Pain in the distribution of the femoral nerve: early evidence of recurrence of a retroperitoneal sarcoma

Pain in the distribution of the femoral nerve following resection of a retroperitoneal sarcoma may signify tumor recurrence and should require exploration of the nerve to its origin from the spine in order to rule out a small, undetectable recurrence by CT scan.

Desmoid tumors in patients with familial adenomatous polyposis

BACKGROUND

Sporadic desmoid tumors occur mainly in the abdominal wall and in extraabdominal sites. Desmoid tumors in patients with familial adenomatous polyposis (FAP) usually occur in the abdominal wall and in the bowel mesentery. Surgical resection of desmoids in patients with FAP has been controversial.

METHODS

A retrospective review of patients with FAP and desmoid tumors treated from 1950 to 1991 was performed. Patients were evaluated for gender, age, site of desmoid tumors, treatment, recurrence, and survival.

RESULTS

Twenty-one of 24 patients underwent 60 surgical procedures related to the desmoid tumors. Seven of nine patients who underwent potentially curative surgery had recurrences; three were reresected. Major morbidity after palliative or curative surgery was 47%. Five patients were alive with no evidence of disease at a median of 198 months, 10 patients were alive with disease at a median of 102 months, and 5 patients died with disease at a median of 31 months after diagnosis.

CONCLUSIONS

Desmoid tumors are common in patients with FAP. Unresectability and recurrence are more common than cure. Palliative and curative resections have a high morbidity. Surgery should be reserved for those patients with symptomatic mesenteric desmoids.

Groin dissection in malignant melanoma

BACKGROUND

There is controversy about the extent of groin dissection necessary (whether superficial or radical) and about its utility when the deep nodes are affected.

METHODS

A total of 198 groin dissections (1977-1991) were reviewed; 94 (48%) were superficial and 104 (52%) were radical dissections. Of 72 patients with palpable positive inguinal nodes, 31 (43%) had involvement of the deep nodes; of 39 patients with nonpalpable, histologically positive inguinal nodes, seven (18%) had or later manifested involvement of the deep nodes.

RESULTS

The mean number of positive nodes (median) in the group with clinically palpable disease was six (two), and in the group with occult disease the number was two (one). The estimated overall (disease-free) 5-year and 10-year survival rates for patients with negative nodes were 73% (67%) and 64% (58%), respectively, and for those with positive nodes they were 36% (27%) and 30% (23%), respectively. Survival was significantly poorer for patients with positive nodes (p < 0.0001). The respective 5-year and 10-year survival rates for patients with positive nodes and involvement of the inguinal nodes only were 41% (33%) and 36% (29%), and for those with involvement of the inguinal and deep nodes the rates were 28% (17%) and 19% (13%). Survival was significantly poorer for patients with deep node involvement (p = 0.006).

CONCLUSIONS

The survival rates after therapeutic groin dissection are substantial and unattainable with any other treatment at the present time. Incontinuity dissection of the deep nodes is advisable in the presence of palpable inguinal nodes, since the incidence of deep node involvement is considerable and the survival rate appreciable after removal of involved deep nodes.

Subungual melanoma: an eighteen-year review

BACKGROUND

Subungual melanoma is a rare lesion comprising 1% to 3% of all melanoma cases.

METHODS

Records of twenty-two patients with subungual melanoma treated at Roswell Park Cancer Institute during the period September 1971 to September 1989 were reviewed in a retrospective manner. Most common sites of involvement were the great toe on the foot (n = 7), the thumb (n = 4), and the index (n = 3) and ring fingers (n = 3) on the hand. Common signs included pigmentation of the nail bed, nail loss, and nail destruction.

RESULTS

Thickness of the lesion could be determined in 10 patients. All four patients with lesions 1.0 mm and thinner at the time of biopsy were alive and disease free at 19, 20, 55, and 78 months, whereas three of six patients with lesions thicker than 1.0 mm were dead at 15, 51, and 56 months. Patients with ulcerated lesions had an estimated 5-year survival rate of 39% as compared with 80% for the group without ulceration. Seven patients underwent finger amputations distal to the metacarpophalangeal joint, and none experienced local recurrence. Four amputations were just proximal to the distal interphalangeal joint, and three were just proximal to the proximal interphalangeal joint. One of these patients died of metastatic melanoma at 56 months, and the other six were alive and disease free at 13, 19, 20, 32, 72, and 78 months from the time of diagnosis.

