadecitabine was observed to also arrest the cell cycle.

Treatment with guadecitabine led to a decrease in growth across the spectrum of sensitivity in LMS cell lines, both in a delayed in vitro and in vivo model; in parallel experiments, apoptotic pathways were activated in sensitive and less sensitive lines. Additional studies are required to explore potential therapeutic applications and mechanisms for leiomyosarcoma treatment.

Pulmonary metastasectomy in uterine malignancy: outcomes and prognostic factors

Metastatic uterine cancer is a form of systemic disease. As for other solid tumours, it is advocated by some authors that in selected patients, lung metastasectomy may play a role in long-term disease control. The practice of lung metastasectomy is however open to criticism as there is lack of convincing evidence, and over-encouraging outcomes may be attributed to intrinsic selection bias. The case of metastatic uterine tumours is reviewed in the light of the available literature, in order to identify common patterns and prognostic factors that may influence and determine an individualised and informed patient decision.

Photochemical internalization (PCI) of bleomycin is equally effective in two dissimilar leiomyosarcoma xenografts in athymic mice

BACKGROUND

Photochemical internalization (PCI) is a novel technique for delivery of active macromolecules into cancerous cells, via light activation of a specific photosensitizer and a low dose systemic drug. Numerous pre-clinical studies and one clinical trial have confirmed the treatment potential in carcinomas. Soft tissue sarcomas are rare and generally resistant to radio- and chemotherapy. Due to treatment resistance and surgical morbidity in sarcoma care, we seek to increase knowledge on PCI effects in sarcomas by studying two different, but closely related leiomyosarcomas.

METHODS

MES-SA and SK-LMS-1 tumours were established in the leg muscles of athymic mice. Treatment effects after AlPcS_2a-PCI of bleomycin, PCI with no drug (photodynamic therapy, PDT) and control groups were evaluated by: 1) assessment of tumour growth, 2) uptake of contrast agent during MRI and 3) histopathology.

RESULTS

PCI of bleomycin induced a similar and significant increase in time to reach the end point in both tumour models, while neither responded to AlPcS_2a-PDT. In the MES-SA tumours PCI reduced the growth rate, while in the SK-LMS-1 tumours the growth was blocked for 12days followed by exponential growth close to that of untreated tumours. SK-LMS-1 tumours were more homogenously and better vascularized than MES-SA. After PCI the vascular shutdown was more complete in the SK-LMS-1 tumours than in the MES-SA tumours.

CONCLUSIONS

AlPcS2a-based PCI, but not PDT, induced significant tumour growth delay in the evaluated sarcomas. Cellular responsiveness to bleomycin and tumour vascularity are identified as predictive markers for PCI treatment effects.

Update on the role of trabectedin in the treatment of intractable soft tissue sarcomas

Soft tissue sarcomas (STS) represent a variety of tumors of mesenchymal origin, accounting for about 1% of all adult cancers. This group of tumors comprises over 60 different histotypes with different biology showing different sensitivity to therapeutic agents. For decades, the standard first-line systemic treatment of metastatic STS has comprised anthracycline based-chemotherapy. Second-line therapy options include agents such as ifosfamide, gemcitabine, and pazopanib, but the optimal sequential therapy for the management of metastatic disease has yet to be defined. Trabectedin is one of the new molecules approved for patients in progression after first-line chemotherapy with anthracyclines or for those unfit for these agents. The compound is characterized by multiple potential mechanisms of action combining cytotoxic, targeted, and immunological effects. This article takes an in-depth look at the role of trabectedin in the management of metastatic STS, including L-sarcoma and non-L-sarcoma.

Current Status of Uterine Leiomyosarcoma in the Tohoku Region: Results of the Tohoku Translational Center Development Network Survey

BACKGROUND

To prepare for a future clinical trial for improving the long-term prognosis of patients with uterine leiomyosarcoma (ULMS), we conducted a multi-institutional survey in the Tohoku region of Japan.

METHODS

We conducted a retrospective cohort study between 2011 and 2014 in member institutions of the Tohoku Translational Research Center Development Network.

