Uterine Sarcomas Harbouring Novel FOXO1 Gene Rearrangements

Increasing availability and utilisation of high-throughput sequencing techniques has resulted in a rapidly expanding range of uterine mesenchymal lesions harbouring recurrent and nonrecurrent gene rearrangements. Within the literature, 3 molecularly confirmed FOXO1 -rearranged uterine corpus tumors have been reported, all representing alveolar rhabdomyosarcomas (ARMS). We report 5 cases of non-ARMS uterine mesenchymal tumors, in patients aged 36 to 71, harbouring novel FOXO1 rearrangements with different fusion partners ( JRK , PIK3R4, MEIS1 , and ATP7B); in the fifth case, FISH revealed a FOXO1 gene rearrangement with an unknown fusion partner. Although morphologically heterogenous, all 5 cases had a low-grade spindle cell component with 3 cases showing prominent myxoid stroma. Two cases were originally diagnosed as myxoid leiomyosarcoma, one as high-grade endometrial stromal sarcoma, one as an undifferentiated sarcoma with a fibrosarcoma-like appearance, and the other as a myxoid neoplasm of uncertain malignant potential. In 3 cases, the rearrangements showed similar breakpoints to known recurrent FOXO1 gene fusions; 2 rearrangements ( JRK::FOXO1 and MEIS1::FOXO1 ) incorporate both an intact transactivation domain and a DNA-binding domain akin to the rearrangements seen in ARMS, likely representing true oncogenic driver events. Although all 5 cases were confined to the uterine corpus at presentation, recurrences occurred in 2 patients indicating a potential for malignant behaviour and justifying the designation of sarcoma. These cases expand the landscape of FOXO1 -rearranged neoplasms and describe a potential new uterine mesenchymal entity. Further study of additional cases is needed to establish whether these rearrangements truly represent an initiating event for a distinct subset of uterine sarcomas, or whether FOXO1 rearrangements simply represent an additional noninitiating/nondriver event within other established tumor types.