The clinical challenge of a uterine cotyledonoid dissecting leiomyoma with adenomyosis: A case report

Cotyledonoid dissecting leiomyoma (CDL) is a rare uterine tumor with unique clinical and histological features. We present a case of a 46-year-old woman with a 3-month history of left-flank pain radiating to the back. The patient had a history of infertility and a previous miscarriage. Ultrasound revealed a solid tissue mass suggestive of a degenerated fibroid. Laparoscopy identified subserosal leiomyoma and leiomyoma in the broad ligament. Histologically, CDL is characterized by disorganized smooth muscle with hyaline degeneration and no evidence of malignancy. Clinically, CDL can present with a variety of symptoms, including heavy menstrual bleeding, pelvic pain, and infertility. The coexistence of CDL and adenomyosis is exceedingly rare. This case highlights the importance of considering CDL in the differential diagnosis of pelvic mass, malignant neoplasms, and infertility, even with atypical symptoms. It also emphasizes the value of cooperation between clinicians and pathologists for accurate diagnosis and management of CDL. Adenomyosis in this case further complicated the diagnosis and highlighted the need for an index of suspicion for this rare condition.

Uterine Lipoleiomyoma in the Context of Adenocarcinoma

We describe a case of a 63-year-old woman referred to an oncologist for treatment of endometrial adenocarcinoma. A computed tomography scan revealed the incidental finding of a 11.5 × 10.5 × 9.0 cm myomatous mass in the uterine corpus adjacent to, yet uninvolved with, the adenocarcinoma. Histopathological analysis confirmed the mass to be a lipoleiomyoma, a rare single variant of lipoma. These fatty tumors present similar to leiomyomas and as such are generally not harmful; however, the potential exists for diagnostic confusion with other uterine tumors. This case serves to further illuminate the findings associated with these rare tumors.

Retrospective Analysis of Patients with Gynecological Uterine Sarcomas: Leiomyosarcomas and other Histological Subtypes at a Single Institution from 1996 to 2015

Uterine sarcomas are a rare group of malignancies that account for less than 10% of all uterine malignancies. They are histologically diverse and fall into two broad groups: mesenchymal and epithelial tumors. The treatment in both these groups is marked by high failure rates and quick progression of disease. Patients with stage I to II with resectable disease benefit from operative cytoreduction. Those with advanced stages, benefit from chemotherapy with or without external beam radiation therapy. Our research in this paper looks at the number of LMS cases at our institution, Wyckoff Heights Medical Center in Brooklyn, NY for a period of 20 years from 1996 until 2015 and assesses our cohort's age at diagnosis and their survival in accordance to grade and stage of diagnosis. Our findings suggest that disease stage is a strong prognostic factor with good survival rates in stage I and II, with higher incidence in African-American women. All LMS patients with distant metastasis died within five years.

How to differentiate uterine leiomyosarcoma from leiomyoma with imaging

Uterine leiomyomas, the most frequent benign myomatous tumors of the uterus, often cannot be distinguished from malignant uterine leiomyosarcomas using clinical criteria. Furthermore, imaging differentiation between both entities is frequently challenging due to their potential overlapping features. Because a suspected leiomyoma is often managed conservatively or with minimally invasive treatments, the misdiagnosis of leiomyosarcoma for a benign leiomyoma could potentially result in significant treatment delays, therefore increasing morbidity and mortality. In this review, we provide an overview of the differences between leiomyoma and leiomyosarcoma, mainly focusing on imaging characteristics, but also briefly touching upon their demographic, histopathological and clinical differences. The main indications and limitations of available cross-sectional imaging techniques are discussed, including ultrasound, computed tomography, magnetic resonance imaging (MRI) and positron emission tomography/computed tomography. A particular emphasis is placed on the review of specific MRI features that may allow distinction between leiomyomas and leiomyosarcomas according to the most recent evidence in the literature. The potential contribution of texture analysis is also discussed. In order to help guide-imaging diagnosis, we provide an MRI-based diagnostic algorithm which takes into account morphological and functional features, both individually and in combination, in an attempt to optimize radiologic differentiation of leiomyomas from leiomyosarcomas.

