Clinical outcome of metastatic uterine leiomyosarcoma and carcinosarcoma in a single institute

AIM: To investigate the clinical outcome of uterine sarcomas, particularly in patients with pulmonary and abdominal metastasis, treated at a single institute. METHODS: We identified five patients with uterine leiomyosarcoma (LMS), one patient with endometrial stromal sarcoma (ESS), and three patients with carcinosarcoma (CS) between 2003 and 2006. RESULTS: All patients underwent at least hysterectomy and bilateral adnectomy. All five LMS cases (two patients in International Federation of Obstetrics and Gynecology stage I and three in stage III) recurred: one patient showed metastasis to the lung and four patients showed metastasis to the abdomen 16.6 months (mean) after hysterectomy. Two of three (66.7%) CS recurred: one patient showed metastasis to the lung and the other to the abdomen 5 months (mean) after hysterectomy. The ESS (stage I) patient showed metastasis to the lung 11 months after hysterectomy. Five patients with metastases received surgical interventions (two pulmonary resections and three abdominal resections), and all of these patients are currently alive 1.1-5.1 years postoperatively. Two patients with CS (stage I) and one patient with LMS (stage III) died of sarcoma dissemination, but neither of these three patients had undergone surgical intervention after hysterectomy (one for pulmonary and two for abdominal metastases). CONCLUSIONS: Resection of lung and abdominal metastases in uterine LMS and CS is beneficial to improve patient survival.     

Pulmonary Resection in Metastatic Uterine and Cervical Malignancies

OBJECTIVE: Although thoracotomy for removal of pulmonary metastasis is well documented in a wide variety of solid tumors, data are sparse regarding management of patients with gynecologic malignancies metastatic to the lung. METHODS: We retrospectively reviewed the Roswell Park Cancer Institute experience between 1982 and 1999. Of 82 eligible patients with gynecologic tumors metastatic and confined to the lung, 25 underwent pulmonary resection. RESULTS: There were 60 uterine and 22 cervix cancer patients with pulmonary metastases. Among patients with uterine cancer primaries undergoing pulmonary resection (n = 19) median survival was 26 months. Uterine cancer patients who underwent surgical resection for leiomyosarcomas (n = 11) had a median survival of 25 months compared to 46 months in patients with adenocarcinoma (n = 6, P = 0.02). Median survival in cervix cancer patients undergoing resection for pulmonary metastases (n = 6) was 36 months. CONCLUSIONS: Pulmonary resection may provide a survival advantage for selected patients with uterine and cervical malignancies with metastases isolated to the lung.     

Clinical outcomes of uterine sarcomas: results from 14 years worth of experience in the Kinki district in Japan (1990–2003)

To review clinical outcomes and therapeutic varieties, we were invited to submit data from the patients who were treated for uterine sarcomas in Japan from 1990 to 2003. Uterine sarcomas were defined as leiomyosarcoma (LMS), endometrial stromal sarcoma (ESS), and carcinosarcoma (CS). Of a total of 97 patients, 36 (37.1%) were diagnosed with LMS of the uterine corpus, 15 (15.5%) with ESS, 46 (47.4%) with CS. Median age at diagnosis was 59 (21-85) years. Clinical stages based on FIGO were 41 (42.3%) with stage I disease, 6 (6.2%) with staged II, 34 (35.1%) with stage III, and 16 (16.5%) with stage IV. The median follow-up period for all patients was 13 (1-108) months and median disease-free period was 9 (0-96) months. The 1-year survival rate and disease-free survival (DFS) rate were calculated in patients with all sarcomas (overall survival [OAS], 61.3%; DFS, 46.6%). Statistical analysis showed that younger age (less than 50 years), early stage (stages I and II), and surgical procedure (extended hysterectomy [EH] and radical hysterectomy [RH]) were associated with significantly better OAS. Histologic types did not affect the survival period. In conclusion, aggressive surgery including EH or RH at the time of initial operation offers the possibility of prolonged survival.     

Hysteroscopic endomyometrial resection of three uterine sarcomas.

