Müllerian adenosarcoma of the uterus with sarcomatous overgrowth following tamoxifen treatment for breast cancer

Müllerian Adenosarcoma of the Urinary Bladder: Clinicopathologic and Immunohistochemical Features With Novel Genetic Aberrations

BACKGROUND

Müllerian adenosarcoma is a biphasic neoplasm most commonly occurring in the uterus and less frequently of the ovary. It has been rarely described to occur in other sites such as peritoneum and liver.

PATIENTS AND METHODS

In this study, we report the clinicopathologic, immunohistochemical and molecular features of a primary Müllerian adenosarcoma of the urinary bladder in a 62-year-old woman. To our knowledge, this is the first report of detailed pathologic characterization of Müllerian adenosarcoma primary to the urinary bladder in the literature.

RESULTS

Light microscopy showed a biphasic epithelial and stromal tumor with benign-appearing glands surrounded by densely cellular endometrial-type stroma that is densely cellular with increased mitotic figures. The stroma surrounding the glands was more cellular than the intervening areas, which were more loose and edematous. Immunohistochemistry staining revealed positive staining for Pax-2/8 within the glands, for positive CD10 and WT-1 within the spindle cell stroma, and for estrogen and progesterone receptors in both. Staining for desmin, GATA3, p63, and human papillomavirus was negative. Molecular analyses identified mutations in protein kinase B E17K, fms related tyrosine kinase 3 D835N, KRAS proto-oncogene, GTPase G12D, and HRAS proto-oncogene, GTPase G12S. These novel molecular aberrations have yet to be reported in the medical literature. X chromosome inactivation analysis revealed a clonal pattern in the stromal component and a nonclonal pattern in the epithelial component. Currently, the patient is disease/recurrence-free after regular follow-up of approximately 84 months.

CONCLUSION

This case represents, to our knowledge, the first reported diagnosis of Müllerian adenosarcoma arising in the urinary bladder with extensive clinicopathologic, immunohistochemical, and molecular analyses.

Müllerian adenosarcoma arising from rectal endometriosis

A Müllerian adenosarcoma is an extremely rare tumor characterized by a stromal component of usually low-grade malignancy and by a benign glandular epithelial component. A Müllerian adenosarcoma occurs mainly in the uterus, but also in extrauterine locations. Extrauterine Müllerian adenosarcomas are thought to arise from endometriotic deposits. A 36-year-old female presented to Daegu Catholic University Medical Center with a symptom of loose stool for several months. The imaging studies revealed a rectal mass, so she underwent a laparoscopic low anterior resection. Although extemporary pathology revealed an inflammatory myofibroblastic tumor, the final histologic diagnosis was a Müllerian adenosarcoma arising from rectal endometriosis. To our knowledge, except a concomitant rectal villotubular adenoma, cases of Müllerian adenosarcomas arising the rectal wall are rare. An adenosarcoma arising from endometriosis should be considered in the differential diagnosis of a pelvic mass, even one appearing in rectal wall, because ectopic endometrial tissue exists everywhere.

Uterine adenosarcoma in a patient with history of breast cancer and long-term tamoxifen consumption

Adenosarcoma is a rare tumour which usually originates from endometrium. This paper presents a 69-year-old woman with adenosarcoma of uterus and a history of breast cancer and 10 years tamoxifen therapy.

Endometrial mullerian adenosarcoma after toremifene treatment in breast cancer patients: a case report

Toremifene is an anti-estrogen which has been shown to be effective in the treatment of breast cancer, and is thought to be a less uterotrophic agent than tamoxifen. The risk assessment concerning endometrial cancer has been inconclusive because of its rare use up to the mid-1990s. We report a case of an adenosarcoma, which is a very rare type of uterine malignancy, after toremifene treatment for 5 years in a breast cancer patient. After 1 year of toremifene use, the patient had a benign Mullerian adenofibroma. After an additional 4 years of toremifene treatment, the endometrial polypoid lesion was transformed into a Mullerian adenosarcoma. Although toremifene is a promising anti-estrogenic agent in the treatment of breast cancer patients, clinicians should not neglect the possibility of a uterine malignancy.

Tumorigenic effects of tamoxifen on the female genital tract

Tamoxifen is widely used for endocrine treatment and breast cancer prevention. It acts as both an estrogen antagonist in breast tissue and an estrogen agonist in the female lower genital tract. Tamoxifen causes severe gynecologic side effects, such as endometrial cancer. This review focuses on the effects of prolonged tamoxifen treatment on the human female genital tract and considers its tumorigenicity in the gynecologic organs through clinical data analysis. Tamoxifen is associated with an increased incidence of benign endometrial lesions such as polyps and hyperplasia and a two- to four-fold increased risk of endometrial cancer in postmenopausal patients. Moreover, the incidence of functional ovarian cysts is significantly high in premenopausal tamoxifen users. To prevent tamoxifen from having severe side effects in gynecologic organs, frequent gynecological examination should be performed for both premenopausal and postmenopausal patients with breast cancer who are treated with this drug.

Müllerian adenosarcoma with sarcomatous overgrowth of the cervix: unusual large polypoid mass

Müllerian adenosarcoma (MS) is a rare neoplasm of uterine cervix composed of benign epithelial and malignant stromal components. An aggressive variant of adenosarcoma, müllerian adenosarcoma with sarcomatous overgrowth (MASO) is extremely rare. The difference between MS and MASO is the pure high grade sarcoma features in MASO. In this report we present a MASO case, derived from uterine cervix of a 60 year-old-female patient presenting as a cervical polypoid mass, to our knowledge the second case of the English literature. In spite of sarcomatous overgrowth, high mitotic activity and huge tumor size of 12,5 cms, it displayed no myometrial invasion, vascular invasion and heterologous elements. The patient has been clinically free of disease for 14 months of follow up after total abdominal hysterectomy and bilateralsalpingo-oopherectomy. The difficulties in diagnosis and treatment of this entity will be evaluated in this report.