RESULTS

A total of 53 patients with ULMS were registered in 31 institutions for the present survey. The median patient age was 56 years, 67.9% of the patients were postmenopausal, 88.7% had a performance status of 0 or 1, and only 6 patients (11.3%) showed preoperative evidence of malignancy. Although retroperitoneal lymphadenectomy was performed in only 26.4% of patients, 64.2% patients were identified as having FIGO stage 1 disease; 73.6% were eligible to undergo complete surgery. Among 36 patients who were treated with postoperative chemotherapy, 28 (77.8%) received docetaxel and gemcitabine combination therapy. The most frequent recurrence site was the lungs, and the median progression-free survival of all enrolled patients was 11.7 months. However, the median progression-free survival and the median overall survival in patients with stages III and IV disease were 3.4 and 11.4 months, respectively.

CONCLUSION

Although ULMS was associated with a high rate of complete or optimal surgery, the long-term prognosis was poor. Effective postoperative therapy should be developed to improve the long-term prognosis of patients with ULMS.

Improved clinical trial enrollments for uterine leiomyosarcoma patients after gynecologic oncology partnership with a sarcoma center

OBJECTIVE

A retrospective chart review was performed to determine patient outcomes before and after partnership by gynecologic oncologists (GYN/ONC) with a sarcoma center (SC) for patients with recurrent unresectable/metastatic (RM) uterine leiomyosarcoma (uLMS).

METHODS

58 RM patients, identified from medical records of uLMS patients cared for by either GYN/ONC service and/or the SC between 1/1/2000-4/1/2014, were audited for patient and tumor characteristics, outcomes, and clinical trials enrollments.

RESULTS

Of the 58 patients, 26 patients (48%) were treated by GYN/ONC alone and 32 were treated by a combination of GYN/ONC and SC (52%). Age, race, tumor size, grade, presence of lymphovascular invasion, cervical involvement, and FIGO stage at diagnosis were not statistically different between the two groups. There was a significant difference between the number of clinical trial enrollments (0.07 vs 0.84 trials/patient, p<0.001) and the number of chemotherapy regimens prescribed (2.67 vs 4.29/patient, p=0.03) by GYN/ONC vs SC; the latter was driven by the number of clinical trial enrollments by the SC. Sixty-nine percent of patients referred to the SC were enrolled in at least one clinical trial, while just 8% of patients in the GYN/ONC group were enrolled in at least one clinical trial, a difference that is significant (p<0.0001).

CONCLUSIONS

Referral of RM uLMS patients by GYN/ONC to a dedicated clinical trials-based SC resulted in an increase in the number of chemotherapy regimens prescribed and clinical trial enrollments. Partnership between GYN/ONC and a dedicated SC with access to clinical trials should be encouraged for all RM uLMS patients.

Leiomyosarcoma: One disease or distinct biologic entities based on site of origin?

BACKGROUND

Leiomyosarcoma (LMS) can originate from the retroperitoneum, uterus, extremity, and trunk. It is unclear whether tumors of different origin represent discrete entities. We compared clinicopathologic features and outcomes following surgical resection of LMS stratified by site of origin.

METHODS

Patients with LMS undergoing resection at a single institution were retrospectively reviewed. Clinicopathologic variables were compared across sites. Survival was calculated using the Kaplan-Meier method and compared using log-rank and Cox regression analyses.

RESULTS

From 1983 to 2011, 138 patients underwent surgical resection for LMS. Retroperitoneal and uterine LMS were larger, higher grade, and more commonly associated with synchronous metastases. However, disease-specific survival, recurrence-free survival, and recurrence patterns were not significantly different across the four sites. Synchronous metastases (HR 3.20, P < 0.001), but not site of origin, size, grade, or margin status, were independently associated with worse DSS. A significant number of recurrences and disease-related deaths were noted beyond 5 years.

CONCLUSIONS

Although larger and higher grade, retroperitoneal and uterine LMS share similar survival and recurrence patterns with their trunk and extremity counterparts. LMS of various anatomic sites may not represent distinct disease processes based on clinical outcomes. The presence of metastatic disease remains the most important prognostic factor for LMS.