STUDY OBJECTIVE: To describe our experience with three uterine sarcomas associated with hysteroscopic endometrial ablation. DESIGN: Cohort study (Canadian Task Force classification II-2). SETTING: University-affiliated teaching hospitals. PATIENTS: Three of 2402 women undergoing hysteroscopic endometrial ablation who had uterine sarcomas. INTERVENTION: Hysteroscopic endomyometrial resection. MEASUREMENTS AND MAIN RESULTS: One low-grade endometrial stromal sarcoma and two carcinosarcomas were resected. After hysterectomy in two patients, no residual cancer was identified in one of them. The third patient was an 82-year-old woman with moderate menorrhagia who refused hysterectomy. After endomyometrial resection she remained amenorrheic for the last 14 months of her life. CONCLUSION: From our experience the incidence of uterine sarcomas is approximately 1/800 women undergoing hysteroscopic ablation for abnormal uterine bleeding. Complete endomyometrial resection is feasible and may be offered as diagnostic and palliative therapy in women at high risk for hysterectomy.     

Cervical sarcomas: an analysis of incidence and outcome

OBJECTIVE: Cervical sarcomas are exceedingly rare neoplasms associated with a poor prognosis. The objective of this study was to examine the treatment and outcome of women with cervical sarcomas. METHODS: A hospital-based tumor registry was searched to identify all patients with cervical sarcomas treated between 1986 and 2003. The medical records of all patients were reviewed. All pathologic specimens were reviewed by a single pathologist. RESULTS: Among 1583 with cervical malignancies, 8 cervical sarcomas were identified. All patients presented with vaginal bleeding. The lesions were clinically staged as IB1 (2), IB2 (4), IIIA (1), and IIIB (1). Five of the tumors were carcinosarcomas. Other histologies included sarcoma NOS (12.5%), leiomyosarcoma (12.5%), and endometrial stromal sarcoma (12.5%). Initial treatment included surgery in 5 patients, radiation in 2, and chemoradiation in 1. Six patients were treated with curative intent, 5 received adjuvant therapy. While both patients treated palliatively died from progressive disease, the other 6 patients remain alive after a mean follow-up of 2.5 years. Two patients have recurred. One patient underwent a thoracotomy for an isolated pulmonary metastasis and is alive with no evidence of disease. The second patient developed pulmonary metastases and is alive 8 months after recurrence. CONCLUSIONS: Cervical sarcomas are rare neoplasms. Most patients present with vaginal bleeding and a palpable cervical mass. While the optimal management of these tumors is uncertain, aggressive primary therapy can result in prolonged survival and cure.     

Long-term results of hysteroscopic myomectomy in 235 patients

OBJECTIVE: To assess the efficacy of transcervical resection of submucous fibroids according to type and size. MATERIALS AND METHODS: Retrospective follow-up of 235 women with submucous fibroids at outpatient hysteroscopy who underwent a hysteroscopic transcervical resection. The main indications were the abnormal uterine bleeding and fertility problems. Thirty-seven percent of patients had an associated endometrial ablation and 32% had a polyp resection. Fifty-one percent of women were menopausal. In cases of incomplete resection a repeat procedure was offered. RESULTS: Intra-operative complications were rare (2.6%) and there was no major complication. Eighty-four percent of cases were followed-up. The median follow-up was 40 months (range 18-66 months). The procedure was classed as a success in 94.4% of patients. Among the cases that were classed as a failure, four patients had a repeated hysteroscopic procedure, three patients had a subsequent hysterectomy and four patients presented with abnormal uterine bleeding at follow-up. CONCLUSION: The hysteroscopic transcervical resection of submucous fibroids is a safe and highly effective long-term therapy for carefully selected women presenting with abnormal uterine bleeding and fertility problems. It produces satisfactory long-term results with few complications.     

Pulmonary resection for metastases from gynecologic cancers: Massachusetts General Hospital experience, 1943-1982

Fifteen patients with pulmonary metastases from gynecologic cancers have been evaluated and treated surgically at the Massachusetts General Hospital from 1943 to 1982. These women have had primary tumors involving the cervix (6), endometrium (3), and ovary (2) as well as uterine sarcomas (2) and choriocarcinomas (2). Two-year Kaplan-Meier survival for this group was 71%; the corresponding survival at 5 years was 36%. No hospital mortality was encountered. Patients with solitary lesions of less than 4 cm diameter appeared to have the most favorable prognosis in the group. A prolonged time to initial recurrence (latent period) of greater than 36 months was associated with improved survival and there was a 60% survival among patients with latent periods of 60 months or more. An aggressive approach to resection of pulmonary metastases in selected patients provides gratifying palliation for the majority of women and long-term cure in a significant minority.     

