Amplification and Over-Expression of the MDM2 Gene in Human Soft Tissue Tumours

Purpose. Amplification of genetic sequences on chromosome 12q13 is frequently found in soft tissue tumours. However, for the MDM2 gene, over-expression of the MDM2 protein has not always been shown to accompany gene amplification, raising the possibility that amplification of genetic sequences targets alternative genes on chromosome 12q13 for over-expression. To investigate this discrepancy, we have examined 129 soft tissue tumours for amplification of the MDM2 gene using Southern analysis, and 39 of these tumours were also examined by immunohistochemical staining for MDM2 over-expression.Results. Gene amplification was identified in 14/114 (12.3%) of the malignant tumours, but was not identified in any of the benign tumours; 21/39 (54%) of the malignant tumours also demonstrated MDM2 over-expression. Within this group the MDM2 gene was over-expressed in every tumour in which the gene amplification was found, and over-expression in the absence of gene amplification was also found in an additional 10 tumours.Discussion. These data demonstrate a clear correlation between the presence of MDM2 amplification and MDM2 over-expression, and provide persuasive evidence therefore that the amplification of genetic sequences on chromosome 12q13 in soft tissue sarcomas targets the MDM2 gene for over-expression. These data also indicate that alternative mechanisms may contribute to MDM2 over-expression within some tumours.

Treatment of epithelioid sarcoma at the royal marsden hospital

Purpose: The aim of this study was to assess treatment and outcome with respect to clinical and pathological features.

Patients and methods: Thirty-nine patients were identified (range 7–66 years, mean 23). Initial treatment comprised local excision in 11 patients and wide excision in 14. Post-operative external beam radiotherapy was prescribed in 22 patients with a total dose of 60 Gy, delivered in two phases.

Results: The cause-specific survival for the entire group was 79, 63, 56 and 45% at 1, 3, 5 and 10 years, respectively. A distal limb location was associated with a better prognosis than proximal limb location (P = 0.04).

Conclusions: Our data favour treatment with wide functional excision followed by radical dose radiotherapy in attempt to minimize risk of local recurrence, especially when primary tumours are bigger than 3 cm. Our data also suggest the same treatment for local recurrence, when technically possible, to avoid amputation.

Pulmonary tumour embolism complicating a case of leiomyosarcoma

Patient. A case of peripheral leiomyosarcoma presenting with features of pulmonary thromboembolism is described.

Discussion. Persistence of the embolus despite triple-armed thrombolytic therapy and the presence of intravascular tumour invasion suggest the rare entity of pulmonary tumour embolism from a leiomyosarcoma.

The role of core needle biopsy in the diagnosis of suspected soft tissue tumours

BACKGROUND

Controversy surrounds the biopsy method of choice for the histological diagnosis of soft tissue sarcoma. The objective of this study was to evaluate the diagnostic accuracy of core needle biopsy (CNB) in patients referred with the suspicion of a soft tissue sarcoma.

METHODOLOGY

Previously undiagnosed patients (n = 530) with a suspected soft tissue tumour (STT) who underwent CNB at initial presentation were identified. Specific end-points were the ability to differentiate benign from malignant tumours, soft tissue from non-STT, and for sarcomas to define subtype and grade.

RESULTS

Of the 530 patients, 426 patients (80.4%) with soft tissue tumours were identified, of which 225 (52.8%) were malignant and 201 (47.2%) benign. In the remaining 104 patients, tumours masquerading as STT were diagnosed. CNB could differentiate soft tissue sarcomas from benign soft tissue tumours with an accuracy of 97.6%. High grade were differentiated from low grade sarcomas with an accuracy of 86.3%. Tumour subtype was accurately assigned in 89.5% of benign tumours and 88.0% of sarcomas.

CONCLUSION

CNB is simple, safe and can accurately diagnose benign and malignant soft tissue tumours. It can reliably identify other tumours masquerading as sarcoma. CNB should be the method of choice to obtain a histological diagnosis in suspected STT.

