Mesonephric adenocarcinoma of the uterine cervix with a prominent spindle cell component
- Authors:
- Published online on: August 22, 2024 https://doi.org/10.3892/ol.2024.14641
- Article Number: 508
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Copyright: © Fan et al. This is an open access article distributed under the terms of Creative Commons Attribution License.
Abstract
Introduction
Mesonephric adenocarcinomas (MAs) are rare malignant human papillomavirus (HPV)-independent cervical tumours that arise from vestiges of the embryological female reproductive system (Wolffian/mesonephric duct) remnants located deep in the cervical wall (1,2). MAs constitute <1% of cervical adenocarcinomas (3). While these tumours can arise across a wide age range, they are rarely diagnosed in patients <30 years old (2). Clinically, this type of tumour typically manifests as abnormal vaginal bleeding or is identified as a cervical mass during a pelvic examination (4). MAs display diverse morphologic architectural patterns, including tubular, glandular, papillary, cribriform, retiform, spindle cell and solid structures (2). Morphologically, the tumour is characterized by mesonephric remnants, mesonephric hyperplasia and eosinophilic luminal secretions (5). MAs are characterized by recurrent KRAS mutations (3). Molecularly, 75–100% of patients with MAs exhibit KRAS mutations (3,6,7).
Patients with MAs have a worse prognosis compared with those with cervical squamous cell carcinoma and other types of adenocarcinomas (8,9). Spindle cell components are observable in MAs; however, they have been minimally explored in studies concerning their biological behaviour and prognosis (3). A total of 3 cases of cervical MAs that featured prominent spindle cell components are reported in the present study, and a comprehensive literature review was carried out to determine the potential associations between spindle morphology and, unique clinicopathological and molecular characteristics.
Materials and methods
Samples and clinical data
Female patients diagnosed with primary uterine cervical MA with prominent spindle cell components at West China Second University Hospital, Sichuan University (Chengdu, China) between January 2020 and December 2023 were included in the present study. All procedures performed in studies involving human participants adhered to ethical standards. The staging system used for cervical MAs with spindle cell components was the 2018 revision by the International Federation of Gynaecology and Obstetrics (FIGO) (10). The clinicopathological information of the patients, including age, clinical presentations, procedures, tumour size, follow-up information and FIGO stage, were extracted from the electronic medical records of the patients. Two gynaecological pathologists reviewed all haematoxylin and eosin (H&E) sections, and the immunohistochemical findings of the included cases. A total of 5 cases were excluded due to the lack of complete clinicopathological information or the absence of a spindle cell component. Ultimately, 3 cases were included in the present study.
Immunohistochemistry
The tissue was fixed using a 10% neutral buffered formalin solution at room temperature for 24 h. Immunohistochemical staining was performed on 4-µm-thick formalin-fixed paraffin-embedded (FFPE) tumour samples with the automated staining system Bond III (Leica Biosystems) based on the EnVision method. FFPE sections (4-µm-thick) were immersed in xylene, and 100, 95, 85 and 75% ethanol for dewaxing and hydration. Antigen retrieval was performed by heating the sections to 95°C in citrate buffer (pH 6.0) for 20 min. For intracellular antigens or membrane proteins with an internal epitope, 0.1% Triton X-100 solution was used for permeabilization at room temperature for 10 min. The BOND polymer Refine Detection kit (cat. no. DS9800) from Leica Biosystems, using Bond III, including 3–4% hydrogen peroxide as the peroxide block, was used for 5 min at room temperature. For blocking of non-specific binding, the sections were incubated with BOND™ Primary Antibody Diluent (Leica Biosystems), which