Phase 1/2 study of immunotherapy with dendritic cells pulsed with autologous tumor lysate in patients with refractory bone and soft tissue sarcoma

BACKGROUND

There are limited options for the curative treatment of refractory bone and soft tissue sarcomas. The purpose of this phase 1/2 study was to assess the immunological and clinical effects of dendritic cells (DCs) pulsed with autologous tumor lysate (TL) in patients with advanced bone and soft tissue sarcomas.

METHODS

Thirty-seven patients with metastatic or recurrent sarcomas were enrolled in this study. Peripheral blood mononuclear cells obtained from the patients were suspended in media containing interleukin 4 (IL-4) and granulocyte-macrophage colony-stimulating factor. Subsequently, these cells were treated with TL, tumor necrosis factor α, and OK-432. The DCs were injected into the inguinal or axillary region. One treatment course comprised 6 weekly DC injections. The toxicity, clinical response (tumor volume, serum interferon-γ [IFN-γ], and serum IL-12), and oncological outcomes were observed.

RESULTS

In total, 47 courses of DC therapy were performed in 37 patients. No severe adverse events or deaths associated with the DC injections were observed in the study patients. Increased serum IFN-γ and IL-12 levels were observed 1 month after the DC injection. Among the 37 patients, 35 patients were assessed for clinical responses: 28 patients showed tumor progression, 6 patients had stable disease, and 1 patient showed a partial response 8 weeks after the DC injection. The 3-year overall and progression-free survival rates of the patients were 42.3% and 2.9%, respectively.

CONCLUSIONS

Although DC therapy appears safe and resulted in an immunological response in patients with refractory sarcoma, it resulted in an improvement of the clinical outcome in only a small number of patients. Cancer 2017;123:1576-1584. © 2017 American Cancer Society.

A clinicopathologic study on SS18 fusion positive head and neck synovial sarcomas

OBJECTIVE

To determine clinicopathologic factors on survival in patients with head and neck synovial sarcoma.

PATIENTS AND METHODS

We retrospectively identified patients with molecularly confirmed synovial sarcomas of the head and neck (SS-HN), either by the presence of SS18-SSX fusion transcript by RT-PCR or SS18 gene rearrangement by FISH, who were managed at our institution over a 20-year period (1996-2015). Kaplan-Meier survival analysis and log-rank test were performed to evaluate variables related to disease specific survival (DSS). Fisher exact test was performed to evaluate variables related to local recurrence.

RESULTS

Thirty-four patients (20 males and 14 females, mean of 31years) with SS18-SSX fusion-positive SS-HN were identified. The parapharyngeal region of the neck was the most common site. The mean tumor size was 4.8cm (0.8-10cm). Two-thirds (n=23) of cases had a monophasic histology. The 2, 5 and 10-year DSS rates were 97%, 79% and 68%. The 5-year DSS rates for the adult/pediatric cohort were 74%/88%. Recurrence showed significant effect on DSS (p=0.021). There was no significant effect on DSS with age, therapy modality, tumor site, surgical margin, tumor size (⩽5cm vs. >5cm) and histopathologic subtype. Tumor site (i.e. skull base/paranasal sinus region) was associated with local recurrence (p=0.003).

CONCLUSION

In our cohort DSS rate was associated with recurrence. Tumors located in the skull base/paranasal sinus region were associated with a higher rate of local recurrence. Thus appropriate selection of high risk patients who can benefit from multimodality therapies might improve survival.

First-in-human Phase 1 CRISPR Gene Editing Cancer Trials: Are We Ready?

