Low-grade extrauterine endometrial stromal sarcoma arising from vaginal endometriosis: a case report and literature review

Low-grade endometrial stromal sarcoma (ESS) is typically a uter- ine mesenchymal neoplasm but it may also occur in extrauterine sites. Extrauterine ESS (EESS) is rare and the exact incidence is un- known. The majority of these cases are associated with endometri- osis and have a relatively higher tendency to disseminate than uterine ESS. The commonest extrauterine site of origin is the gas- trointestinal tract, but cases from the pelvis, sciatic nerve, vulva and retroperitoneum have also been reported [1]. ESS arising in the va- gina is a rare entity. The diagnosis may be difficult owing to associ- ated endometriosis that presents with similar clinical features. W e report a case of low-grade EESS arising in vaginal endometriosis. This case merits mention because of the difficulty in diagnosis due to overlapping clinical features and response to medical therapy, timely management, and good survival outcomes. An informed written consent was obtained from the patient for the publication of this report. CASE REPORT A 38-year-old P2L2 patient presented with complaints of dyspa- reunia, dysmenorrhea, and painful defecation for a year, along with blood-mixed vaginal discharge for 3 months. Her systemic examination was normal. On per speculum examination, the cer- vix was normal but multiple brownish irregular nodules were seen in posterior vaginal fornix. On bimanual examination, fixed ten- der nodules were felt in the posterior fornix with irregularity in the overlying vaginal mucosa. The uterus was retroverted, nor - mal-sized with restricted mobility. Examination during menstrua- tion noted the presence of blood-mixed mucoid discharge from the nodules in the posterior fornix (Fig. 1A). With clinical suspi- cion of vaginal endometriosis, imaging and biopsy were per - Case Report Korean Journal of Clinical Oncology 2023;19:73-79 https://doi.org/10.14216/kjco.23013 pISSN 1738-8082 ∙ eISSN 2288-4084 Low-grade extrauterine endometrial stromal sarcoma arising from vaginal endometriosis: a case report and literature review Seema Singhal1, Aarthi S Jayraj1,2, Ekta Dhamija3, Sachin Khurana4 1Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India 2Department of Gynecologic Oncology, James Cook University Hospital, South Tees NHS Foundation Trust, Middlesbrough, UK 3Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India 4Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India Extrauterine endometrial stromal sarcoma arising from malignant transformation of the vagina is an extremely rare condition. The diagnosis is often difficult as the symptomatology and pathological features overlap with that of pelvic endometriosis. A 38 years old female presented with complaints of dyspareunia, dysmenorrhea, and painful defecation along with blood-stained vaginal discharge for a year. Examination revealed the presence of multiple brownish irregular nodules in posterior vaginal fornix and fixed tender nodules which on biopsy revealed florid vaginal endometriosis. She improved symptomatically on medical therapy. After 18 months of diagnosis, she presented again with a necrotic growth in posterior fornix, which on repeat biopsy revealed a low-grade endometrial stromal sarcoma. Laparotomy revealed a 7×5 cm mass in the pouch of Douglas, infiltrating the posterior vaginal wall and rectum. A complete cytoreductive surgery with retrograde hysterectomy, excision of posterior vaginal wall and rectosigmoid resection was done. The patient is disease-free at a follow-up of 65 months.