Scar recurrence of uterine sarcoma: a case report

BACKGROUND: Uterine leiomyosarcoma is an aggressive tumor that has a propensity for recurrence. Most of the recurrences occur at either pelvic or distant sites, such as lung or liver. Recurrences in the laparotomy scar are extremely rare. CASE: A 52-year-old woman underwent hysterectomy for stage I, grade 2 uterine leiomyosarcoma. She did not receive any adjuvant treatment. She presented 2 years later with wound recurrence. She had no evidence of intraabdominal disease. She underwent radical resection with mesh repair. Pathology revealed high grade spindle cell sarcoma very similar to the previous cancer. After completion of 18 months of follow-up, she was disease free. CONCLUSION: Radical resection of isolated metastases may be of benefit for these patients.     

Uterine sarcomas: A clinicopathologic study, 1965–1981

Forty-six cases diagnosed as uterine sarcoma from 1965 to 1981 were analyzed. Using mitotic count, 7 of 21 leiomyosarcomas (LMS) were redesignated leiomyomas and all are NED. The actuarial survival rates for the 38 considered sarcomas were 55 and 27% at 2 and 5 years. (The 22 patients eligible for 5-year follow-up had a 27% absolute survival, with 3 of 22 NED.) Fourteen LMS patients had a superior 5-year actuarial survival (42%) than 18 malignant mixed mesodermal (MMM) patients (15%), but the difference disappears when only patients under 70 are considered. Stage and age were the most important prognostic indicators. Complete surgical resection was essential for long-term survival. Six resected patients given adjuvant chemotherapy (mostly VAC) had an improved actuarial survival (61 vs 15% for the 23 resected patients not receiving chemotherapy). Seventy percent of 23 recurrences occurred within 2 years and average survival post-recurrence was 7.6 months. Survival post-recurrence for 8 patients was not improved by chemotherapy. Seventy-eight percent of recurrences had a distal component, with lung being the most common site.     

Uterine sarcomas: the Curie Institut experience. Prognosis factors and adjuvant treatments

PURPOSE: With a retrospective study at a single institution, we propose to analyze the prognosis factors and adjuvant treatment for uterine sarcomas. MATERIALS AND METHODS: From 1975 to 1995, 73 uterine sarcomas were treated at the Institut Curie, corresponding to 61 T1, 5 T2, and 8 T4 tumors. Thirteen patients had metastatic disease at the time of diagnosis. The mean age was 58 years. In 71% of patients, the presenting sign was bleeding. This series consisted of 44% leiomyosarcomas (LMS), 19% endometrial stromal sarcomas (ESS), and 31% carcinosarcomas or mixed mesodermal sarcomas (MMS). For the grading classification, we used the classification of the Sarcoma Group of the French Federation of Cancer Centres for soft tissue sarcomas. Of the patients, 66% presented a high-grade tumor. RESULTS: The median overall survival was 42 months, with a 5-year survival of 45%. Histological grade, FIGO stage, histology types, and menopausal status were the four independent factors in multivariate analysis. Eighteen patients relapsed locally (25.7%), with 77% central pelvic sites. Patients with radiotherapy and ESS had better local control in multivariate analysis. Thirty-four patients developed metastases (48.6%), mainly pulmonary (58.8%). Eight patients presented with peritoneal disease. High grades and LMS had the worst survival without metastasis in multivariate analysis. CONCLUSION: This study validated our classification for sarcoma grading and confirmed the finding of worst prognosis for LMS and the importance of radiotherapy in local control.     

Prognostic value of initial surgical procedure for patients with uterine sarcoma: analysis of 123 patients

BACKGROUND: The aim of this series was to study the clinical impact of initial surgical management, particularly of uterine morcellation. on patients treated for uterine sarcoma (US). PATIENTS AND METHODS: Clinical data of 157 patients treated for US in our institution were analyzed. Data concerning this initial management was available in 123 patients. We consider as "uterine morcellation" the following procedures: hysterectomy (vaginal or laparoscopic) with uterine "morcellation" described in the surgical report, myomectomy, operative hysteroscopy or simple biopsy of the tumor. The clinical outcome considered as related to the initial surgical procedure was the rate of pelvic recurrence at three months. RESULTS: Of the 123 patients for whom data concerning initial surgical management was available, uterine morcellation was performed in 34 (28%). One-hundred and sixteen patients had a follow-up > or = 3 months after surgery. Recurrence was observed in 87 patients. Six had a pelvic recurrence within three months following the end of the treatment. The rates of pelvic recurrence at three months according or not to uterine morcellation were 3/31 (8.82%) and 3/79 (3.66%) respectively (p = 0.25). The rates of pelvic recurrences at six months were not different in either group (10% versus 10.4%). Overall and disease-free survival were similar in both groups. CONCLUSION: In this preliminary study, the rates of pelvic recurrence at three months was increased in patients who underwent uterine morcellation for US but this difference was not statistically significant. A prospective study should be performed in order to clarify the prognostic value of initial surgery in patients treated for US and to recommend an adequate surgical management for patients in whom the diagnosis of uterine sarcoma is suspected before the surgical procedure.     

