PMC8435728_01
(A) Hematoxylin and eosin (H&E) staining shows uterine leiomyosarcoma (left) with lymphovascular invasion (right). (B) CT (left) and PET-CT (right) scans of the pelvis. Lesion in the area of the removed right ovary in March 2019, December 2019 and March 2020. (C) PET-CT scans of the abdomen. Nodes along the anterior abdominal wall in March 2019, December 2019 and March 2020, sagittal plane.
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Histological examination of the material indicated UL (Figure 1A), G1, pT1b, size 12 cm, with invasion of the entire thickness of the uterine myometrium wall and endometrial invasion. IHC examination revealed spindle-shaped cells with mild nuclear polymorphism and an abundance of mitoses (Figure1A). Lymphovascular invasion was detected (Figure 1A), resection margin and appendages were without a tumor. Figure S1), in the area of the removed right ovary (3 cm, Figure 1B) and along the anterior abdominal wall (up to 1 cm2, Figure 1C). First-line polychemotherapy (PCT) with ifosfamide (2500 mg/m2/day on days 1 to 4) and doxorubicin (25 mg/m2 intravenously, on days 1 to 3) started, and the patient received two out of four prescribed therapy courses. The patient received regorafenib as monotherapy (80 mg daily) from September till December 2019, and PET-CT investigation from 21.12.2019 revealed a complete metabolic regression of the tumor (Figures 1 and S1). Complete metabolic response of the patient's tumor was confirmed in March 2020 (Figures 1B, C), but then the treatment was terminated due to poor tolerability of the drug: the patient developed gastrointestinal toxicity, stomatitis, cheilitis, and arterial hypertension.
Schematic representation of YWHAE-JAZF1 fusion transcript identified. (A) gene structures upstream and downstream of fusion site. (B) JAZF1 gene exon coverage by normalized RNA sequencing reads.
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According to MRI data from June 2019 (Figure S2), the disease progressed: a pathological lesion with dimensions - transverse 2.4 cm, vertical 3.0 cm, craniocaudal 7.5 cm, unevenly accumulating a contrast agent was observed on the right, with the spread to the area of the iliac vessels. However, RNAseq analysis detected a previously unknown in-frame cancer fusion transcript of genes YWHAE and JAZF1, directly supported by nine sequencing reads (Figure 2). The relative exon coverage of JAZF1 by RNAseq reads downstream to the fusion site was higher than upstream, thus confirming abnormal activation of this gene (Figure 2B).
(A) Top-10 up-regulated (green color, top) and top-10 down-regulated (red color, bottom) molecular pathways in the patient's tumor. Line width for each pathway is proportional to the pathway activation level (PAL), scale for PAL values is presented on the right; (B) Gene expression level of Regorafenib targets. Targets included in the "KEGG Pathways in cancer" pathway are highlighted in red.
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MRI in September 2019 revealed lesions in the right iliac region - secondary altered lymph nodes, with signs of invasion in the right ureter (Figure S3). We found that the most strongly upregulated pathways dealt with (i) FOXA1 transcription factor network, (ii) downregulation of MTA3 in breast cancer, (iii) basal cell carcinoma network, (iv) elastic fiber formation, (v) cell migration branch of VEGFR signaling in lymphatic endothelium pathway, (vi) keratan sulfate degradation, (vii) endothelial cell regulation branch of cAMP pathway, (viii) L1CAM interactions, (ix) CXCR4 signaling, and (x) tumor cell invasion branch of Syndecan 1 signaling pathway (Figure 3A, top). The main downregulated pathways dealt with (i) type 2 diabetes network, (ii) muscle contraction, (iii-iv) cardiomyopathy network, (v and viii) PPAR signaling, (vi) noradrenaline and adrenaline degradation, (vii and x) acyl chain remodeling, and (ix) antibody-mediated complement activation (Figure 3A, bottom). Based on the results of this molecular profiling, the institutional tumor board approved administration of regorafenib, a targeted tyrosine kinase inhibitor with multiple specificities (Figure 3B).
"KEGG Pathways in cancer" signaling pathway shown as an interacting network. This pathway was hyperactivated in the patient's tumor tissue. Green arrows indicate activation, red arrows-inhibition. Transcript nodes are shown in ovals. The color depth of transcript nodes reflects the extent of node activation (logarithms of the case-to-normal (CNR) expression rate for each node, in which "normal" is a geometric average between expression levels in normal tissue samples). Molecular targets of regorafenib are indicated by black arrows. Visualization was implemented using Oncobox software. The PI3Ks-AKT signaling axis is marked in blue ellipse.
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Gene Ontology (GO) analysis of the top-100 up-regulated genes in the patient's biosample according to RNAseq data revealed terms associated with extracellular matrix organization, mesenchyme development and organ development (Figure S4).