Standing Hand-Assisted Laparoscopic Diagnosis and Treatment of a Rare Case of Uterine Adenocarcinoma in an 18-Year-Old Mare

An 18-year-old French Trotter mare was presented to the Clinique Equine, Ecole Nationale Vétérinaire d'Alfort, for exploration of a 3-month-duration vaginal bleeding. A transrectal ultrasound examination identified a mass within the right uterine horn wall, which had been suspected during transrectal palpation. It was described as a firm heterogeneous intramural mass (7 × 12 cm) in the right uterine horn, located few centimeters cranially to the bifurcation. Hysteroscopy confirmed the ulcerated and irregular shape of the mass. A standing hand-assisted flank laparoscopy was performed to carry out a partial ovariohysterectomy. Two days after surgery, the mare presented with acute and severe signs of colic and was euthanized. Postmortem examination revealed a 720° small intestine volvulus at the mesenteric root, a left dorsal displacement of the large colon, and iliac and tracheobronchial lymph node hypertrophy. Histopathological examination of the removed uterine mass revealed a well-differentiated and infiltrating uterine adenocarcinoma, with lymph node metastasis. Uterine neoplasia, especially adenocarcinoma, is uncommon in the mare and can be successfully removed using a standing hand-assisted laparoscopic technique, which avoids the risks associated with general anesthesia and allows a histologic diagnosis of malignancy. In such cases, though, initial staging and identification of metastasis remain a challenge that will influence the treatment strategy.

A high dose mode of action for tetrabromobisphenol A-induced uterine adenocarcinomas in Wistar Han rats: A critical evaluation of key events in an adverse outcome pathway framework

TBBPA is a non-genotoxic flame retardant used to improve fire safety in a wide variety of consumer products. Estimated human exposures to TBBPA are very low (<0.000084 mg/kg-day), relative to the doses (500 and 1000 mg/kg-day of TBBPA) administered in a recent bioassay that resulted in uterine tumors in Wistar Han rats following chronic exposure. As part of an effort to characterize the relevance of the uterine tumors to humans, data and biological knowledge relevant to the progression of events associated with TBBPA-induced uterine tumors in female rats were organized in an adverse outcome pathway (AOP) framework. Based on a review of possible MOAs for chemically induced uterine tumors and available TBBPA data sets, a plausible molecular initiating event (MIE) was the ability of TBBPA to bind to and inhibit estrogen sulfotransferases, the enzymes responsible for sulfation of estradiol. Subsequent key events in the AOP, including increased bioavailability of unconjugated estrogens in uterine tissue, would occur as a result of decreased sulfation, leading to a disruption in estrogen homeostasis, increased expression of estrogen responsive genes, cell proliferation, and hyperplasia. Available data support subsequent key events, including generation of reactive quinones from the metabolism of estrogens, followed by DNA damage that could contribute to the development of uterine tumors. Uncertainties associated with human relevance are highlighted by potential strain/species sensitivities to development of uterine tumors, as well as the characterization of a dose-dependent MIE. For the latter, it was determined that the TBBPA metabolic profile is altered at high doses (such as those used in the cancer bioassay), and thus an MIE that is only operative under repeated high dose, administration. The MIE and subsequent key events for the development of TBBPA-induced uterine tumors are not feasible in humans given differences in the kinetic and dynamic factors associated with high dose exposures in rats relative to human exposure levels to TBBPA.