CONCLUSIONS

More distal amputations of subungual melanomas of the hand preserve function and do not compromise survival or local control.

Soft tissue sarcomas in adults

Soft tissue sarcomas are relatively rare in adults, accounting for less than one percent of newly diagnosed cancers in the United States each year. However, increased physician awareness of these tumors may lead to earlier diagnosis and improved results. The five-year survival rate has been increasing, and treatment using a combination of modalities has significantly reduced the number of amputations performed. This article reviews the clinical presentation, diagnosis, pathology, and treatment of soft tissue sarcomas in adults.

Residual nodal disease after excisional biopsy of a palpable, positive node in melanoma

The medical records of 365 patients with the diagnosis of malignant melanoma who underwent axillary (n = 210) or groin (n = 155) dissection at a cancer referral center were reviewed. Sixty-one patients were referred after excisional biopsy of a palpable, histologically positive node. After node dissection, 75% of these patients were found to have additional, microscopically involved nodes, which confirms the advisability of node dissection after biopsy of a positive regional node.

Regional chemotherapy in the canine liver

Using a fluorometric assay, mean drug levels of Adriamycin were significantly higher in the normal canine liver following bolus injection of this drug via the hepatic artery or portal vein as compared to hepatic tissue levels following systemic intravenous administration (P < 0.001). However, the variations in tissue levels observed after hepatic artery (+/- 16.8 mcg/gm tissue) or portal vein (+/- 21.1 mcg/gm) infusion were significantly wider than those observed after systemic (+/- 1.3 mcg/gm) administration (P = 0.03). Using C14-labeled drugs, regional infusion of Adriamycin through the hepatic artery or portal vein resulted in significantly higher mean drug levels in the liver than after systemic intravenous administration, but the difference was more pronounced with bolus infusion of the drug than 1-hour infusion. 5-FU bolus or 1-hour infusion in the hepatic artery resulted in significantly higher mean drug levels in the liver compared to peripheral intravenous administration, but this was not so with the 3-hour infusion. The above experiments confirm previous studies that regional chemotherapy results in higher drug levels in the regional tissues compared to systemic administration. They also: (1) demonstrate the spotty drug distribution in the regional tissues after regional administration, a potentially correctable problem, and (2) suggest that the advantage of intra-arterial infusion may be more pronounced within a certain range of infusion times.

Eccrine porocarcinoma

Eccrine porocarcinoma, a malignancy of the eccrine sweat glands, is extremely rare. Our report and a review of the literature (70 cases) emphasize the features of this tumor. Age at time of treatment ranged from 19 to 94 years (mean 67 years). Duration of the lesion ranged from two months to 50 years; 31 (44%) had the lesion present > or = 5 years. Forty-four patients (62%) had tumors located on the extremities, 13 (19%) on the head and neck region and 12 (17%) on the trunk. All patients whose race is known were white. Primary treatment should consist of wide local excision and regional lymphadenectomy, if clinically indicated. Although there is a significant risk of cutaneous, regional lymph node, or visceral metastases, the value of elective or therapeutic regional lymphadenectomy is unknown, as is the role of adjunctive therapy.

Malignant melanoma of the female genital system

Among 2,500 patients with malignant melanoma treated in our Institute since 1975, 25 patients were treated for melanoma of the female genital system. The sites of involvement were the vulva (11 patients), the vagina (13 patients) and the ovaries (one patient). The surgical treatment comprised radical vulvectomy (seven patients), vaginectomy (five patients) and wide local excision (11 patients). One of two patients with distant metastases at diagnosis received no local treatment. The patient with the ovarian melanoma was treated initially with salpingoophorectomy. The overall estimated 5-year survival rate was 64%. There was no statistical difference between the two primary modes of surgical treatment (radical vs local) in the survival of the patients (estimated 5-year survival = 73% and 67%, respectively), but patients receiving the radical treatment had thicker lesions. Malignant melanoma of the female genital tract, despite earlier reports, is apparently curable in the majority of patients and with increased awareness of this condition and earlier diagnosis, the results may further improve in the future.

