*Łukasz Światłowski, Michał Górnik, Tomasz Roman, Ewa Kuklik, Małgorzata Szczerbo-Trojanowska
Chemoembolization in the treatment of metastasis from uterine sarcoma to the spine
Department of Interventional Radiology and Neuroradiology, Medical University in Lublin
Head of Department: Professor Małgorzata Szczerbo-Trojanowska, MD, PhD
Uterine sarcomas are a heterogeneous group of rare tumors taking its origin from mesenchymal tissue. They are responsible for about 8% of malignant changes in the uterus (1). Depending on the tissue from which it can develop, sarcoma of the uterus can be divided into leiomyosarcoma (LMS), endometrial stromal sarcoma (ESS), undifferentiated endometrial sarcoma (UES) and adenosarcoma (2). Gynecologic Oncology Group (GOG) implemented an additional division of uterine sarcomas on nonepithelial and mixed epithelial-nonepithelial (3).
The most common histological type of uterine sarcomas is leiomyosarcoma. Most of these tumors take its origin de novo, only about 0.2% of the lesions develop in the process of benign uterine myoma malignant transformation (4). These are characterized by an aggressive process (even if the change is located only in the uterus) of 5-year survival rates fluctuating from 18.8 to 68%. The risk of relapse ranges between 45 and 73% (1, 5, 6).
Most leiomyosarcomas occurs in women over 40 years of age (mean age 60 years). While the etiology is not fully understood, it is supposed that factors which can be associated with the development of the tumor is long-term taking of tamoxifen and the exposure to radiation of the pelvis in the past (3).
The symptoms of sarcomas may be similar to the symptoms resulting from benign fibroid and include abnormal vaginal bleeding (56%), palpable tumor in the pelvis (54%) and can lead to pelvic pain (22%). Bleeding from the tumor into the peritoneal cavity, due to the rupture of the tumor mass, occurs less frequently. As a result of the uterine sarcoma metastases the first symptom can appear in a completely different place (6). Although the rapid growth of the fibroid is suspicious, diagnosis of a sarcoma on the basis of this feature is controversial. Therefore, preoperative differentiation of benign uterine fibroids from the leiomyosarcoma is very difficult (if not impossible) and is based only on clinical symptoms and remains a challenge for clinicians (1, 6).
Leiomyosarcomas can metastasize usually to the surrounding soft tissues with involvement of retroperitoneal, internal organs (e.g. lung, liver), and skin. Spinal metastasis occurs very rarely, although it is the most common site of leiomyosarcoma bone metastases (6). Most common site of metastatic lesions in the spine is the upper part of the thoracic segment, which is a problem in finding a suitable method for the treatment of these lesions, especially if typical surgery treatment is chosen (7, 8). Nowadays, the procedure depends mainly on the extent of lesions in the spine and the symptoms reported by patient, which results from the extent of lesions in the spine. In most cases, interdisciplinary approach is necessary. In the early stage of non-metastatic uterine sarcoma radical hysterectomy is performed. In those cases, the role of adjuvant chemotherapy or local radiation therapy is still controversial (6, 9, 10).
In sarcomas of the uterus with the occurrence of metastasis in the management standards surgical removal of metastases, chemotherapy, hormone therapy and targeted therapy is performed. The primary drug used in all lines in chemotherapy is doxorubicin (6-12). In the literature there are cases of long-term response to chemotherapy in advanced stages of leiomyosarcoma. This is a case report of the patient with leiomyosarcoma of the uterus and recurrence of the spine metastasis pre-treated previously with surgery. Disqualification of the patient from a surgery treatment, concomitant severe pain, which prevents the normal functioning of the patient, was a reason to perform transarterial chemoembolization of spinal metastases using particles soaked with doxorubicin (DEM-TACE).
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