Gemcitabine-based regimen for primary ovarian angiosarcoma with MYC amplification

Our patient presented with advanced ovarian angiosarcoma and bone metastases and still achieved 7 years of progression-free survival after treatment with a gemcitabine-based regimen. Recently, MYC amplification was proposed to occur in a proportion of primary31 and radiation-induced angiosarcomas32. Enhanced expression of c-Myc is an important mediator leading to disease development33. We therefore report our case and the results of retrospective MYC gene amplification and c-Myc protein expression analyses, discuss the relevance of those factors in terms of therapy and prognosis, and review the related literature.


INTRODUCTION
Angiosarcoma, an aggressive soft-tissue neoplastic disease, is rare, having an annual incidence of less than 1 per million population 1 .Angiosarcomas arise at various sites; in elderly people, these tumours commonly arise in the scalp and face 2 .Primary angiosarcoma of the ovary is extremely rare 3 , with only 35 cases being reported to date (Table i).The median overall survival of patients with metastatic angiosarcoma is generally less than 11 months 30 , and the median overall survival of patients with angiosarcoma of the ovary is 6-7 months 17 .Systemic chemotherapy for patients presenting with unresectable disease is therefore generally considered palliative.values were 40.3 IU/mL (reference range: 0-35 IU/ mL), 1349.0IU/mL (reference range: 0-37 IU/mL), and 48.6 ng/mL (reference range: 0-5 ng/mL) respectively.In other words, all values exceeded their reference range.We considered that the right ovarian tumour was malignant in nature.
Given the patient's wish to preserve fertility, a right salpingo-oophorectomy was performed.Bloody ascites was observed, and the right ovarian tumour was found to ooze from a minute surface rupture.We re-examined the tumour markers at 13 days post-surgery and found normalized levels (cancer antigen 125, 26.5 IU/mL; carbohydrate antigen 19-9, 14.0 IU/mL; carcinoembryonic 1.2 ng/mL).We continued to evaluate those markers for 7 years post-surgery, and the values never rose above their reference range.
The resected specimen revealed a cystic tumour with a maximum diameter of approximately 9 cm and  A diagnosis of primary angiosarcoma of the ovary with bone metastases (stage iv, T1cN0M1) was clinically appropriate.Although no evidence-based chemotherapeutic regimen was available at the time, gemcitabine-based chemotherapy had been reported to be efficacious in a few angiosarcoma cases 34,35 .We therefore administered gemcitabine-based therapy in combination with cisplatin, which is frequently used for ovarian cancers.The patient received intravenous  gemcitabine 1000 mg/m 2 on days 1 and 8 and intravenous cisplatin 70 mg/m 2 on day 1 every 28 days for 6 cycles.No significant adverse events were observed during chemotherapy; however, grade 1 neutropenia and grade 2 nausea were identified according to the Common Terminology Criteria for Adverse Events (version 3.0).The patient's status was repeatedly monitored using tumour markers and computed tomography, without suggestion of tumour recurrence.Notably, immediately after the 6 chemotherapy courses, computed tomography revealed low-density areas of ossification in several bones [Figure 2(B)].Those areas remained ossified for 7 years after chemotherapy initiation [Figure 2(C)], reflecting progression-free survival of at least 7 years' duration.

Systemic computed tomography showing the long-term response of bone metastases in T3, sacral bone, and right ilium. (A) Initial admission (baseline). (B) Immediately after 6 courses of chemotherapy. (C) After 7 years of chemotherapy. Low-density areas were ossified from peripheral areas at time B and remained ossified at time C, suggesting that the regimen was effective in treating the metastatic angiosarcoma; the patient experienced 7 years of progression-free survival. figure 3 Pathology observations. (A) The cystic tumour has a hemorrhagic mural nodule (arrow) containing mucinous material and a large blood clot (arrowhead). (B) A low-power view shows the cyst wall, comprising mucinous epithelium (arrow) and an abrupt transition to the hemorrhagic nodule (arrowhead). Hematoxylin and eosin (he
During the follow-up period, to the time of writing, the patient had not achieved pregnancy-not for organic reasons, but likely because of side effects from the chemotherapeutic agents.