Myxoid leiomyosarcoma of the uterus in a patient receiving tamoxifen therapy: a case report

In this paper, we present a case of myxoid leiomyosarcoma development in a patient receiving tamoxifen for 3 years because of breast cancer. The myxoid leiomyosarcoma should be included in the differential diagnosis of any uterine tumor with a predominantly myxomatous composition. A review of the literature indicates that tamoxifen may increase not only the risk for endometrial cancer but also for uterine sarcoma, suggesting vigilance for uterine cancer in women who are being treated with this drug.

Uterine sarcomas in breast cancer patients treated with tamoxifen

Tamoxifen (TMX) has been related with the development of uterine sarcomas. Since the first reported case in 1988, 65 TMX-related cases have been referred to. Here we present three new cases of uterine sarcomas in patients with breast cancer treated with TMX and we comment on the outcome of the cases described in the literature. In the past 25 years, 60 uterine sarcomas have been diagnosed and treated in Hospital Clínic. Three patients have previously received TMX 20 mg/day for 3, 5, and 7 years for breast cancer. Uterine sarcoma appeared 5, 5, and 7 years, respectively, after the start of TMX treatment, and all of them had stage I (FIGO) disease. Two patients had a carcinosarcoma and one patient had an adenosarcoma. After treatment, the disease progressed in two patients and the third patient is alive having a follow-up of 42 months. The low incidence of uterine sarcomas makes it difficult to establish a relationship with TMX. Nevertheless, looking at the literature data, 20 mg/day of TMX over 1 year could be enough to develop uterine sarcoma; the sarcoma appears mainly during the first 8 years and seem to behave more aggressively. Although only 65 cases have been reported in the past 14 years, a strict follow-up is necessary in patients with breast cancer receiving TMX therapy.

Mullerian adenosarcoma with sarcomatous overgrowth of the cervix presenting as cervical polyp: a case report and review of the literature

An aggressive variant of adenosarcoma, mullerian adenosarcoma with sarcomatous overgrowth (MASO) in the cervix is extremely rare. This variant contains obvious, high-grade sarcoma in addition to a low-grade form. In this report, we describe a case of MASO of the uterine cervix and review the clinical and pathological features of these tumors. The patient was a 37-year-old woman with a cervical polypoid mass, which was morphologically considered as a benign endocervical polyp. Microscopically, polypoid cervical mass showed diffuse and dense malignant spindle cell proliferation around the benign endocervical glands and also an area of markedly anaplastic and pleomorphic spindle cell proliferation, so called, sarcomatous overgrowth. Total abdominal hysterectomy and bilateral salpingo-oophorectomy with pelvic lymph node dissection were performed. The patient has been followed-up and neither chemotherapy nor other adjuvant therapies have been administered. At present, she has been clinically free of disease for 9 months since she received surgery. It is extremely rare that MASO of the uterine cervix is presented in premenopausal woman. Gynecologists and pathologists should be aware of the difficulties associated with a delay in the diagnosis of MASO when the tumor is present as a benign looking cervical polyp.

Endometrial mixed Müllerian tumor with heterologous elements following tamoxifen therapy for breast cancer: a case report and literature review

CASE

A 67-year-old multiparous woman received 20mg tamoxifen daily for four years after surgical treatment of breast cancer. She presented with vaginal bleeding. Uterine curettage revealed a uterine MMT with heterologous elements. She was treated surgically with adjuvant radiotherapy. Tumor cells were found to be estrogen receptor negative and progesterone receptor positive. Uterine MMT may be linked to long term use of tamoxifen. A mechanism in developing MMT other than estrogen receptor pathway may be possible.

Toxicity of antiestrogens

The object of this article is to review briefly the preclinical and clinical safety of some antiestrogens. Tamoxifen, toremifene, droloxifene, and idoxifene are polyphenylethylene antiestrogens, whereas the pure antiestrogen, ICI 182,780 or faslodex, as well as raloxifene, is of a different structure. Tamoxifen has been shown to be genotoxic in several studies. It induces unscheduled DNA synthesis in rat hepatocytes and micronuclei in MCL-5 a cells in vitro. Tamoxifen also induces aneuploidy in rat liver in vivo and chromosome aberrations and micronuclei in mouse bone marrow. Toremifene has also shown to be genotoxic, but to a far lower extent, by inducing micronuclei in MCL-5 a cells in vitro and by inducing aneuploidy in rat liver in vivo. Tamoxifen has been shown to be hepatocarcinogenic in the rat in at least four independent long-term studies. The initiation of tumors in the rat is the result of metabolic activation by cytochrome P450 isoenzymes to an electrophile(s) that binds irreversibly to DNA. The other antiestrogens have not been shown to be carcinogenic in rodents. In several independent clinical studies, the risk of endometrial cancer has increased among tamoxifen-treated women. After reviewing the available data, the International Agency for Research on Cancer concluded that there was sufficient evidence to show that tamoxifen is a class I human carcinogen. The increased risk for endometrial cancer occurs predominantly among women who are 50 years old or older and who have been treated with tamoxifen. It is not yet clear whether the uterine tumor formation is a result of genetic mechanisms, analogous to those seen in the rat liver or due to the estrogen agonist action of tamoxifen. However, the other antiestrogens with a more or less similar intrinsic estrogenic potential have not been shown to be carcinogenic in humans.