Adjuvant chemotherapy following surgery in the management of uterine sarcomas

OBJECTIVE: The aim of this study was to investigate the use of imaging tools in the diagnosis of uterine sarcomas, and to evaluate the effect of the adjuvant chemotherapy for uterine sarcomas. PATIENTS AND METHODS: The data of 29 patients with uterine sarcomas who received cytostatic polychemotherapy between 1990 and 2000 at the Oncological Division of the Ist Department of Obstetrics and Gynecology, Semmelweis University were evaluated by the authors. Symptoms leading to diagnosis and methods of diagnosis were examined. Vascular changes shown by two-dimensional, color and pulsed Doppler ultrasonography were observed. For staging the currently accepted FIGO method was adopted. Most of the patients underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH & BSO). In each case we administered adjuvant combination chemotherapy according to the CYVADIC-protocol. The effect of adjuvant chemotherapy was evaluated. RESULTS: Six patients had Stage I, ten had Stage II, 11 had Stage III, and two had Stage IV disease. The mean age of the patients was 53.6 years with a range of 22 to 77 years. Histopathologic distribution included nine leiomyosarcomas (LMS), 13 mixed mesodermal sarcomas (MMS), and seven endometrial stromal sarcomas (ESS). Although most patients experienced neutropenia following cytotoxic chemotherapy, other non-hematologic adverse effects were easy to control. The average progression-free interval was 22.14 months, in which no significant difference was found between the histologic types. Different stages showed highly varied responses: surprisingly, patients in Stage IV with lung metastases were documented to have the longest progression-free survival. The three-year survival rate for all stages was demonstrated in 34.4% of cases. Patients with progressive disease had an average survival period of 4.4 months. CONCLUSIONS: These findings suggest that adjuvant cytostatic therapy for patients with distant metastasis confined to a single organ may produce better results than expected.     

子宫肉瘤放射治疗的临床观察

目的　观察子宫肉瘤对手术后辅助放射治疗（放疗）的疗效,及原发肿瘤或复发肿瘤对放疗的反应。方法　回顾分析我院1960年5月～1999年6月收治的子宫肉瘤102例,其中单纯手术组45例,手术+放疗组29例,单纯放疗组4例,复发肿瘤放疗组24例。结果　5年生存率,单纯手术组为56.7%,手术+放疗组为58.6%,两组比较,差异无显著性（P>0.05）。局部复发率,单纯手术组为42.2%,手术+放疗组为20.7%,两组比较,差异有显著性（P<0.05）。单纯放疗组4例中有3例肿瘤完全消失,其中1例生存时间达36个月,另2例于放疗后9个月和11个月死于远处转移。复发肿瘤放疗组有效率达50.0%。放射敏感性依次为子宫内膜间质肉瘤、子宫恶性苗勒管混合瘤、子宫平滑肌肉瘤。结论　子宫肉瘤手术后放疗可明显减少盆腔复发,放疗应作为子宫肉瘤综合治疗的一部分。     

Long survival with metastatic uterine leiomyosarcoma

A case of intramural uterine leiomyosarcoma is reported in which solitary asymptomatic subcutaneous metastases at two different sites appeared 3 and 4½ years, respectively, after hysterectomy without roentgenologic or clinical evidence of pulmonary metastases during this period. Three months after removal of the second subcutaneous metastasis, a large solitary pulmonary metastasis was removed by a right total pneumonectomy. Recurrent tumor in the chest wall near the thoracotomy incision was resected 3 months later, following which the patient was asymptomatic and apparently free of cancer until her sudden death 3 months after the last operation. In the absence of an autopsy, death at 68 was attributed to a cerebrovascular accident secondary to hypertensive cardiovascular disease.     