Endometrial stromal sarcoma, Endometriosis, Dyspareunia, Dysmenorrhea, Case reports Received: Jul 17, 2023 Revised: Dec 4, 2023 Accepted: Dec 5, 2023 Correspondence to: Aarthi S Jayraj Department of Gynecologic Oncology, James Cook University Hospital, South Tees NHS Foundation Trust, Middlesbrough, UK Tel: +44-1642-54858 E-mail: [email protected] Copyright © 2023 Korean Society of Surgical Oncology This is an Open Access article distributed under the terms of the Creative Commons Attri- bution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 74 Korean Journal of Clinical Oncology formed. Computed tomography pelvis showed normal uterus and adnexa with nodularity and thickening of posterior vaginal fornix with ill-defined planes posteriorly with rectum (Fig. 1B). Biopsy of the irregular nodular areas in posterior fornix showed proliferative endometrial glands and cellular stroma suggestive of extrauterine endometriosis (Fig. 1C). The patient opted for medical therapy and was started on le - uprolide acetate 3.75 mg intramuscular injection monthly for 3 months. There was a significant improvement in her symptoms with disappearance of the vaginal forniceal lesions. Thereafter, the patient was started on depot intramuscular injection of medroxy- progesterone acetate 150 mg every 3 monthly for 12 months. Eigh- teen months after diagnosis, she presented again with blood-mixed vaginal discharge for 3 months with dyspareunia and dyschezia. On per speculum examination, there was an irregular exophytic necrotic growth in posterior vaginal fornix. The cervix appeared A B C Fig. 1. (A) Image showing raised irregular areas in posterior fornix on speculum examination. (B) Computed tomography pelvis axial image showing ill-defined planes of posterior wall of vagina with the rectosigmoid. (C) Biopsy from posterior fornix shows presence of endometrial glands and stroma suggestive of endometriosis (hematoxylin and eosin stain, ×100). Fig. 2. (A) T2 weighted magnetic resonance imaging image of pelvis showing heterogeneously enhancing mass of 7×6 cm at posterior vagi- nal wall with exophytic component and necrosis with diffusion restriction and loss of fat planes with the rectosigmoid colon. (B) En bloc specimen of excised tumor along with uterus, ovaries, rectum, vagina and rectosigmoid colon up to perineum. A B Seema Singhal et al. • ESS from vaginal endometriosis www.kjco.org 75 tubes and ovary were normal with no evidence of endometriosis. The tumor cells were immunopositive for CD10, ER, PR and focal- ly for cyclin D1 and desmin, while negative for SMA, consistent with a diagnosis of ESS (Fig. 3). There were foci of endometriosis found embedded within the periphery of the tumor. The patient re- covered uneventfully and was discharged on third postoperative day. The patient was diagnosed with stage IIIA low grade, EESS of the vagina and was started on the aromatase inhibitor anastrozole 1 mg daily. The patient was followed up in a combined oncology clin- ic every month for the first 3 months; 3 monthly till 2nd year and 6 monthly till the 5th year. At every visit, a careful evaluation of symp- toms was done, thorough clinical examination was performed and imaging was advised accordingly. She also underwent dual-energy X-ray absorptiometry scan every 1–2 yearly to monitor bone min- eral density. She was on calcium and vitamin D supplementation and was provided advice on a healthy lifestyle and importance of regular physical exercise. At 65 months follow-up, the patient is dis- ease-free. W e plan to continue anastrozole therapy till disease pro- gression or development of significant toxicity in terms of osteope- nia/osteoporosis. normal. On bimanual examination, a hard fixed mass was felt pos- teriorly in the rectovaginal septum. The uterus was normal in size with restricted mobility. On rectal examination, the mucosa was free with external compression by the mass. A repeat biopsy from necrotic growth in the posterior fornix was suggestive of low-grade ESS. Magnetic resonance imaging showed a T1 isointense and T2 heterogeneously enhancing hyperintense mass of 7× 6 cm in the rectovaginal septum with an exophytic component and necrosis with diffusion restriction (Fig. 2A). The patient was taken up for laparotomy. Intraoperatively, the pouch of Douglas was obliterated by