includes 1–3% BSA, at room temperature for 10 min. The sections were incubated with anti-rabbit poly-HRP IgG (<25 µg/ml; from the DS9800 kit) for 15 min at room temperature. All immunohistochemically stained tumour samples were evaluated using appropriate internal (including liver, kidney, tonsil, renal, fallopian tube and thyroid tissues) and external (including lymphocytes, mesothelial cells and normal cervical epithelial cells) controls. The chromogen used to visualize the staining was 3,3′-diaminobenzidine (included in the BOND Polymer Refine Detection kit). The following antibodies were used: Cytokeratin (CK) pan (cat. no. RAB-0050; 1:500; Fuzhou Maixin Biotechnology Development Co., Ltd.), epithelial membrane antigen (EMA; cat. no. Kit-0011; 1:100; Fuzhou Maixin Biotechnology Development Co., Ltd.), paired box 8 (PAX8; cat. no. RMA-1024; 1:200; Fuzhou Maixin Biotechnology Development Co., Ltd.), oestrogen receptor (ER; cat. no. Kit-0012; 1:100; Fuzhou Maixin Biotechnology Development Co., Ltd.), progesterone receptor (PR; cat. no. Kit-0013; 1:100; Fuzhou Maixin Biotechnology Development Co., Ltd.), p16 (cat. no. MAB-0673; 1:1,000; Fuzhou Maixin Biotechnology Development Co., Ltd.), GATA3 (cat. no. MAB-0695; 1:100; Fuzhou Maixin Biotechnology Development Co., Ltd.), CD10 (cat. no. MAB-0668; 1:400; Fuzhou Maixin Biotechnology Development Co., Ltd.), transcription termination factor 1 (TTF1; cat. no. MAB-0266; 1:100; Fuzhou Maixin Biotechnology Development Co., Ltd.), p53 (cat. no. MAB-0674; 1:1,000; Fuzhou Maixin Biotechnology Development Co., Ltd.), vimentin (Vim; cat. no. MAB-0735; 1:600; Fuzhou Maixin Biotechnology Development Co., Ltd.), hepatocyte nuclear factor-1β (HNF1β; cat. no. ZA-0129; ready-to-use; OriGene Technologies, Inc.) and Ki67 (cat. no. MAB-0672; 1:300; Fuzhou Maixin Biotechnology Development Co., Ltd.). Sections were incubated with primary antibodies at room temperature for 15 min. The immunohistochemical staining was analyzed using an Olympus BX43 light microscope (magnification, ×100; Olympus Corporation).
Targeted next-generation sequencing (NGS)
The genomic alteration profiling test was conducted by Precision Scientific, Inc. using targeted NGS technology. The targeted NGS panel assessed 107 genes (Table SI). DNA was extracted from unstained FFPE tumour samples from all 3 patients after selecting a region with >20% tumour cells. DNA was prepared for sequencing using the QIAamp DNA FFPE Tissue Kit (cat. no. 56404; Qiagen, Inc.) according to the manufacturer's protocol. Quality control was completed using a Qubit (Thermo Fisher Scientific, Inc.), and agarose gel electrophoresis was carried out to assess the extracted genomic DNA. Library construction and capture were performed using the KAPA HyperPlus Kit (cat. no. KK8514; Roche Sequencing), with a standard DNA starting quantity of ≥200 ng and an output library concentration of ≥0.5 ng/µl. Sequencing was conducted on the Illumina NovaSeq 6000 platform (Illumina, Inc.), using the NovaSeq 6000 S4 Reagent Kit (300 cycles; cat. no. 20028312; Illumina, Inc.), with an average sequencing depth of ≥100× for control samples and ≥500× for tumour tissue samples. The sequencing type was paired-end with a read length of 150 bp. The final library loading concentration was 300 pM, and was measured using the Qubit 3.0 Fluorometer (Thermo Fisher Scientific, Inc.). Post-sequencing, internally developed bioinformatics analysis was carried out, where the proportion of sites in the capture region with a depth >0.2× had an average depth of ≥90%, the sequence alignment rate was ≥90%, and the sequencing data Q30 were ≥80%. Variant detection included single nucleotide variations, small fragment insertions/deletions, gene copy number variations and gene fusions within the capture range with breakpoints. Data analysis was conducted using the DRAGEN Bio-IT Platform (version 3.8.4; Illumina, Inc.), and the results were interpreted using the software's variant calling pipeline (Illumina DRAGEN variant caller; http://www.illumina.com/products/by-type/informatics-products/dragen-bio-it-platform.html).