Low-Grade Endometrial Stromal Sarcoma Preoperative Treatment with Depo-Lupron and Megace

A 46-year-old women presented with an inoperable low-grade endometrial stromal sarcoma. Two doses of Depo-Lupron, 7.5 mg, and Megace, 160 mg/day, were given to control uterine bleeding and shrink the tumor mass. In 9 weeks, significant reduction in the tumor occurred allowing for surgical resection. Total abdominal hysterectomy with bilateral salpingo-oophorectomy is the mainstay for primary treatment. The role of chemotherapy, radiation therapy, and hormonal therapy is poorly defined. This is a case report of neoadjuvant hormonal therapy which may improve outcomes in patients with endometrial stromal sarcomas. Additional research is needed to define the exact role of these agents.     

Uterine adenosarcoma with sarcomatous overgrowth versus uterine carcinosarcoma: comparison of treatment and survival

OBJECTIVE: Uterine adenosarcoma with sarcomatous overgrowth (ASSO) is a rare variant of uterine sarcoma first described in 1989. This clinicopathologic study was undertaken to compare the treatment and survival of uterine adenosarcoma with sarcomatous overgrowth to that of uterine carcinosarcomas. METHODS: A review of uterine sarcomas diagnosed at Washington Hospital Center from January 1988 to December 1998 was performed. Records were reviewed for demographic data, surgical staging, primary and adjuvant therapy, metastatic site, disease recurrence, and survival. All pathology was reviewed and diagnosis confirmed. Statistical analysis included chi(2) test and Student's t test. Kaplan-Meier survival curves were plotted to estimate the median and 5-year survival times. The log-rank test was used to compare survival times. A P value <0.05 was considered significant. RESULTS: Sixty patients were diagnosed with uterine sarcoma at Washington Hospital Center. Of these, 33 (55%) were uterine carcinosarcomas, 11 (18%) ASSOs, 6 (10%) adenosarcomas, and 10 (17%) leiomyosarcomas. Of the patients diagnosed with uterine ASSO, 3 (27%) were stage I, 3 (27%) stage II, 1 (9%) stage III, and 4 (36%) stage IV. All 11 patients with uterine ASSO underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and tumor debulking. Postoperative adjuvant therapy included chemotherapy (n = 4), radiation (n = 4), combination radiation and chemotherapy (n = 1), and no adjuvant therapy (n = 2). The overall median survival time of patients with uterine ASSO was 13 months. Nine of eleven patients are dead of disease, and two patients (both with stage I) are alive without evidence of disease at 18 and 19 months. Thirty-three patients with carcinosarcoma were identified, with follow-up available on 29 patients. Of these, 10 (34%) were stage I, 6 (22%) stage II, 3 (10%) stage III, and 10 (34%) stage IV. Twenty-seven of the twenty-nine patients diagnosed with carcinosarcoma underwent surgical therapy to include total abdominal hysterectomy, bilateral salpingo-oophorectomy, staging and tumor debulking. Two patients died prior to treatment. Postoperative adjuvant therapy included chemotherapy (n = 9), radiation (n = 13), combination (n = 1), and no further therapy (n = 4). Twenty of the twenty-nine patients are dead of disease; there were nine surviving patients at the time of this report (stage I-5, stage II-3, stage III-1). The median survival of these patients was 31 months, with an overall 5-year survival of 22%. Comparison of the Kaplan-Meier survival curves using the log-rank test suggests a worse prognosis for uterine ASSO. However, this did not reach statistical significance (P = 0.0522). CONCLUSIONS: Patients diagnosed with uterine ASSO have a poor prognosis similar to that of carcinosarcoma. Management should include complete surgical staging. Additional therapy in the form of radiation, chemotherapy, or both has been reported; however, the superiority of one modality could not be determined from our data.     

Survival with regional and distant metastases from cutaneous malignant melanoma

The clinical course of 312 consecutive patients after initial presentation with metastatic melanoma, 165 of whom presented with regional metastases at cutaneous or subcutaneous, or both, nodal sites and 147 with metastases at distant sites, was reviewed. The five year survival rate for regional metastases was 43.4 per cent compared with a five year survival rate for distant metastases of 4.9 per cent (p less than 0.0001). Favorable prognostic variables for survival from first regional metastases included primary melanoma sites on the extremities compared with the head, neck and trunk (p = 0.043) and a disease-free interval of more than one year from primary surgical treatment to regional metastases (p = 0.0058). Favorable prognostic variables for survival from the first distant metastasis included a disease-free interval of more than one year from primary surgical treatment to distant metastases (p = 0.0092), the type of resection of metastatic disease (p = 0.00027) and the addition of systemic immunotherapy (p = 0.0011). Forty-nine patients with totally resectable distant metastases had a five year survival rate from the treatment of the initial metastasis of 13.1 per cent, whereas 33 patients having palliative resections had a five year survival rate of 7.5 per cent. All 165 patients who did not have resection for distant metastases died within five years. The results of our experience support therapeutic efforts to ablate both regional and distant metastases of malignant melanoma when feasible.     