A prospective first-in-human Phase 1 CRISPR gene editing trial in the United States for patients with melanoma, synovial sarcoma, and multiple myeloma offers hope that gene editing tools may usefully treat human disease. An overarching ethical challenge with first-in-human Phase 1 clinical trials, however, is knowing when it is ethically acceptable to initiate such trials on the basis of safety and efficacy data obtained from pre-clinical studies. If the pre-clinical studies that inform trial design are themselves poorly designed - as a result of which the quality of pre-clinical evidence is deficient - then the ethical requirement of scientific validity for clinical research may not be satisfied. In turn, this could mean that the Phase 1 clinical trial will be unsafe and that trial participants will be exposed to risk for no potential benefit. To assist sponsors, researchers, clinical investigators and reviewers in deciding when it is ethically acceptable to initiate first-in-human Phase 1 CRISPR gene editing clinical trials, structured processes have been developed to assess and minimize translational distance between pre-clinical and clinical research. These processes draw attention to various features of internal validity, construct validity, and external validity. As well, the credibility of supporting evidence is to be critically assessed with particular attention to optimism bias, financial conflicts of interest and publication bias. We critically examine the pre-clinical evidence used to justify the first-inhuman Phase 1 CRISPR gene editing cancer trial in the United States using these tools. We conclude that the proposed trial cannot satisfy the ethical requirement of scientific validity because the supporting pre-clinical evidence used to inform trial design is deficient.

Primary Pulmonary Synovial Sarcoma Showing a Prolonged Survival with Multimodality Therapy

A 54-year-old man was referred to our hospital due to a mass shadow noted on a chest X-ray. Thoracoscopic lobectomy yielded a diagnosis of primary pulmonary synovial sarcoma according to the histology and SYT-SSX1 gene analyses. Five months after the thoracic surgery, he developed brain metastasis; therefore, we performed resection of the brain metastatic focus followed by radiotherapy. As a local recurrence in the thoracic cavity concurrently emerged, systemic chemotherapy was also administered. These observations indicated that a multidisciplinary approach may be useful against primary pulmonary synovial sarcoma, although there is presently no established therapeutic strategy due to its rarity and highly aggressive nature.

Primary Pulmonary Synovial Sarcoma in a Tertiary Referral Center: Clinical Characteristics, CT, and 18F-FDG PET Findings, With Pathologic Correlations

The purpose of this study was to describe the patient characteristics, computed tomography (CT) and F-fluorodeoxyglucose positron emission tomography (FDG PET) findings, and clinical outcomes of primary pulmonary synovial sarcoma (PPSS), together with their pathologic correlations. The medical records of 14 patients with pathologically proven PPSS in a tertiary hospital from January 1997 to December 2014 were retrospectively reviewed. The CT findings were evaluated. The maximum standardized uptake value (maxSUV) of the tumors was obtained, and clinical outcomes with respect to tumor recurrence and mortality were assessed by Kaplan-Meier analysis. The median tumor size was 10.2 cm and the most common anatomic location was the lung followed by the pleura/chest wall and mediastinum. Most of the tumors appeared as single lesions and had circumscribed margins. All the cases showed heterogeneous enhancement with necrotic or cystic portions, and intratumoral vessels were frequently seen. Half of the tumors had intratumoral calcifications, and tumor rupture, pleural/chest wall extension, and pleural effusion occurred frequently. However, lymph node enlargement was rare. The median maxSUV of the tumors was 4.35. Patient outcomes with respect to tumor recurrence (n = 8, 57.1%) and death (n = 3, 21.4%) were poor despite their young age, and the mean follow-up period was 28.5 months.In conclusion, PPSS usually occurs in young adults, generally in the lung, presents as a large, circumscribed mass, and tumor rupture or extension of the pleura/chest wall may occur. The tumors often contain calcifications and vessels; they may exhibit triple attenuation on enhanced CT images, and clinical outcomes are poor.