Results
Clinical features
The clinicopathological features of the patients are summarized in Table I. The present study included 3 postmenopausal female patients aged 51–60 years (mean age, 56 years) with primary uterine cervical MA with prominent spindle cell components. The 3 patients presented with different clinical symptoms, including cervical ThinPrep cytologic test results indicating abnormal (11), abdominal distension and pain, and postmenopausal vaginal bleeding. In case 1, colposcopy demonstrated a 1×0.5 cm ulcerated area on the cervix at the 11 o'clock position.
Imaging examinations indicated cervical masses in 2 cases. In case 2, a contrast-enhanced computed tomography scan demonstrated a solid-cystic mass on the left side of the pelvic cavity, measuring 7.3×6.4×5.4 cm, and unclear boundaries with the left adnexa and the posterior wall of the uterus were. Additionally, computed tomography imaging also showed a low-density uterine cervical mass in case 3, measuring 3.5×2.8×2.7 cm.
The 3 cases showed slightly elevated serum tumour markers, including serum CA125, CA19-9 and CEA. Furthermore, case 1 and 2 both had a history of surgery for pulmonary adenocarcinoma. The family histories of all patients were unremarkable.
Treatment and follow-up
All 3 patients underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAHBSO) with pelvic lymph node dissection (LND). Of the included patients, 2 patients were classified as FIGO stage IIB, while the remaining patient was classified as FIGO stage IB. Patients with FIGO stage IIB received postoperative adjuvant chemotherapy (CT) using carboplatin and paclitaxel for 6 cycles, while case 2 additionally underwent adjuvant radiation therapy at a dose of 6 Gy/fraction (total of 28 times).
Follow-up information was obtained for all 3 patients. The latest prognostic data showed no recurrences or deaths among the 3 patients, who were followed up for 9, 11 and 16 months.
Pathological features
On gross examination, two tumours presented as cauliflower-like masses in the cervix (Fig. 1A). A total of two biopsy specimens, one frozen and three surgical specimens were reviewed from all 3 cases.
Histologically, all surgical specimens from the 3 cases exhibited biphasic tumours characterized by the coexistence of epithelioid and spindle cell areas. There was a transition from the epithelioid areas to the spindle cell areas. In the spindle cell areas, tumour cells exhibited an invasive growth pattern, arranged in fascicular and storiform patterns (Fig. 1B). These spindle cells had small amounts of indistinct cytoplasm, oval to fusiform nuclei, non-prominent nucleoli and moderate nuclear atypia. Mitotic figures were identified. Heterologous sarcomatous components, highly heterotypic tumour cells and definite necrosis were not present.
In the adjacent area to the spindle cell areas, glandular, papillary, cribriform and back-to-back tubular structures were observed, lined by cuboidal tumour cells with moderate-to-marked nuclear atypia, mitotic figures and nuclear grooves. The cuboidal epithelioid cells formed glandular tubular structures with luminal eosinophilic hyaline secretions (Fig. 1C). Additionally, benign mesonephric remnants and hyperplasia surrounding the tumour were visible (Fig. 1D).
In the biopsy specimens of case 1, the tumour was primarily composed of spindle cells with occasional glandular components, when examined microscopically. The initial diagnosis, at the local hospital, had been synovial sarcoma. In another biopsy specimen of case 3, no spindle cell component was observed, leading to an initial diagnosis of clear cell carcinoma. Prominent spindle cell components were also observed in the frozen specimen. In the frozen sections, only diffuse spindle tumour cells were observed, with no evidence of epithelioid areas. Based on the aforementioned morphological features, the initial diagnosis of the intraoperative frozen sample was spindle cell tumour, tending towards mesenchymal tumour.
The immunohistochemistry results are shown in Table II. Immunohistochemically, tumour cells stained positive for epithelial markers, EMA and CK pan (Fig. 2A-D), PAX8 (Fig. 2E and F) and Vim (Fig. 2G and H) both in spindle cell components and in epithelioid areas. Staining for TTF1 (Fig. 2I and J) and CD10 (Fig. 2K and L) were positive in 1 case and in 2 cases, respectively. Staining for p16 (Fig. 3A and B) was focal or patchy positive in tumour cells. Tumour cells were negative or focal positive for ER (Fig. 3C and D) and PR (Fig. 3E and F) staining. Tumour cells were negative for HNF1β staining (Fig. 3G and H) in 1 case. In case 1 and 2, staining for GATA3 was positive both in spindle cell components and epithelioid areas, while in case 3, staining for GATA3 was negative in spindle cell components and positive in epithelioid areas (Fig. 3I and J). p53 was expressed at normal levels in all 3 cases (Fig. 3K and L). The range of the Ki67 proliferative index was 5–40% (Fig. 3M and N).