Prostate cancer in BRCA2 germline mutation carriers is associated with poorer prognosis

Background:

The germline BRCA2 mutation is associated with increased prostate cancer (PrCa) risk. We have assessed survival in young PrCa cases with a germline mutation in BRCA2 and investigated loss of heterozygosity at BRCA2 in their tumours.

Methods:

Two cohorts were compared: one was a group with young-onset PrCa, tested for germline BRCA2 mutations (6 of 263 cases had a germline BRAC2 mutation), and the second was a validation set consisting of a clinical set from Manchester of known BRCA2 mutuation carriers (15 cases) with PrCa. Survival data were compared with a control series of patients in a single clinic as determined by Kaplan–Meier estimates. Loss of heterozygosity was tested for in the DNA of tumour tissue of the young-onset group by typing four microsatellite markers that flanked the BRCA2 gene, followed by sequencing.

Results:

Median survival of all PrCa cases with a germline BRCA2 mutation was shorter at 4.8 years than was survival in controls at 8.5 years (P=0.002). Loss of heterozygosity was found in the majority of tumours of BRCA2 mutation carriers. Multivariate analysis confirmed that the poorer survival of PrCa in BRCA2 mutation carriers is associated with the germline BRCA2 mutation per se.

Conclusion:

BRCA2 germline mutation is an independent prognostic factor for survival in PrCa. Such patients should not be managed with active surveillance as they have more aggressive disease.

Surgical management of primary retroperitoneal sarcoma

BACKGROUND

Local recurrence after surgical resection is the main cause of disease-related mortality in patients with primary retroperitoneal sarcoma (RPS). This study analysed predictors of local recurrence and disease-specific survival.

METHODS

A prospective database was reviewed to identify patients who underwent surgery for primary RPS between 1990 and 2009. Patient demographics, operative outcomes and tumour variables were correlated with local recurrence and disease-specific survival. Multivariable analysis was performed to evaluate predictors for local recurrence and disease-free survival.

RESULTS

Macroscopic clearance was achieved in 170 of 200 patients. The median weight of tumours was 4.0 kg and median maximum diameter 27 cm. Resection of adjacent organs was required in 126 patients. The postoperative mortality rate was 3.0 per cent. Seventy-five patients developed local recurrence during follow-up. At 5 years the local recurrence-free survival rate was 54.6 per cent and the disease-specific survival rate 68.6 per cent. Inability to obtain macroscopic clearance at resection and high-grade tumours were significant predictors for local recurrence and disease-specific survival.

CONCLUSION

Complete macroscopic excision should be the goal of surgical resection. Ability to resect a RPS completely and tumour grade are the most important predictors of local recurrence and overall survival.

Radiofrequency ablation is a feasible therapeutic option in the multi modality management of sarcoma

The role of radiofrequency ablation (RFA) in metastatic sarcoma is not well defined. The aim of this study was to evaluate the efficacy and safety of RFA in a series of sarcoma patients. A retrospective search of a prospectively maintained database identified 13 gastrointestinal stromal tumour (GIST) patients and 12 with other histological subtypes treated with RFA. All the GIST patients received RFA for metastatic disease in the liver: 12 of these responded to the first RFA procedure and one achieved stable disease. Two GIST patients received RFA on two occasions to separate lesions within the liver and both responded to the second RFA procedure. Of the other subtypes: 7 underwent RFA to liver lesions, 5 of these responded to RFA, one progressed and 1 was not assessable for response at the time of analysis. All 5 patients with lung metastases achieved a response following their first RFA procedure. RFA was effective and well tolerated in this series of sarcoma patients. RFA may have a role in patients with GIST who have progression in a single metastasis but stable disease elsewhere. Further larger studies are required to better define the role of this technique in this patient population.

Magnitude and contributory factors of postnatal depression: a community-based cohort study from a rural subdistrict of Bangladesh

BACKGROUND

Recent evidence suggests that the prevalence of postnatal depression (PND) is highest in low-income developing countries. This study aimed to estimate the prevalence of PND and its associated risk factors among Bangladeshi women.