Metastasectomy in malignant melanoma

BACKGROUND

Resection of distant metastases in melanoma is occasionally helpful. The extent of applicability of this treatment, the benefit derived, and the prognostic parameters aiding in the selection of the patients need to be defined further.

METHODS

The cases of one hundred fourteen patients with resected distant metastases were reviewed and subjected to multivariate analysis.

RESULTS

The median survival after metastasectomy was 19 months and the estimated 5-year survival rate was 22%. The 5-year survival rate was 33% for those with distant subcutaneous metastases, 22% for those with distant lymph node metastases, and 14% for those with pulmonary metastases (p = 0.12). Twenty patients (18%) are disease free at a median follow-up of 106 months. Significant prognostic parameters were the thickness of the primary melanoma (p = 0.05), the number of metastatic lesions (p = 0.03), and the prior disease-free interval (p = 0.05).

CONCLUSIONS

Resection of distant metastases is applicable in about one fourth of patients with disseminated melanoma. With adherence to certain selection criteria the resulting 5-year survival rate is appreciable and higher than that after other, currently available treatments.

Adrenal adenocarcinoma: a review of 53 cases

PROBLEM

Fifty-three patients (30 men, 23 women) with histologically proven adrenal carcinoma were reviewed. Nineteen (36%) had endocrine manifestations from functioning tumors. Arteriography was positive in 95% (19/20), CT scan in 94% (17/18), and ultrasound in 92% (12/13). Seventy-six percent of the patients, at the time of diagnosis, were stage III and IV. Most common metastatic sites were the liver, lymph nodes, bone, and lungs. Local recurrence developed in 39% of cases (15/38).

METHOD

Forty-one patients underwent an operation. Complete surgical removal of all gross tumor was achieved in 24 patients.

RESULT

The overall median survival time was 8 months, and the estimated 5-year survival rate 19%. There were significant differences in survival between the various stages (P = 0.01) and between the group of patients who underwent complete excision of the tumor and those with incomplete resection (P = 0.002).

CONCLUSIONS

Complete surgical excision offers the best prospect for long-term survival in localized adrenal carcinoma.

Band 11q13 is nonrandomly rearranged in hibernomas

Cytogenetic study of a short-term culture from a hibernoma, a very rare benign proliferation of the brown fat, demonstrated a four-break translocation t(5;7;11;17)(p14;q11.23;q13.1-13.3;p11.2) as the sole abnormality in all analyzed cells. Complex translocation involving band 11q13 have also been detected in the two other published cases of hibernoma. The consistent finding of 11q13 rearrangements appears to distinguish hibernoma from other benign adipose tissue tumors cytogenetically and suggests that 11q13 changes may play an important role in hibernoma pathogenesis.

Malignant melanoma of the scrotum: report of 2 cases

Primary melanoma of the scrotum is a rare entity, with only 4 cases reported previously. Of about 2,000 patients with malignant melanoma treated in the last 15 years at our hospital only 2 had primary melanoma of the scrotum. The treatment and outcome of these patients are presented.

Efficacy of 2-cm surgical margins for intermediate-thickness melanomas (1 to 4 mm). Results of a multi-institutional randomized surgical trial

BACKGROUND

A prospective, multi-institutional, randomized surgical trial involving 486 localized melanoma patients was conducted to determine whether excision margins for intermediate-thickness melanomas (1.0 to 4.0 mm) could be safely reduced from the standard 4-cm radius.

METHODS

Patients with 1- to 4-mm-thick melanomas on the trunk or proximal extremities were randomly assigned to receive either a 2- or 4-cm surgical margin.

RESULTS

The median follow-up time was 6 years. The local recurrence rate was 0.8% for 2-cm margins and 1.7% for 4-cm margins (p value not significant [NS]). The rates of in-transit metastases were 2.1% and 2.5%, respectively (p = NS). Of the six patients with local recurrences, five have died. Recurrence rates did not correlate with surgical margins, even among stratified thickness groups. The overall 5-year survival rate was 79.5% for the 2-cm margin patients and 83.7% for the 4-cm margin patients (p = NS). The need for skin grafting was reduced from 46% with 4-cm surgical margins to 11% with 2-cm surgical margins (p < 0.001). The hospital stay was shortened from 7.0 days for patients receiving 4-cm surgical margins to 5.2 days for those receiving 2-cm margins (p = 0.0001). This reduction was largely due to reduced need for skin grafting, since the hospital stay for those who had a skin graft was 2.5 days longer than that for those who had a primary wound closure (p < 0.01).