Molecular features
NGS was performed in all 3 cases. Microsatellite instability was not identified in any of the included cases. In case 1, only one KRAS mutation (p.Q61K) was identified. In case 2, one KRAS mutation (p.G12D) and one checkpoint kinase 2 mutation (c.909-1G>A), along with amplifications of KRAS, MDM4 and neurotrophic receptor tyrosine kinase 1 (NTRK1) were identified. A PIK3CA mutation (p.E726K) and amplification of NTRK1 were identified in case 3. The histopathological and immunohistochemical findings of case 3 are shown in Fig. 4. Microscopically, the tumour consisted of two components: An epithelioid area with glandular (Fig. 4A) and papillary (Fig. 4B) patterns, and a solid spindle cell area (Fig. 4C). Immunohistochemically, both EMA (Fig. 4D) and CK pan (Fig. 4E) showed positive expression. In the epithelioid area, CD10 luminal staining was positive (Fig. 4F), and p16 staining showed patchy positive expression (Fig. 4G). PAX8 was positively expressed in both the epithelioid and spindle cell areas (Fig. 4H).
Discussion
Primary cervical MAs are rare malignant tumours, that represent only 1% of all cervical malignancies (2). Currently, cervical MAs have only been reported as case reports or small series (3,4,6,9,12,13). The largest study on cervical MAs to date is the multicentre study conducted by Pors et al (9), which included 30 cases. In the published literature, most MA reports did not clearly describe the presence of spindle cell components, and a few MAs with spindle cell components were diagnosed as mesonephric carcinosarcomas, previously referred to as mesonephric mixed tumours. To the best of our knowledge, only 11 cases of cervical MAs with spindle cell components have been reported, which includes the cases described in the present study (Table III).
 | Table III.Mesonephric adenocarcinomas with spindle cell components in the literature and the present cases. |
The median age at diagnosis of cervical MAs with spindle cell components was 54 years (range, 37–76 years). The age at diagnosis was similar to that previously reported in cases of MAs without spindle cell components (52–59 years) and mesonephric carcinosarcomas (54 years) (8,9,14). The median tumour size of cervical MAs with spindle cell components was 4.5 cm (range, 1–12 cm), which was larger compared with that of mesonephric carcinosarcomas (3.5 cm) (14). Among the 7 patients with MAs and spindle cell components, 5 (71%) were diagnosed at FIGO stage II–IV. A previous review reported that only 30% of patients with MAs without spindle cell components are diagnosed at FIGO stage II–IV (8). Contrary to the aforementioned review, the multicentre study by Pors et al (9) showed that a higher proportion of patients (60%) with MAs and without spindle cell components were diagnosed at an advanced stage (FIGO stage II–IV). Moreover, ~40% of patients with mesonephric carcinosarcomas were diagnosed at FIGO stage II–IV (14,15). These reports indicate that MAs with spindle cell components are more likely to be diagnosed at an advanced stage compared with MAs without spindle cell components and mesonephric carcinosarcomas. In the current study, spindle cell components displayed moderate nuclear atypia with readily identified mitotic figures. The advanced stage and malignant morphology suggest that spindle cell components may contribute to disease progression and aggressive biological behaviour.
