Metastatic high-grade endometrial stromal sarcoma (HG-ESS) with BCOR rearrangement: A case report

Background: The ZC3H7B-BCOR fusion gene has recently been described in tumours with kinship to so-called high grade endometrial stromal sarcoma (HG-ESS). This subset of tumour behaves similarly to YWHAE-NUTM2A/B HG-ESS, however, they are both morphologically and immunophenotypically distinct neoplasms. The identification rearrangements in the BCOR gene has been accepted as both the driver and requisite feature in creating a novel sub-entity within the category of HG-ESS.Preliminary investigations into BCOR HG-ESS have shown similar outcomes to YWHAE-NUTM2A/B HG-ESS with patients tending to present with high stage disease. Clinical recurrences and metastases to lymph nodes, sacrum/bone, pelvis/peritoneum, lung, bowel and skin have been identified. In this report, we describe a case of BCOR HG-ESS, that is deeply myoinvasive and widely metastatic. Metastatic deposits include a tumor in the breast discovered on self-examination; a metastatic site that has yet to be reported in the literature. Case Presentation: A 59-year-old female underwent biopsy for post-menopausal bleeding, yielding a diagnosis of “low-grade spindle cell neoplasm with myxoid stroma and endometrial glands”, favouring endometrial stromal sarcoma (ESS). She was referred for total hysterectomy and bilateral salpingo-oophorectomy. The uterine neoplasm was both intracavitary and deeply myoinvasive with morphology consistent with that of the biopsy specimen. Characteristic immunohistochemistry (IHC) was noted, and fluorescence in situ hybridization confirmed BCOR rearrangement, supporting a diagnosis of BCOR high grade ESS (HG-ESS). Notably, BCOR HG-ESS has been proposed to have an association with MDM2 amplification but there were no abnormalities of MDM2 associated with this case. A few months postoperatively, the patient underwent breast core biopsy which revealed metastatic HG-ESS at a site not previously reported in the literature. Conclusions: : This case highlights some of the diagnostic challenges posed by uterine mesenchymal neoplasms, and exemplifies the emerging histomorphologic, immunohistochemical, molecular and clinicopathologic features of the recently described HG-ESS with ZC3H7B-BCOR fusion gene. It adds to the body of evidence supporting the inclusion of BCOR HG-ESS as a sub-entity of HG-ESS within the endometrial stromal and related tumours subcategory of uterine mesenchymal tumors, as well as the poor prognosis and high metastatic potential of this tumor.