a fixed mass of 7× 5 cm arising from the posterior vaginal wall and rectovaginal septum filling the pouch of Douglas, encasing the left ureter and invading the recto- sigmoid. Inferiorly, the tumor was extending almost up to 4–5 cm from the anal sphincter. A retrograde hysterectomy with excision of posterior vaginal wall, abdominoperineal resection of rectosigmoid colon and a permanent end colostomy was performed (Fig. 2B). Gross histopathological examination of the specimen showed a 7.5 × 5.5× 3 cm grey-white tumor involving the rectovaginal septum, infiltrating the serosal aspect of rectosigmoid, posterior myometri- um up to endometrium isthmus and part of cervix. The cut end of vaginal cuff, colonic and rectal margins were free of tumor. Bilateral A C D E B Fig. 3. (A) Sections from the uterine tumor show proliferation of endometrial stromal cells in a sheet-like pattern with formation of whorls around arterioles suggestive of low-grade endometrial stromal sarcoma (hematoxylin and eosin staining, ×100). (B) The tumor cells are oval to spindle-shaped and show mild nuclear atypia and fine nuclear chromatin (hematoxylin and eosin stain, ×200). The tumor cells are immu- nopositivity for CD10 (C), ER (D), and PR (E). (C-E) Immunohistochemical staining, ×200. 76 Korean Journal of Clinical Oncology Table 1. Review of cases reporting endometrial stromal sarcoma in vagina Author Age (yr) Clinical presentation Previous history of hormonal therapy Size of tumor (cm) Site of tumor Association with endometriosis Stage Treatment Hormonal therapy Immunohistochemistry Margins Follow up (mo) RFS (mo) OS (mo) Comments Berkowitz, 1978 [3] 57 Intermittent vaginal bleeding, nodule Yes 8 Vaginal apex Yes II Exploratory laparotomy+ radical vaginectomy+ radiotherapy - - - 18 18 18 H/o TAH+ BSO 15 yr ago- no malignancy Ulbright, 1981 [4] 32 Vaginal nodule - 2.5 Right lateral vagina No I TAH+BSO+ resection of the mass - - - 36 36 36 - Kondi- Paphitis, 1998 [5] 45 Vaginal discharge, nodules - 2 Posterior vagina Yes II Excision of tumor - Vimentin+Desmin, smooth muscle actin, factor VIII, EMA and LCA – Free 36 36 36 - Chang, 2000 [6] 34 - - - - No - TAH+BSO+ LND+partial vaginectomy+RT - - - 18 18 18 - Corpa, 2004 [7] 40 Periurethral vaginal nodule No 2 Periurethral No I Excision of the nodule - CD10, ER, PR+Desmin, actin, S-100 protein, and cytokeratin – - 38 38 38 - Masand, 2013 [1] 52 Pelvic mass - Pelvis, round ligament, vagina Yes IVB Surgery+ chemoradiation - - - 96 Yes 96 Died of disease 51 - - Vagina No - Surgery - - - - - - Lost to follow-up 40 Vaginal bleeding - Vagina, pelvis No III Surgery+ chemotherapy+ hormonal therapy - - - 9 Yes 9 Alive with disease 44 Vaginal bleeding - Vagina, colon Yes IVA Surgery+ chemotherapy - - - 36 Yes (dedifferentia ted tumor) 36 Died of disease 49 Pelvic pain and menorrhagia - Ovary, uterine serosa, vagina, urinary bladder, colon, hypogastric LN Yes IVB Surgery+ chemotherapy+ hormonal therapy - - - 84 Yes 84 Alive with no evidence of disease (Continued to the next page) Seema Singhal et al. • ESS from vaginal endometriosis www.kjco.org 77 Author Age (yr) Clinical presentation Previous history of hormonal therapy Size of tumor (cm) Site of tumor Association with endometriosis Stage Treatment Hormonal therapy Immunohistochemistry Margins Follow up (mo) RFS (mo) OS (mo) Comments Liu, 2013 [8] 32 Postcoital bleeding No 1 Middle and upper right posterior vaginal wall No I TAH+BSO+partial vaginectomy+ 6 cycles of chemotherapy (PAC) - CD10, ER, PR and Vimentin+desmin, muscle actin, S-100 – Free 18 18 18 - Rivard, 2015 [9] 43 Asymptomatic No 5 Vaginal introitus Yes I Surgery - - - - - - - Wang, 2015 [10] 40 Vaginal discharge, mass - 5 Left vagina, bladder, rectum No IVA Radiotherapy MPA - NA 12 Disease progressed during therapy 12 Died of disease 32 Mass - 1.5 Right lower third of vagina No I TAH+BSO+wide local excision Free 21 21 21 - Sanverdi, 2016 [11] 46 Postcoital vaginal bleeding, pain, constipation, mass No 7 Posterior fornix Yes II TAH+BSO+partial vaginectomy - CD10 (+), ER (+), PR (+), and vimentin (+) Free 22 22 22 Elevated preop CA125 at 75 IU/mL Abu Jamea, 2017 [12] 58 Vaginal heaviness, mass No 3 Left vagina No I TAH+BSO+LND Letrozole 2.5 mg Vimentin, CD10, ER, PR, focal CD99+h- Caldesmon, calponin, desmin, smooth mus- cle