Prognostic information was available for only 5 cases of MAs with spindle cell components, which includes the 3 cases presented in the present study. The mean duration of the follow-up was 16.4 months (range, 9–36 months). Only 1 patient (20%) lived with disease at FIGO stage IIIB and no death was observed. The sites of recurrence and metastasis included the abdomen, pelvis and liver (3). A previous literature review of 31 patients reported that ~30% of patients with MAs lacking spindle cell components experienced recurrence and 23% died from the disease, irrespective of the disease stage (8). The recent study by Pors et al (9) which included 30 cases reported that patients with MAs lacking spindle cell components had a worse prognosis, with a 5-year overall survival rate of 74% and progression-free survival rate of 60% in cervical MAs, compared with the findings of previous literature reviews. However, the composition of spindle cell components is not clearly described in the literature, which potentially makes prognostic evaluations challenging and unreliable when compared between MAs with and without these components. Patients with MAs and spindle cells components appear to have an improved prognosis compared with those patients without these components. Fregnani et al (16) reported that among the 35 cases of cervical adenocarcinomas, the recurrence rate was 16%, which was lower compared with that of MAs with spindle cells components. In addition, in a literature review containing 9 mesonephric carcinosarcomas, the recurrence rate was 22%, which was slightly higher compared with that of MAs with spindle cells components (8,15). Despite limited data, MAs with spindle cell components still show a poor prognosis.
In the present study, 2 of the 3 cases had a history of surgery for pulmonary adenocarcinoma. Histologically, both cases diagnosed with MAs showed glandular tubular structures with luminal eosinophilic hyaline secretions, and benign mesonephric remnants and hyperplasia. The TTF1 expression in MAs overlapped with that in pulmonary adenocarcinoma. Therefore, additional immunohistochemical markers were used to differentiate the cases. PAX8, a specific marker for differential diagnosis, was positively expressed in both cases in the present study. PAX8 primarily contributes to the organogenesis of the thyroid gland, kidney and Müllerian system. PAX8 typically shows negative expression in primary and metastatic lung cancers, and positive expression in MAs (2,17,18). The luminal staining pattern of CD10 is useful for confirming primary cervical MAs, as it is absent in pulmonary adenocarcinoma (19). Histological and immunohistochemical characteristics aided in ruling out metastatic pulmonary adenocarcinoma of the uterine cervix.
Histologically, MAs typically exhibit a mixture of architectural patterns and overlap with other tumours (2). Spindle cell components in MAs pose diagnostic challenges and complicate accurate diagnosis. In the 2 cases reported in the present study, the initial diagnoses were initially considered to be mesenchymal tumours. Therefore, MAs should be included in the differential diagnosis when obvious spindle cell components are present morphologically, particularly in biopsy specimens. The correct diagnostic rate is only 10% in initial biopsy specimens (9). Histological and immunohistochemical features serve an important role in diagnostic work. Diagnostic clues include luminal eosinophilic hyaline secretions, nuclear grooves, mesonephric remnants, mesonephric hyperplasia, HPV independence and the absence of heterologous sarcomatous components. Recommended immunohistochemical panels include the epithelial markers EMA and/or CK pan, and PAX8, CD10, GATA3, TTF1, ER, PR, HNF1β and p16.
MAs typically exhibit positive epithelial marker expression (EMA and/or CK pan) in both epithelial and spindle cell areas, PAX8 positivity, luminal CD10 staining, negative or focal positive ER and PR, positive GATA3 and/or TTF1, negative HNF1β and non-diffuse positive p16 (18). In the present study, there were no differences in the immunohistochemical characteristics between MAs with and without spindle cell components. Among the aforementioned immunohistochemical markers, GATA3 is a highly sensitive and specific marker for MAs (20,21). In case 3, GATA3 showed negative staining in the spindle cell areas and positive staining in the adenoid areas. The staining intensity of GATA3 may decrease in the solid areas, which is consistent with previous studies (20,21). Therefore, it is noteworthy that if a spindle cell component is recognized with GATA3 expression as negative or weakly positive in the biopsy specimen, it may also be suspected of being MA. TTF1 may be useful in diagnosing cases where GATA3 is negatively expressed, due to the inverse staining pattern between GATA3 and TTF1 (21).
The overlapping morphological features of MAs with prominent spindle cell components make for a broader range of differential diagnoses. The main differential diagnoses include endocervical adenocarcinoma, clear cell carcinoma and endometrioid adenocarcinoma (2). Endocervical adenocarcinoma, often associated with HPV, exhibits mucin production or ciliation (2,4). p16 shows diffuse staining in HPV-related endocervical adenocarcinomas but shows patchy staining pattern in MAs (2,4). In cases with overlapping morphological features that are challenging to diagnose, a combination of immunohistochemical markers such as CEA, p16, GATA3 and CD10 can be used (2). Clear cell carcinoma, HPV-independent adenocarcinoma, is characterized by clear, eosinophilic and hobnailed tumour cells (22). HNF1β, a marker commonly used in the diagnosis of clear cell carcinoma, is also positively expressed in a subset of MAs (18). Squamous and mucinous differentiation can be used for the diagnosis of endometrioid adenocarcinoma (2). Immunohistochemical staining for ER and PR is usually positive in endometrioid adenocarcinoma (23).