Biphasic synovial sarcoma in a 19-year-old pregnant woman: a case report

Synovial sarcoma is a rare malignant tumor of mesenchymal multipotent cells. We hereby present a case of synovial sarcoma of the upper left thigh. A 19-year-old patient was referred to our clinic by another hospital in Bucharest, Romania, for a soft tissue mass in the left upper thigh. Local examination of the left thigh revealed a 15÷13 cm, ovoid, painful upon touch, soft tissue mass occupying the proximal-medial aspect of the thigh. Bilateral inguinal nodes' enlargement was noticed. Upon suspecting regional node involvement, the surgical team decided to perform left limb amputation due to tumor size and the proximity to major arterial and nervous trunks as well as the femoral shaft, making curative surgery and 'free of disease' resection margins improbable. The patient refused the operation. The surgical team (plastic surgeon, orthopedic surgeon) decided to attempt limb-sparing surgery. After tumor resection, free-of-disease surgical margins were achieved. The pathological examination as well as the immunohistochemistry (IHC) diagnosed a large biphasic synovial sarcoma warranting oncologic treatment. The association between tumor growth and pregnancy poses important therapeutic problems, such as the use of preoperative chemotherapy, potential pregnancy termination, limb amputation versus limb salvage intervention and types of protocols of chemotherapy or radiotherapy indicated.

A rare synovial sarcoma of the spine in the thoracic vertebral body

INTRODUCTION

Synovial sarcomas of the spine are very rare, most rare of which was occurring in the thoracic vertebral body. The diagnosis of synovial sarcomas was very difficult. It depends on the radiological examination, immunohistochemical examination and gene examination. The best treatment to them was completely surgical resection with negative margins. Other treatments such as radiation therapy and chemotherapy were just adjuvant. The prognosis of synovial sarcomas was disappointing.

CASE PRESENTATION

A 26-year-old male patient had low back pain. The radiological examination showed bony erosion of the T7 vertebral body and no soft tissue mass around the spine. He underwent T7 resection en bloc and internal fixation with two levels above T7 and two levels below T7. Then histopathological and gene examination revealed high malignant synovial sarcoma. So he was treated by chemotherapy and external beam radiation therapy after surgery.

CONCLUSION

Primary vertebral body synovial sarcoma is very rare and difficult to diagnose and treat.

L-carnitine treatment in a seriously ill cancer patient with severe hyperthyroidism

OBJECTIVE

To report a case of vaccine-induced Graves' disease successfully managed with L-carnitine and propranolol and without antithyroid drugs (ATDs). ATDs sometimes need to be used at low doses or can be contraindicated/refused. One of the ancillary compounds available is L-carnitine. L-carnitine is a naturally occurring quaternary amine, which acts by impairing thyroid hormone access to the cell nucleus.

REPORT

A 32-year-old Chinese woman with a synovial sarcoma received radiotherapy, chemotherapy and experimental immunotherapy. Two months after the start of immunotherapy, she developed autoimmune hyperthyroidism [thyroid-stimulating immunoglobulins (TSI)=152%, normal values <140]. Left untreated, hyperthyroidism worsened (TSI=248%), so that for 3 months she took L-carnitine (1-4 g/d) and propranolol (20-80 mg/d). Though the hyperthyroidism worsened biochemically (FT4>50 pg/ml, FT3>20 pg/ml, TSI=501%), it was tolerated very well clinically. Fearing a life-threatening thyroid storm, she agreed to have, while still hyperthyroid, total thyroidectomy. The operation was uneventful.

CONCLUSIONS

This case expands previous observations involving two more patients who survived thyroid storms while being treated with L-carnitine (combined with low doses of ATD). Taking also into account that tissue concentrations of L-carnitine decrease in hyperthyroidism, there is room for wide therapeutic use of L-carnitine in several hyperthyroidism settings.

Autoimmune thyroid disease elicited by NY-ESO-1 vaccination

BACKGROUND

Immunotherapies and targeted therapies are frequently associated with thyroid dysfunction, which is in contrast with the rare thyroid abnormalities induced by cytotoxic agents. Immunotherapy with NY-ESO-1, a tumor-associated antigen expressed by a number of malignancies, was reported to trigger hyperthyroidism or hypothyroidism in two HLA-A2 patients with ovarian cancer. We describe now a case of Graves' disease triggered by NY-ESO-1 in a HLA-A2-negative woman.