DISCUSSION
Table i summarizes the 35 previously reported primary angiosarcomas.As mentioned earlier, few ovarian angiosarcomas have been treated with adjuvant chemotherapy, and the associated effects have been poorly characterized.However, several regimens have been reported to effectively treat angiosarcoma, regardless of origin.Combination therapy with anthracyclines and ifosfamide has been proved to be effective for the treatment of metastatic soft-tissue sarcoma, including angiosarcoma 23 .Doxorubicin-based and weekly paclitaxel regimens have demonstrated similar efficacy ranges for metastatic angiosarcomas 30 .However, we selected gemcitabine in the present case because several publications had reported its efficacy in angiosarcoma treatment 34,35 .After we initiated chemotherapy for our patient, gemcitabine monotherapy was reported to effectively treat advanced angiosarcoma 36 .Although the clinical diagnosis of bone metastases in our case was not definitive because no bone biopsy was conducted for histologic confirmation, the patient's clinical outcome is consistent with reports proposing that gemcitabine-based chemotherapy regimens could be considered effective for angiosarcomas, including advanced disease.
After surgery, serum levels of the tumour markers cancer antigen 125, carbohydrate antigen 19-9, and carcinoembryonic antigen promptly declined to within their reference ranges, even before chemotherapy for angiosarcoma control was introduced.Those levels remained normal for 7 years.Mucinous cystadenomas are known to elevate levels of those markers above their normal range 37,38 .Assuming that bone metastases were truly present, the initially elevated tumour marker levels might have been primarily a result of the mucinous cystadenoma component of the tumour rather than the angiosarcoma component.
To the best of our knowledge, this report is the fourth of an ovarian angiosarcoma arising from a mucinous cystadenoma 4,12,25 and the first to be treated with postoperative chemotherapy.In our retrospective analysis, the mural nodule of the mucinous cystadenoma was identified as angiosarcoma with MYC gene amplification and c-Myc protein overexpression.This case is therefore also extremely rare pathologically, because ovarian mucinous tumours are rarely associated with mural nodules reflecting any type of sarcoma-like (benign) disease, sarcoma, or carcinoma 39,40 .The features as described suggest that the primary ovarian angiosarcoma in this case developed sequentially as a mural nodule from the mucinous cystadenoma.During angiosarcoma formation, which appears to have been prompted by a mucinous cystadenoma, alterations in the molecular signatures similar to those observed in secondary angiosarcomas might have occurred.One such similarity might have been the observed MYC amplification in the present case 32 .
The c-Myc protein regulates numerous processes, including cell cycle progression, epithelial-mesenchymal transition, stem-cell progression, and angiogenesis, thereby facilitating tumour initiation and progression.Gong et al. showed that gemcitabine downregulates MYC gene expression and induces apoptosis in HL-60 cells 37 , a finding that might partly explain that agent's therapeutic efficacy in this case.Also, reduced MYC expression in tumour cells was recently proposed to induce sensitivity to dna-damaging reagents such as cisplatin by stimulating BIN1 transcription and disrupting parp1 activity 41 .Therefore, gemcitabine administration might also have facilitated the antitumour efficacy of cisplatin.
In the present case, a gemcitabine basedregimen treated a primary ovarian angiosarcoma with MYC gene amplification and c-Myc protein overexpression extremely effectively.Although further studies with more enrolled cases are needed to statistically prove the effectiveness of this gemcitabine-based regimen and the correlation between MYC status and clinical outcomes, this remarkable case suggests that gemcitabine-based regimens could be a therapeutic option and even a first-line chemotherapy for the treatment of angiosarcomas.

SUMMARY
The patient reported here experienced 7 years of progression-free survival after treatment with a gemcitabine-based regimen for a primary ovarian angiosarcoma with MYC gene amplification.MYC amplification and the effectiveness of gemcitabinebased regimens in primary angiosarcomas should be addressed in future analyses and studies.
figure 2 Systemic computed tomography showing the long-term response of bone metastases in T3, sacral bone, and right ilium.(A) Initial admission (baseline).(B) Immediately after 6 courses of chemotherapy.(C) After 7 years of chemotherapy.Low-density areas were ossified from peripheral areas at time B and remained ossified at time C, suggesting that the regimen was effective in treating the metastatic angiosarcoma; the patient experienced 7 years of progression-free survival.figure 3 Pathology observations.(A) The cystic tumour has a hemorrhagic mural nodule (arrow) containing mucinous material and a large blood clot (arrowhead).(B) A low-power view shows the cyst wall, comprising mucinous epithelium (arrow) and an abrupt transition to the hemorrhagic nodule (arrowhead).Hematoxylin and eosin (he) stain; 12.5× original magnification.(C) In a highpower view of the mucinous epithelium, no significant atypia is seen.he stain; 400× original magnification.(D) In a high-power view of the hemorrhagic nodule, vascular channels are seen to be covered with highly atypical endothelial cells.he stain; 400× original magnification.Inset, shows atypical endothelial cells positive for CD31.Immunostain; 400× original magnification.(E) Highly atypical endothelial cells are strongly reactive for c-Myc.Immunostain; 400× original magnification.(F) Fluorescence in situ hybridization reveals MYC amplification, as indicated by red (MYC probe) and green (chromosome 8 centromere probe) signals, which were almost equal in number and often exceeded 5 in number.1000× original magnification.
figure 2 Systemic computed tomography showing the long-term response of bone metastases in T3, sacral bone, and right ilium.(A) Initial admission (baseline).(B) Immediately after 6 courses of chemotherapy.(C) After 7 years of chemotherapy.Low-density areas were ossified from peripheral areas at time B and remained ossified at time C, suggesting that the regimen was effective in treating the metastatic angiosarcoma; the patient experienced 7 years of progression-free survival.figure 3 Pathology observations.(A) The cystic tumour has a hemorrhagic mural nodule (arrow) containing mucinous material and a large blood clot (arrowhead).(B) A low-power view shows the cyst wall, comprising mucinous epithelium (arrow) and an abrupt transition to the hemorrhagic nodule (arrowhead).Hematoxylin and eosin (he) stain; 12.5× original magnification.(C) In a highpower view of the mucinous epithelium, no significant atypia is seen.he stain; 400× original magnification.(D) In a high-power view of the hemorrhagic nodule, vascular channels are seen to be covered with highly atypical endothelial cells.he stain; 400× original magnification.Inset, shows atypical endothelial cells positive for CD31.Immunostain; 400× original magnification.(E) Highly atypical endothelial cells are strongly reactive for c-Myc.Immunostain; 400× original magnification.(F) Fluorescence in situ hybridization reveals MYC amplification, as indicated by red (MYC probe) and green (chromosome 8 centromere probe) signals, which were almost equal in number and often exceeded 5 in number.1000× original magnification.

e783 Current OnCOlOgy-VOlume 21, number 6, DeCember 2014
Copyright © 2014 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).

e784 Current OnCOlOgy-VOlume 21, number 6, DeCember 2014 Copyright
© 2014 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).Current OnCOlOgy-VOlume 21, number 6, DeCember 2014 Copyright © 2014 Multimed Inc.Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).