Moreover, the most challenging differential diagnosis is that of mesonephric carcinosarcomas. Mesonephric carcinosarcomas, which are biphasic tumours, consist of distinguishable malignant epithelial and spindle cell components (6). In these two subtypes tumours, mesonephric hyperplasia and a transition from the malignant epithelioid components to the spindle cell components were observed (3,24–26), which supports both tumours originating from mesonephric duct remnants. Both MAs and mesonephric carcinosarcomas may contain a population of morphologically spindle cells, and there are no clear criteria for distinguishing between these two subtypes of tumours. The present study demonstrated that there were differences in histological and immunohistochemical features between these two subtypes tumours. In MAs, the spindle cells are typically cytologically more bland (27); however, in mesonephric carcinosarcomas, spindle cells usually show more marked atypia and heterologous sarcomatous components can also be observed (15,26). Mirkovic et al (27) recommended that MAs with heterologous mesenchymal elements should be diagnosed as mesonephric carcinosarcomas. At present, reported heterologous sarcomatous components in the literature have included osteosarcoma, chondrosarcoma and rhabdomyosarcoma, while the homologous component has been limited to endometrial stromal sarcoma (15). Immunohistochemically, Vim is positively expressed in 70–100% of MAs, ranging from focal positive to diffuse strong positive expression (18,26). The present study showed that Vim was positively expressed in both malignant epithelioid and spindle cell areas, which showed no difference compared with mesonephric carcinosarcomas (24,25). The spindle cell components have diffuse positive expression for epithelial markers such as EMA and CK pan in MAs, while the expression of patterns is reversed in mesonephric carcinosarcomas (15,24,25). In addition, Mirkovic et al (3) reported that there was no association between molecular features and spindle cell composition in MAs. Therefore, it was suggested that the spindle cell components in MAs may be part of the morphologic spectrum of the tumours, which was consistent with previous studies (27,28). Although a transition from the malignant epithelioid components to the spindle cell components was also observed in mesonephric carcinosarcomas, in contrast to MAs, the sarcomatoid spindle cell components of mesonephric carcinosarcomas may originate from the malignant epithelioid components. Similar to uterine carcinosarcoma (29), the development of sarcomatoid spindle cell components in mesonephric carcinosarcomas may be caused by epithelial-to-mesenchymal transition. In addition, the co-expression of both cytokeratin and Vim was observed in malignant epithelial areas of MAs, likely enhancing the progression of epithelial-to-mesenchymal transition (30). These may explain the lack of expression of epithelial immunohistochemical markers in spindle cell components of mesonephric carcinosarcomas and the presentation of sarcomatoid features on the histology. Therefore, epithelial immunohistochemical markers and histological features, including heterologous sarcomatous components and frankly malignant spindle cell components, are useful for distinguishing between these entities.
Consistent with previous studies (3), no specific molecular events were found to differentiate MAs with spindle cell components from those without spindle cell components. The molecular alterations of MAs without spindle cell components mainly included KRAS/NRAS mutations, microsatellite stability and gains of chromosome 1q (3,7). KRAS/NRAS mutations are the most common molecular alterations in MAs and are mutually exclusive. KRAS mutations are more recurrent than NRAS mutations, and it has been reported that the majority of patients with MAs (range, 75–100%) harboured KRAS mutations, which mainly affected the hotspot codons 12 and 13 (3,6,7). The mutation range of KRAS in cervical adenocarcinoma is 13.9–17.5%, regardless of histological type (31,32). Among the reported MAs with spindle components, including those in the present study, 72.7% exhibited KRAS/NRAS mutations, a rate similar to that of MAs without spindle components and markedly higher compared with that in cervical adenocarcinomas. Meanwhile, mesonephric hyperplasia lacks KRAS/NRAS mutations (33). KRAS/NRAS mutations may contribute to the development of MAs (3,6). Other molecular changes have also been reported, including chromatin remodelling of ARID1A/B and SMARCA4 (3).