actin, CD68, CD34, Bcl-2, NSE, S100 protein, cyclin-D1, GFAP, HMB45, inhibin, EMA & synaptophysin – - 7 7 7 - Zou, 2020 [13] 61 - - - - - I Surgery - - - 12 - 12 Alive with disease Tang, 2020 [14] 74 Irregular vaginal bleeding, mass No 6 Left vagina No - Partial vaginectomy - Beta-catenin, ER, PR, vimentin+; CD10, EMA, CD31, CD34, CD117,CD99, SMA, desmin, h-caldesmon, S-100, MelanA, &HMB45 – Free 46 46 46 - Wu, 2022 [15] - - - - - Yes - Surgery+RT - - - - - - - Present case 38 Pain Yes 7 Posterior fornix Yes IIIA TAH+BSO+ vaginectomy+ rectosigmoid resection Anastrozole 1 mg CD10, ER, PR and focally for cyclin D1 and desmin+; SMA – Free 65 65 65 - RFS, recurrence-free survival; OS, overall survival; TAH, total abdominal hysterectomy; BSO, bilateral salpingo-oophorectomy; EMA, epithelial membrane antigen; LCA, leucocyte common antigen (CD45); LND, lymphadenectomy; ER, estrogen receptor; PR, progesterone receptor; LN, lymph node; PAC, cisplatin, doxorubicin, and cyclophosphamide; MPA, medroxyprogesterone acetate; CA125, cancer antigen 125; RT, radiotherapy; SMA, smooth muscle antigen. Table 1. Continued 78 Korean Journal of Clinical Oncology

Malignant transformation of long-standing endometriosis occurs in 0.7% to 1% of cases and the most common histopathology is ad- enocarcinoma, particularly of the endometrioid or clear cell sub- type. Rarely endometriotic foci can give rise to ESS. EESS arising from endometriosis is an extremely rare condition, reported only in few case reports. The symptoms of ESS and endometriosis are similar and depend on the site of involvement. EESS can arise as a primary disease as a result of metaplasia of sub-coelomic mesenchyme or secondarily from malignant trans- formation of pre-existent endometriosis. It may not always be pos- sible to differentiate primary EESS from secondary EESS. Accord- ing to Sampson criteria, to diagnose endometriosis-associated ma- lignancy, the following points should be met: (1) demonstration of benign endometriotic foci in the proximity of the malignant tu- mor; (2) no other primary site for the tumor; or (3) histology of tu- mor consistent with origin from an endometriotic foci [2]. Our case met all of Sampson’s criteria (presence of multiple endometri- otic foci in the periphery of the tumor, presence of tumor in rec- tovaginal septum and posterior vaginal wall excluding any other source of primary origin, histopathological examination consistent with that of ESS arising from endometriosis) suggesting that the initial vaginal endometriosis had undergone malignant transfor- mation into low-grade ESS subsequently. It has also been noted that it is not always necessary to identify a focus of endometriosis near the tumor because growth of tumor may destroy the transi- tional areas of endometriosis. Therefore, any tumor of histological type known to be associated with endometriosis occurring at an unusual age and at an uncommon site may point towards the diag- nosis of malignant transformation even without a demonstrable focus of endometriosis in real time. One of the most important differential diagnoses to be consid- ered is gastrointestinal stromal tumor (GIST). GIST s are rounded smooth tumors, arising as an endoluminal, exophytic growth. They are immune positive for CD117 and DOG-1. In compari- son, the characteristic appearance of gastrointestinal tract ESS is that of an extrinsic mass that may involve the complete thickness of rectal wall with luminal protrusion. The presence of invasive tongues of tumor at the periphery of the neoplasm, short fascicles or sheets of monotonous plump spindle cells and prominent arte- rioles favor the diagnosis of ESS. Most common site of origin of EESS are the ovaries. Only few cases were reported arising from the vagina (T able 1) [1,3-15]. ESSs are characterized by the presence of the fusion of JAZF1 and SUZ12 (JJAZ1) genes resulting from translocation of t(7,17) (p15;q21). But, in contrast, EESS rarely harbors this genetic abnor- mality. The factors that lead to malignant transformation in endometri- osis are not clear. Exogenous hormone therapy with estrogen was considered as a potential contributing factor for the development of the colonic ESS in a few case reports. Conversely, hormonal therapy may have checked the tumor growth as medroxyproges- terone acetate is known to