Conservative management of a uterine tumor resembling an ovarian sex cord-stromal tumor

BACKGROUND: Sex cord-stromal tumors usually arise in the ovary but may arise in the uterus. Only 55 cases have been reported thus far. A hysterectomy is typically recommended. We report a case of uterine tumor resembling an ovarian sex cord-stromal tumor managed conservatively. CASE: A 32-year-old nulliparous woman presented with infertility secondary to suspected uterine leiomyomata. A laparoscopic resection of the presumed leiomyomata was performed, and the pathology showed a uterine tumor resembling an ovarian sex cord tumor. Because of the patient's desire to preserve fertility, a hysterectomy was not performed. She has been followed for the past 18 months, and there is no evidence of tumor recurrence. CONCLUSION: Resection of the tumor without hysterectomy and close follow-up may preserve fertility without compromising survival in patients with uterine tumors resembling ovarian sex cord-stromal tumors.     

Endometrial stromal sarcoma: review of Mayo Clinic experience, 1945-1980

Uterine sarcomas are uncommon malignancies. We retrospectively examined 24 cases of "high grade" endometrial stromal sarcomas (ESS). The histologic diagnosis was made if there was a high grade sarcoma with a high mitotic index and nuclear anaplasia. Heterologous elements could be present, if focal only. Leiomyosarcomas, mixed mesodermal sarcomas, and carcinosarcomas were excluded. Mitotic index was expressed as the number of mitoses per 10 high-power fields in active areas. Tumor grade was based on nuclear anaplasia. ESS were 5.7% of all uterine sarcomas. Median age was 58.2 years; median duration of symptoms was 67.5 days. Abnormal bleeding was the presenting complaint in 91.7%. Uterine enlargement was seen in 33%; protrusion through the cervical os was seen in 9 cases. Total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed in 95.8%. Twenty patients had myometrial involvement; 5 patients had serosal spread and extrauterine disease; residual disease was seen in 3 patients. Adjuvant radiation was not beneficial. Ten patients had recurrences: 60% in the pelvis, 50% each with subcomponent of abdominal or distant disease. Overall survival was 3.4 years and was significantly associated with extent of disease, size of the primary tumor, and grade.     

Sarcomas metastatic to the ovary: a report of 21 cases

Twenty-one cases in which sarcomas metastasized to the ovaries are reported. The patients ranged from 18 to 79 (average 42) years of age; only five of them were over 50 years old. Eleven tumors were primary in the uterus and 10 outside the genital tract. Three uterine tumors were leiomyosarcomas, and eight, endometrial stromal sarcomas. The extragenital primary tumors were leiomyosarcoma of the stomach (1) and small intestine (2), retrovesical leiomyosarcoma (1), fibrosarcoma of the anterior abdominal wall (1), sarcoma of the mesentery of smooth muscle or neural type (1), hemangiosarcoma probably primary in the heart (1), osteosarcoma of the maxilla (1), chondrosarcoma of the rib (1), and Ewing's sarcoma of the pubic bone (1). The ovarian tumors, most of which were large, were discovered at the same time as the primary tumors in 11 cases; in seven cases, the ovarian tumor was discovered 7 months to 9 years after diagnosis of the primary tumor. In three cases, the ovarian tumors were discovered 4, 7, and 10 months before detection of the primary neoplasm. Two of these tumors were endometrial stromal sarcomas, and one, an epithelioid leiomyosarcoma of the stomach. Eleven ovarian metastases were bilateral. On microscopic examination, the greatest difficulty in pathologic interpretation was posed by the metastatic endometrial stromal sarcomas because of their simulation of sex cord-stromal tumors. Features helpful in their distinction from these tumors included the frequent presence of extra-ovarian disease, bilaterality, and a characteristic content of small arteries resembling the spiral arteries of the late secretory endometrium. The other tumor that caused major diagnostic difficulty was the metastatic epithelioid leiomyosarcoma from the stomach, which had a pattern that initially suggested the solid-tubular pattern of a Sertoli cell tumor.