In the female reproductive system, PIK3CA mutations are more common in endometrial and other types of cervical adenocarcinomas arising from the Mullerian ducts (32,34–36). The PIK3CA mutation rate range is 25–32.2% in cervical adenocarcinoma, and 52% in HPV-independent cervical cancers (31,32,37). In the study by Mirkovic et al (3), PIK3CA mutations were not identified from 13 cervical MAs. Subsequently, da Silva et al (6) reported that 2 cervical patients with MAs harboured simultaneous KRAS and PIK3CA mutations. To the best of our knowledge, there have been no previously reported cases of PIK3CA mutations without KRAS or NRAS mutations in MAs or mesonephric-like carcinomas and the present study is the first to describe a case of a cervical MA with a PIK3CA mutation only, without KRAS or NRAS mutations. Additionally, β-catenin (CTNNB1) mutations are commonly found in carcinomas originating from the Mullerian ducts, and a recent study described an MA with mutations in both CTNNB1 and KRAS (4). These observations suggest that there are shared molecular alterations between MAs and carcinomas that arise from the Mullerian ducts.
The present study demonstrated that MAs with spindle cell components can harbour KRAS and PIK3CA mutations independently. Activation of the mitogen-activated protein kinase (MAPK) pathway leads to abnormal activation of the RAS-MAPK pathway, promoting cellular proliferation, differentiation and survival (38). PIK3CA encodes the p110α catalytic subunit of the class IA PI3Ks (39). Mutations in PIK3CA can result in abnormally increased catalytic activity of PI3Ks, thus promoting cell carcinogenesis (39,40). According to a recent study in HPV-independent cervical cancers, aberrant activation of the PI3K-AKT pathway due to overexpression of ERBB4 and FGFR1/4 and deletion of PTEN may drive oncogenesis, affecting cell proliferation, survival and glycolysis (37). This suggests that the oncogenic drivers of these tumours may involve the RAS-MAPK and PI3K/AKT pathways, either individually or in combination. This finding provides new insights into the pathogenesis of MAs. However, the present study only included a small number of these tumour subtypes; and it remains uncertain whether this is a unique molecular alteration in MAs with spindle components. To validate the findings of the current study, NGS and whole exome sequencing on MAs without spindle components, mesonephric carcinosarcomas and sufficient MAs with spindle components are needed in future studies, which could enhance the understanding of the molecular changes in these tumours.
NTRK genes encode tropomyosin receptor kinases (Trk) (41). Fusion of NTRK1/2/3 genes is the most common mechanism of Trk activation in various cancers (41). In malignant melanoma, the amplification of the NTRK1 gene is associated with poor clinical outcomes (42). NTRK1 amplification was detected in both cases of MAs with FIGO stage IIB that reported in the current study. NTRK1 amplification may promote tumour cell proliferation in MAs leading to an advanced stage.
All 3 patients included underwent TAHBSO and pelvic LND. Of these, 2 patients received adjuvant CT with carboplatin and paclitaxel, and 1 patient also underwent adjuvant radiation therapy following primary surgery. Currently, there is no standardized treatment for this rare tumour. Treatments depend on the stage of MA, and the treatment principles are consistent with other types of cervical adenocarcinomas (12). The majority of patients with early-stage MAs underwent TAHBSO, while a small proportion of patients also received adjuvant radiotherapy and CT (8). While adjuvant CT with carboplatin and paclitaxel is commonly used as first-line treatment, its role in early-stage MAs is currently unclear (43). Similarly, the efficacy of adjuvant radiotherapy is also unclear. In the MAs lacking spindle cell components, patients receiving adjuvant therapy experienced higher recurrence and mortality rates compared with those who did not (8). Adjuvant therapy is reported to improve prognosis in patients with mesonephric carcinosarcomas that contain spindle cell components, evidenced by lower recurrence and mortality rates compared with those not receiving therapy (15). As aforementioned, MAs with spindle cell components often present at advanced stages and have concerning recurrence rates. Therefore, it is hypothesized that adjuvant therapy is crucial for these patients as it may improve prognosis. However, larger studies are needed to clarify the clinical effectiveness of adjuvant therapy in MAs with spindle cell components.