achieve tumor control in already diag- nosed cases of ESS. Our patient was given hormonal treatment with gonadotropin-releasing hormone (GnRH) analogs and pro- gesterone as she was initially diagnosed to have deeply infiltrating rectovaginal endometriosis. Low-grade ESS is a slow growing neo- plasm and the management is primarily surgical with the aim of complete cytoreduction. The most important prognostic variable is stage with 5-year survival rates as good as 90% to 100% for stage 1 and reduced to 50% for advanced stage disease. A systematic re- view on EESS has revealed that small size of the tumor and hor- monal therapy were predictors of a good survival, while the role of chemotherapy or radiation does not seem to affect survival. In cas- es of disseminated intraperitoneal disease survival rates as low as 12% have been reported. Late recurrences are common, even with early-stage tumors, mandating a long time follow-up for these pa- tients. In conclusion, being an extrauterine foci of endometriosis, any primary tumor of the endometrium might arise from endometri- osis. A practicing gynecologist should keep this rare possibility in mind while medically treating long-standing cases of deeply infil- trating endometriosis. Features suggestive of malignant transfor- mation include worsening symptoms, development of resistance to a previously responsive medical treatment or sudden increase in size. CONFLICT OF INTEREST No potential conflict of interest relevant to this article was reported. FUNDING None. ORCID Seema Singhal https://orcid.org/0000-0002-8644-7684 Aarthi S Jayraj https://orcid.org/0000-0002-6913-6876 Ekta Dhamija https://orcid.org/0000-0001-8265-9674 Sachin Khurana https://orcid.org/0000-0002-6308-5481 Seema Singhal et al. • ESS from vaginal endometriosis www.kjco.org 79

1. Masand RP , Euscher ED, Deavers MT , Malpica A. Endometrioid stromal sarcoma: a clinicopathologic study of 63 cases. Am J Surg Pathol 2013;37:1635-47. 2. Alcazar JL, Guerriero S, Ajossa S, Parodo G, Piras B, Peiretti M, et al. Extragenital endometrial stromal sarcoma arising in endometri- osis. Gynecol Obstet Invest 2012;73:265-71. 3. Berkowitz RS, Ehrmann RL, Knapp RC. Endometrial stromal sar- coma arising from vaginal endometriosis. Obstet Gynecol 1978; 51(1 Suppl):34s-7s. 4. Ulbright TM, Kraus FT . Endometrial stomal tumors of extra-uter- ine tissue. Am J Clin Pathol 1981;76:371-7. 5. Kondi-Paphitis A, Smyrniotis B, Liapis A, Kontoyanni A, Deligeor- gi H. Stromal sarcoma arising on endometriosis: a clinicopatholog- ical and immunohistochemical study of 4 cases. Eur J Gynaecol Oncol 1998;19:588-90. 6. Chang YC, W ang TY , Tzen CY . Endometrial stromal sarcoma of the vagina. Zhonghua Yi Xue Za Zhi (T aipei) 2000;63:714-9. 7. Corpa MV , Serafini EP , Bacchi CE. Low-grade endometrial stromal sarcoma presenting as vaginal nodule. Ann Diagn Pathol 2004;8: 295-8. 8. Liu Z, Ding J, Li X, Y u K. Endometrial stromal sarcoma arising in vagina. Int J Clin Exp Pathol 2013;6:2997-3002. 9. Rivard C, Carter JS, Downs LS Jr. Low-grade endometrial stromal sarcoma primarily arising in the vagina: a case report. J Reprod Med 2015;60:433-5. 10. W ang Y , Huang YW , Li YF . Primary vaginal sarcoma: experience of a regional cancer center in China. J Obstet Gynaecol Res 2015;41: 1463-8. 11. Sanverdi I, T emizkan O, V ural F , Koc N, Polat M. Primary vaginal endometrial stromal sarcoma associated with endometriosis: a case report with a review of the literature. Eur J Gynaecol Oncol 2016;37:717-21. 12. Abu Jamea GA, Al Rikabi AC, Akkour K. Primary low-grade en- dometrial stromal sarcoma arising in the vagina: report of an un- usual case and literature review. J Surg Case Rep 2017;2017:rjx238. 13. Zou Y , T urashvili G, Soslow RA, Park KJ, Croce S, McCluggage WG, et al. High-grade transformation of low-grade endometrial stromal sarcomas lacking YWHAE and BCOR genetic abnormali- ties. Mod Pathol 2020;33:1861-70. 14. T ang Y , Chen Y , Tian L, Chen J, Y ang P , Zhang D, et al. V aginal low- grade endometrial stromal sarcoma: an extremely rare case report and review of the literature. Int J Gynecol Pathol 2020;39:447-51. 15. W u Y , Li N, Zhang R, Bai P . Primary low-grade extrauterine endo- metrial stromal sarcoma: analysis of 10 cases with a review of the literature. W orld J Surg Oncol 2022;20:17.