A case of pulmonary lymphangioleiomyomatosis complicated with uterine and retroperitoneal tumors

A 39-year-old female experienced dyspnea on exertion for eight months. Chest CT demonstrated findings of Lymphangioleiomyomatosis (LAM), including diffuse thin-walled cystic lesions. A surgical lung biopsy revealed human melanoma black-45-positive cell infiltration and aggregation, resulting in a diagnosis of sporadic LAM without tuberous sclerosis complex. Pelvic MRI showed two large tumors, one of which was in the myometrium and the other was in the retroperitoneal space. Because we were not able to exclude the presence of malignant tumors using MR imaging, the tumors were surgically resected. The histopathology demonstrated the resected tumors to be composed of LAM cells. The patient's symptoms worsened, and sirolimus was administered, which improved the dyspnea and pulmonary function. The adverse effect was mild liver damage. Following the initiation of treatment with sirolimus, transient elevation of the serum KL-6 level was detected without interstitial pneumonia. This LAM case complicated with large uterine and retroperitoneal tumors was successfully treated with surgical resection and sirolimus.

A peripherally restricted P2Y12 receptor antagonist altered rat tumor incidences with no human relevance: Mode of action consistent with dopamine agonism

Background

Ticagrelor is an orally available, direct acting and reversible P2Y₁₂ receptor antagonist approved for treatment of acute coronary syndrome. The objectives of these studies were to (1) evaluate the Ticagrelor 2-year rat carcinogenicity bioassay data; (2) investigate potential mode of action (MOA) and (3) interpret human relevance.

Methods

The following studies were done (1) rat two-year carcinogenicity study in male and female rats, (2) in vitro and in vivo genotoxicity assays, (3) quantitative whole body autoradiography (QWBA; male and female rats), (4) in vitro pharmacological profiling for more than 300 assays, and (5) in vivo ovariectomized rat assay.

Results

The carcinogenicity study indicated Ticagrelor increased uterine tumor incidence while decreasing mammary and pituitary tumors/hyperplasia incidences in only high dose female rats. However, this altered tumor incidences were not P2Y₁₂ target related since marketed non-reversible P2Y₁₂ receptor antagonists were not associated with alter tumor incidences. MOA studies determined Ticagrelor exposure in the anterior pituitary and Ticagrelor was (1) non-genotoxic, (2) peripherally-restricted, (3) a dopamine transport (DAT) inhibitor with an IC₅₀ lower than systemic free exposure in the rat carcinogenic study and more than a log higher than the free systemic exposure seen in clinical trials and (4) an inhibitor of estradiol-induced prolactin secretion.

Discussion

Similar to Ticagrelor, centrally active dopamine agonists induce the same altered tumor incidence patterns that according to literature do not translate into the clinical setting, with a MOA involving decreased prolactin secretion. The Ticagrelor MOA data and literature suggest that altered dopamine levels in the hypophyseal part of the hypothalamus–hypophyseal axis (by Ticagrelor) will result in similar altered tumor incidences in rat that do not translate into the clinical setting, based on qualitative species differences. In conclusion Ticagrelor increased uterine tumors in the rat carcinogenesis study by a MOA consistent with reduced dopamine inhibition of prolactin, which is not a patient safety risk.

A huge malignant perivascular epithelioid cell tumor (PEComa) of the uterine cervix and vagina

Perivascular epithelioid cell tumors (PEComas) are a family of rare mesenchymal neoplasms, including angiomyolipoma, clear-cell "sugar" tumor of the lung and extrapulmonary sites, lymphangioleiomyomatosis, clear-cell myomelanocytic tumor of the falciform ligament/ligamentum teres, and clear-cell tumors at various other anatomic sites. These tumors are characterized by a proliferation of epithelioid cells with clear to eosinophilic cytoplasm, perivascular distribution, and coexpression of myogenic and melanocytic markers. PEComas show a female predominance, occur with some frequency in the gynecological tract, and have an unpredictable biological behavior. We report a case of a huge malignant PEComa arising from the uterine cervix and vagina. To the best of our knowledge, only 6 cases of PEComa in the cervix and 2 cases in the vagina have been reported in the literature.