The RAS-MAPK and PI3K-AKT pathways may be targets for therapy in MAs with spindle cell components. Common KRAS mutation sites include G12C, G12D and G12V (6,7). The KRAS G12C inhibitor adagrasib has received approval by the United States Food and Drug Administration (44). The KRAS G12D inhibitor has also shown promising efficacy in preclinical studies (45,46). The PI3Kα inhibitor alpelisib demonstrated therapeutic effects in cervical solid tumours (47). Additionally, in animal models, the PI3Kα inhibitor exhibited improved antitumor effects in HPV-independent cervical cancers (37). KRAS and PIK3CA mutations in MAs with prominent spindle cell components suggest that KRAS inhibitors and PI3K inhibitors may be used as potential targeted therapies to improve prognosis. However, KRAS and PI3Kα inhibitors have potential limitations and challenges as targeted therapies for MAs with spindle cell components. At present, there is no valid evidence of preclinical data on the efficacy of KRAS and PI3Kα inhibitors for the treatment of these rare tumours. In addition, MAs with spindle cell components are histologically biphasic tumours, and the expression of immunohistochemical markers, such as GATA3 as aforementioned, may vary between different components. Thus, it is challenging to determine the effect of the different histological components, as well as immunohistochemical expression, on the therapeutic efficacy of KRAS and PI3Kα inhibitors.
Spindle cell components in MAs have been largely overlooked in previous studies. The present study found that MAs with prominent spindle cell components were at an advanced stage and exhibited unique PIK3CA mutations, which distinguished them from MAs without such components. Further research is needed to gather more clinicopathological and molecular data from MAs with spindle cell components and other mesonephric tumours, to enhance the understanding of the role of spindle cell components in biological behaviour and molecular alteration. Prospective studies with larger cohorts are necessary to validate the targeted treatment with KRAS and PIK3CA inhibitors. If feasible, whole genome sequencing could provide a comprehensive genetic analysis of this rare tumour.
The present study had several limitations. Firstly, it is retrospective and spindle cell components of MAs may not be well documented in previous literature, which potentially leads to selection bias in the literature review and data collection. Secondly, the small sample size and lack of long-term follow-up limit the representativeness of the findings regarding prognosis, and molecular and clinicopathological features. Lastly, due to limited resources, the targeted NGS panel only assessed a number of gene mutations.
In conclusion, MAs exhibit morphologic diversity, with those containing spindle cell components associated with advanced stages and aggressive behaviour. Prominent spindle cell components in MAs are diagnostic pitfalls, especially in cervical biopsy specimens. Using a panel of immunohistochemical stains may aid in differential diagnosis. Despite KRAS being the most frequently observed molecular alteration, PIK3CA mutations may also be identified independently in MAs.
Supplementary Material
Supporting Data
Acknowledgements
Not applicable.
Funding
The present study was supported by the Sichuan Science and Technology Program (grant no. 2022NSFSC0708).
Availability of data and materials
The data generated in the present study may be requested from the corresponding author. The NGS data generated in the present study may be found in the BioProject database under the accession number PRJNA1132741 or at the following URL: https://www.ncbi.nlm.nih.gov/sra/PRJNA1132741.
Authors' contributions
YF was responsible for the conceptualization, data curation and writing of the manuscript. YH and LS collected and analyzed the clinicopathologic data. TL contributed to the immunohistochemical materials preparation. YS contributed to the conceptualization, manuscript writing, review and editing, supervision and funding acquisition of the present study. YF and YS confirm the authenticity of all the raw data. All authors read and approved the final manuscript.
Ethics approval and consent to participate
The institutional ethics committee of West China Second University Hospital, Sichuan University approved this study (approval no. 2023125; Chengdu, China). Consent from patients was obtained to perform further scientific research (immunohistochemical staining and NGS) using their samples.
Patient consent for publication
Written informed consent was obtained from each patient for the publication of this article and the accompanying images.
Competing interests
The authors declare that they have no competing interests.
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