CONCLUSION

Margins of excision can be safely reduced to 2 cm for patients with intermediate-thickness melanomas. The narrower margins significantly reduced the need for skin grafting and shortened the hospital stay.

Desmoid tumors of the trunk and extremity

BACKGROUND

Twenty-six patients with desmoid tumors of the extremities (n = 20) or trunk (n = 6) have been treated since 1977. Nine of these were referred with primary tumors and 17 with recurrent tumors.

METHODS

The tumor was removed in all patients, and 10 received adjuvant radiation. Five patients (19%) developed local recurrence; one of them was lost to follow-up, and the remaining four patients had the recurrence controlled with surgical resection or resection plus adjuvant radiation.

RESULTS

All 25 patients who have been followed are alive and disease-free at a mean follow-up of 84 months (median, 81 months). None with extremity tumors (n = 20) required an amputation. The estimated survival rate for the entire group is 95% at 42 months.

CONCLUSIONS

Desmoid tumor of the trunk or extremities treated with surgical resection, supplemented selectively by adjuvant radiation, can be controlled locally in the majority (96%) of patients.

Pseudo-tumor of the calf

The differential diagnosis of calf swelling includes deep venous thrombosis (DVT), ruptured popliteal (Baker's ) cyst, infection, sarcoma and hematoma. Bony erosion is seldom seen in benign conditions and, when present, usually indicates tumor involvement. 'Pseudosarcoma', where hematoma may mimic sarcoma, has been described in hemophiliacs. A case is described of pseudosarcoma with bone erosion occurring as a complication of anticoagulant therapy, a clinical situation not reported previously.

Translocation t(12;22)(q13;q12.2-12.3) in a clear cell sarcoma of tendons and aponeuroses

Cytogenetic analysis of a short-term culture from a clear cell sarcoma revealed a complex karyotype with the mainline of 49,XY,t(7;18)(p11.2;q21.3), +der(7)t(7;18)(p11.2;q21.3), +8, +der (8;17)(q10;q10),t(12;22)(q13;q12.2-12.3),add(13)(p13). An apparently identical translocation t(12;22) has been described recently in four clear cell sarcomas, indicating that this constitutes a primary cytogenetic change specific for this type of tumor. In our case, the breakpoint on chromosome 22 could be assigned to band 22q12.2 or 22q12.3. Together with the present case, trisomy or tetrasomy 8 has been found in six of nine clear cell sarcomas, suggesting that, as in Ewing's sarcoma and myxoid liposarcoma, trisomy/tetrasomy 8 represents a nonrandom secondary aberration. We conclude that the finding of the specific translocation t(12;22) may prove to be an important marker in the differential diagnosis of clear cell sarcoma from some other soft tissue sarcomas and malignant melanoma.

Chromosome 12 breakpoints are cytogenetically different in benign and malignant lipogenic tumors: localization of breakpoints in lipoma to 12q15 and in myxoid liposarcoma to 12q13.3

Cytogenetic study of short-term cultures from 10 adipose tissue tumors (eight lipomas, one myxoid liposarcoma, and one mixed liposarcoma) have revealed clonal chromosome abnormalities in seven cases. In both malignant tumors, translocation (12;16) was the sole aberration, and in the mixed liposarcoma, the breakpoints could be sublocalized to bands 12q13.3 and 16p11.2, thus confirming findings of Eneroth et al., Cancer Genet. Cytogenet., 48: 101-107, 1990. Three lipomas displayed predominantly normal karyotypes; in a fourth case, the karyotype 44,XX,-6,der (7)t(6;7)(p21.3-22;p22)ins(7)(p22q11.2q22),-13 was found. Four remaining lipomas were characterized by structural rearrangements of chromosome 12. We were able to achieve high resolution banding patterns in two tumors with translocations (3;12)(q28;q15) and (1;2;12)(p36.;q13;q15). In both of these cases, the chromosome 12 breakpoint could be unequivocally assigned to band q15. Similarly, band 12q15 was also rearranged in two other lipomas with translocations (12;14)(q15;q32) and (12;20)(q15;q13.1). Our results support the hypothesis that the chromosome 12 breakpoint in lipomas is located more distally than the breakpoint in myxoid liposarcomas and some other soft-tissue malignant neoplasms and that it is cytogenetically identical with breakpoints detected in such benign tumors as uterine leiomyoma and pleomorphic adenoma of the salivary gland.