Soft tissue sarcomas, a look into the future: different treatments for different subtypes

 Soft tissue sarcomas (STS) are a heterogeneous group of rare malignancies frequently studied and treated as if they were one and the same disease. Evidence is emerging that distinct histopathological differences between the subtypes can significantly impact on optimal management of patients with STS. For the majority of patients with localized disease, surgery is the treatment of choice, sometimes combined with radiotherapy. For patients with advanced/refractory disease, there are a number of options. The first option is to consider cytotoxic chemotherapy with doxorubicin ± ifosfamide to reduce tumor size and make the tumor more amenable to surgery. If this is not possible, treatment should be aimed at reducing symptoms, improving patients' wellbeing and prolonging life. In this regard, understanding of the different biologies and sensitivities of the various histological subtypes of STS continues to expand, and an increasing number of targeted therapies are becoming available. Examples of more specific treatment options include taxanes in angiosarcoma, and trabectedin in leiomyosarcoma, liposarcoma and undifferentiated pleomorphic sarcoma. Although much remains to be learned about these rare malignancies, it is anticipated that small steps taken in recent years will lead to bigger leaps forward in future.

Pharmacological treatment for uterine leiomyosarcomas

INTRODUCTION

Pharmacological treatment plays a major role in the management of advanced, persistent or recurrent uterine leiomyosarcoma (LMS), whereas its usefulness in the adjuvant setting is still debated. A thorough literature search was undertaken using the Pubmed databases. Systematic reviews and controlled trials on medical treatment of uterine LMS were collected and critically analyzed. Other study types were secondarily considered when pertinent.

AREAS COVERED

Doxorubicin (DOX), ifosfamide and dacarbazine have been long used in the treatment of this malignancy. Novel active agents are represented by gemcitabine, docetaxel, trabectedin, pazopanib and aromatase inhibitors, whereas the role of eribulin, bevacizumab, aflibercept and mammalian target of rapamycin inhibitors is still investigational.

EXPERT OPINION

DOX alone, gemcitabine alone, DOX + dacarbazine and gemcitabine + docetaxel may be treatment options for first-line and second-line therapies. However, the clinical benefit of the combination chemotherapy versus single-agent chemotherapy is still debated. Trabectedin is a promising agent for recurrent uterine LMS, able to obtain a prolonged disease control, with 3-month and 6-month progression-free survival rates exceeding 50 and 30%, respectively, and with sometimes unexpectedly durable responses. Pazopanib is the only approved targeted therapy. Hormone therapy with aromatase inhibitors may be a therapeutic option in heavily treated patients with slowly progressive, steroid receptor-positive tumors. Whenever possible, women with recurrent uterine LMS should be encouraged to enter well-designed clinical trials aimed to detect novel active agents.

A review of treatment of uterine leiomyosarcomas

Uterine leiomyosarcomas are rare but challenging tumours. They occur most commonly around or shortly after the menopause. Their clinical behaviour is very variable, from highly aggressive to very indolent. Most are diagnosed unexpectedly and thus initially operated on by general gynaecologists. This article discusses the important surgical issues and the role of adjuvant treatments such as radiotherapy and chemotherapy. Important new international trials are opening to address these issues. Relapsed disease is usually incurable, but a subgroup of patients may benefit from repeated surgical procedures, hormones and ablative therapies. The choice of drugs for chemotherapy is discussed. New approaches with targeted agents have yet to establish themselves in treatment of leiomyosarcomas.

Systemic treatment of soft-tissue sarcoma-gold standard and novel therapies

Soft-tissue sarcoma (STS) is a rare and heterogeneous group of tumours that comprise approximately 1% of all adult cancers, and encompass over 50 different subtypes. These tumours exhibit a wide range of differing behaviours and underlying molecular pathologies, and can arise anywhere in the body. Surgical resection is critical to the management of locoregional disease. In the locally advanced or metastatic disease settings, systemic therapy has an important role in the multidisciplinary management of sarcoma. Cytotoxic therapy that usually consists of doxorubicin and ifosfamide has been the mainstay of treatment for many years. However recent advances in molecular pathogenesis, the development of novel targeted therapies, changes in clinical trial design and increased international collaboration have led to the development of histology-driven therapy. Furthermore, genomic profiling has highlighted that some STS are driven by translocation, mutation or amplification and others have more complex and chaotic karyotypes. In this Review, we aim to describe the current gold standard treatment for specific STS subtypes as well as outline future promising therapies in the pipeline.

Leiomyosarcoma: Principles of management

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