PATIENT FINDINGS

A 32-year-old woman with a synovial sarcoma received radiotherapy, chemotherapy, and finally NY-ESO-1 vaccine. The patient was found to have HLA A11/A33(19), B13/B56(22), Cw3/-. One month after the beginning of immunotherapy, thyroid dysfunction was clinically suspected and Graves' disease was biochemically confirmed. Fearful of the antithyroid drugs' side effects, the patient was treated with a beta-blocker (propranolol, 80-20 mg/day). As hyperthyroidism progressively worsened, the patient underwent total thyroidectomy. We hypothesized that NY-ESO-1 shared partial homology with thyroid autoantigens (the so-called molecular mimicry mechanism) and that at least one pair of homologous sequences contained amino acid sequence binding motifs to a restricted number of HLA molecules. We used BLAST software to search amino acid sequence homologies between NY-ESO-1 and thyroid autoantigens (thyrotropin receptor [TSH-R], thyroperoxidase, and thyroglobulin), and the HLA ligand/motif database to look for HLA/T-cell receptor binding motifs in the regions of NY-ESO-1 and thyroid autoantigens that were homologous. We found 15 epitopic regions of NY-ESO-1 homologous to 15 regions of thyroid autoantigens, some of which epitopic: 5 of TSH-R, 8 of thyroglobulin, and 2 of thyroperoxidase. These homologous sequences contain binding motifs belonging to several HLA class I antigens, including HLA A2 and the patient's A11 and A33.

SUMMARY

Genetically predisposed patients who receive NY-ESO-1 vaccination are at risk to develop thyroid dysfunction.

CONCLUSIONS

Considering the increasing use of NY-ESO-1, thyroid dysfunctions induced by NY-ESO-1 are expected to increase in cancer patients over the next years.

A patient with primary pericardial synovial sarcoma who presented with cardiac tamponade: a case report and review of the literature

A 36-year-old man presented with near-syncope. He was found to have massive pericardial effusion with a giant pericardial tumorous lesion. The pericardial effusion exhibited a bloody nature; however, neither malignant cells nor infectious organisms were detected. (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET) showed an increased uptake of FDG in the pericardial tumor only. Although the tumor was not resectable, thoracotomy and tissue sampling were performed. A histological analysis showed CD99 positivity and SYT gene rearrangement, leading to a diagnosis of synovial sarcoma arising from the left lateral pericardial surface. The patient is now receiving chemotherapy.

[Synovial sarcoma of the head and neck--a retrospective study of 39 cases]

OBJECTIVE

Synovial sarcoma (SS) of the head and neck is rare in comparison with those took place in the extremities. This study was planned to investigate the relationship between pathological diagnosis, tumor location and clinical outcome of SS of the head and neck.

METHOD

Thirty-nine cases of SS in head and neck hospitalized in West China Hospital from 1966 to 2011 was retrospectively studied by reviewing the medical record data, the pathological slices of the operative specimen and followed-up from 1 to 192 months with the mean time of 43.2 months postoperatively. The parameters of clinical outcome were focused on the time to first recurrence after primary surgery and follow-up time. The reviewed results were statistically processed.

RESULT

The age of the patients ranged from 8 to 66 years old with the median age of 35, among them 27 are males. Pathologically, 18 cases are biphasic, 17 cases are monophasic and 3 cases are low-differentiated SS. 4 cases were proved by cytogenetic methods of either fluorescence in situ hybridization(FISH) or RT-PCR. 23 cases experienced repeated recurrence with the most up to 4 times operations after sole surgical approach. Only one lymphatic metastasis was suspected in all. 16 patients got adjuvant radiotherapy or chemotherapy. 4 patients died but only one death was associated directly with SS recurrence. There was no significant relationship between pathological subtype and recurrence (Fisher's Exact Test P-value > 0.05), no significant relationship between tumor location and recurrence (Fisher's Exact Test P-value > 0.05).