Increased prostaglandin E2 and cAMP phosphodiesterase levels in Kaposi's sarcoma--a virus against host defense mechanism

In Kaposi's sarcoma tissue, prostaglandin E2 (PgE2) levels and cAMP phosphodiesterase levels were found to be higher than in surrounding normal tissue. We have shown earlier that PgE2 suppresses interferon (IFN) alpha production. High levels of cAMP phosphodiesterases result in low cAMP levels. Thus, this phenomenon may be involved in altered immunologic resistance, growth and differentiation.

Abdominoinguinal incision in resection of pelvic tumors with lateral fixation

Large tumors in the area of the iliac fossa, external iliac vessels, wall of the lesser pelvis, and pubic bone are often considered unresectable through conventional abdominal incisions due to the lack of exposure, or they are managed with hindquarter amputation. The abdominoinguinal incision provides the necessary exposure for en-bloc resection of many of these tumors. It involves a lower midline incision that is extended transversely to the mid-inguinal point on the side of involvement and then vertically, over the course of the femoral vessels, which are exposed. The rectus abdominis is divided off the pubic crest and the inguinal ligament off the pubic tubercle, and the inferior epigastric vessels are ligated and divided at their origin. This allows in-continuity exposure of the lower abdomen, pelvis, and the groin in one field and dramatically improves the exposure.

Claviculectomy for the exposure and en bloc resection of adjacent tumors

Claviculectomy has been described for primary or metastatic tumors of the clavicle. In 11 patients, claviculectomy was used as a technical expedient for the exposure and en bloc resection of large, underlying nodal metastases from melanoma (7 patients) and soft tissue tumors (4 patients). There were no wound complications. Three patients developed moderate edema of the arm. There was little limitation at the shoulder, and the use of the upper extremity has been essentially normal. Claviculectomy is well tolerated, provides good exposure of the underlying neurovascular structures, and, in some patients, provides a method of limb salvage for underlying tumors in preference to forequarter amputation.

Surgery for disseminated abdominal sarcoma

Seventy-two consecutive patients with disseminated soft tissue sarcoma in the abdomen were prospectively placed in a program of debulking surgery. The tumor was completely resectable in 64% of the patients. Following the first exploration, the median survival was 23 months for those with resection of metastases and 9 months for those without resection (p less than or equal to 0.01); the former group had a survival rate of 28% at 3 years, 18% at 4 years, and 4% at 5 years (44%, 37%, and 10%, respectively, for low-grade sarcomas, i.e., grade I or II sarcomas), whereas in the latter group, none survived for 3 years. In the group with resection, patients with grade III tumors had a median survival longer by 6 months, and those with low-grade tumors by 28 months (p less than or equal to 0.001), over the respective median survival of patients with unresectable tumors. Metastasectomy appeared to prolong survival in all patients and significantly so in patients with low-grade tumors and those with long disease-free intervals.

Cytogenetic findings in liposarcoma correlate with histopathologic subtypes

The cytogenetic findings in 31 liposarcomas from 26 patients are reported. Four other tumors did not grow. Three histologic types are represented in this analysis. The well-differentiated liposarcomas were characterized by telomeric associations, large marker chromosomes and ring chromosomes, and in some cases, double minutes. The pleomorphic liposarcomas contained very high clonal chromosomal numbers with near-tetraploid modes and numerous variable, often unidentifiable, chromosomal abnormalities. The myxoid liposarcomas were characterized primarily by a t(12;16)(q13;p11) as the sole abnormality or additional changes. These results indicate that cytogenetic findings may provide a new criterion, not only for establishing the diagnosis of liposarcoma, but also for differentiating confusing histologic types of liposarcoma and these lesions from other types of sarcomas.