CONCLUSION

SS of head and neck is a special entity that has potential of easy recurrence but good prognosis. Surgery should still be the primary treatment approach. Cytogenetic methods are recommended to as certain the diagnosis in order to choose reasonable treatment protocols.

Pelvic synovial sarcoma of unknown primary origin: case report and literature review

A case report of a 26-year-old woman with pelvic pain for one-month duration is presented. The physical exam was unremarkable, but a right pelvic mass was found on ultrasound. Computed tomography (CT) of the abdomen/pelvis confirmed a heterogeneous 6 x 4.4 cm mass within the right pelvis adjacent to the superior-lateral aspect of the uterus. Laparoscopy was performed, and the mass was found to be friable and necrotic. The origin of the mass was not able to be determined due to the collapse of the mass upon instrumentation. Histology revealed spindle cells. Further studies, including immunochemical staining, revealed a synovial sarcoma. Patient underwent laparotomy for staging and in hopes of obtaining clear tumor margins. Surgery revealed subsequent tumors involving the mesentery of the small intestine and the peritoneal wall. Biopsies taken at surgery did not reveal the primary origin of the original pelvic tumor.

Primary synovial sarcoma of the kidney with unusual follow up findings

We present a case report of a 17-year-old patient with a large renal mass that was detected on a computed tomography scan during investigation for secondary hypertension. Radical nephrectomy was performed and the morphologic and immunocytochemical findings were compatible with a diagnosis of monophasic synovial sarcoma of the kidney. A cytogenetic search for t(X;18) translocation was performed, which was negative. The patient underwent an ifosfamide-based chemotherapy regimen. During follow up, a positron emission tomography scan showed increased 18F-fluorodeoxyglucose metabolism at the right femur. Although cancer cells were expected in the biopsy specimen, only fibrous dysplasia of the bone was found. The patient was disease free at his 29 month follow up check up.

Pathological fracture of femur secondary to infected synovial sarcoma

Pathological fracture is not uncommon in musculoskeletal oncological surgical practice. When complicated by infection, it is both limb- threatening and life-threatening problem. Pathological fractures require urgent investigation, not urgent treatment. We present the case of a 75-year-old man who presented with an infected sarcoma causing a pathological fracture of his right femur.

Parapharyngeal space synovial sarcoma

Synovial sarcoma is a rare soft tissue sarcoma that commonly involves the lower extremities and occurs predominantly in young adults. It very rarely occurs in the head and neck region and carries a poor prognosis. The tumor demonstrates both a loco-regional and a systemic pattern of spread that makes management challenging. Combined modality therapy of this aggressive tumor yields better results. Herein, we described a 58 years old lady presented with left parapharyngeal synovial sarcoma. This is to demonstrate the aggressiveness of the disease despite complete surgical excision followed by post operative radiotherapy. Local regional control was difficult and recurrence of disease was seen in this particular patient.

Total allograft transplantation of the elbow joint after wide resection of synovial cell sarcoma: a case series

Total elbow allograft transplantation is an option for patients who have extensive joint defects secondary to tumor surgery, trauma, or failed total elbow arthroplasty. This salvage procedure provides patients with a useful, painless range of motion of the elbow. We report our experience with two complete elbow allograft reconstructions after tumor resection surgery with 5 and 6 years of follow-up.

Laryngeal synovial sarcoma: case report and literature review

Synovial sarcoma is a rare malignant mesenchymal neoplasm of youth with no benign counterpart. This cancer typically occurs about the knee and ankle joints. The involvement of the head and neck region is rare, and the laryngeal location is exceptional, which make the correct diagnosis challenging for the surgical pathologist and unanticipated for the clinician. Up to our knowledge, only 14 cases have been reported so far within this site. Here we add a new case in a 26-year-old Saudi man who presented with voice change and dysphagia, which are common symptoms of a more common benign condition in this site. The patient was operated and the histopathological diagnosis of synovial sarcoma was made, after which he received radiotherapy with no recurrence after 20 months. The correct diagnosis is crucial in such a case for proper management.