METHOD

The study was conducted in the Matlab subdistrict of rural Bangladesh. A cohort of 346 women was followed up from late pregnancy to post-partum. Sociodemographic and other related information on risk factors was collected on structured questionnaires by trained interviewers at 34-35 weeks of pregnancy at the woman's home. A validated local language (Bangla) version of the Edinburgh Postnatal Depression Scale (EPDS-B) was used to measure depression status at 34-35 weeks of pregnancy and at 6-8 weeks after delivery.

RESULTS

The prevalence of PND was 22% [95% confidence interval (CI) 17.7-26.7%] at 6-8 weeks post-partum. After adjustment in a multivariate logistic model, PND could be predicted by history of past mental illness [odds ratio (OR) 5.6, 95% CI 1.1-27.3], depression in current pregnancy (OR 6.0, 95% CI 3.0-12.0), perinatal death (OR 14.1, 95% CI 2.5-78.0), poor relationship with mother-in-law (OR 3.6, 95% CI 1.1-11.8) and either the husband or the wife leaving home after a domestic quarrel (OR 4.0, 95% CI 1.6-10.2).

CONCLUSIONS

The high prevalence of PND in the study was similar to other countries in the South Asian region. The study findings highlight the need for programme managers and policy makers to allocate resources and develop strategies to address PND in Bangladesh.

MR quantification of abnormal stromal enhancement in the periphery of invasive breast tumors

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Background: In dynamic contrast-enhanced MRI (DCEMRI), properties of tissue microvasculature and overall vascularity can be quantified using kinetics of contrast enhancement. It has been shown that areas with high signal enhancement ratio (SER) were significantly correlated with high tumor vascularity, and that mean SER in nearby non-cancerous breast stroma was significantly associated with disease free survival. No universally accepted methods exist to determine the optimal extent of histologically normal breast tissue to treat. Although a relationship between normal tissue SER and recurrence has been observed, the spatial relationship of enhancement within the non-cancerous stroma with respect to proximity of the tumor has not been shown. We hypothesized that abnormalities in vasculature exist within the histologically normal breast stroma that can be detected by measuring changes in enhancement intensity. Methods: We performed a secondary analysis of pre-treatment DCEMRI data from 27 invasive breast cancer patients. An automated, user-independent program was used to segment breast tissue from all other structures. A SER threshold was set to identify invasive tumor regions, and a tumor proximity map was generated giving the 3D distance of each normal breast tissue voxel to the nearest tumor voxel. A percent enhancement (PE) map was calculated for the normal stroma using the signal intensity change between the pre-contrast and post-contrast images. The proximity and PE maps were then combined to measure breast tissue enhancement at various distances from the tumor. Results: PE levels in normal breast tissue situated within 2 cm of the tumor region were significantly higher than at all more distant regions. Pairwise comparisons with Turkey's adjusted p-values indicated that the mean PE at 0 cm-1 cm is significantly higher than all other distant levels (p = < 0.0001) and the mean PE at 1 cm-2 cm is significantly higher than 5 cm-6 cm (p = 0.006). Conclusions: Here, we show that the normal-appearing breast stroma within 0 cm to 2 cm of a primary tumor exhibits higher enhancement levels than stroma located far from the tumor. These results suggest that tissue surrounding the tumor region may contain tumor-related angiogenesis. These findings could help personalize surgery and radiation techniques.

No significant financial relationships to disclose.

Clinical outcomes of extra-thoracic solitary fibrous tumours

BACKGROUND

Extra-thoracic solitary fibrous tumours (ESFTs) have traditionally been regarded as indolent neoplasms similar to their intra-thoracic counterparts. However there has been some evidence that a subset of more aggressively malignant tumours exist. We examined our experience with these rare tumours in an effort to clarify their clinico-pathological behaviour and relate this to their histopathological findings.

PATIENTS/METHODS

All patients with a histopathological diagnosis of solitary fibrous tumour (SFT) who presented to the Royal Marsden Hospital between 1998 and 2006 were reviewed. Clinico-pathological data were recorded for all cases and subset analysis performed to compare rates of locoregional recurrence, distant metastases and death.

RESULTS

There were 33 cases included in the study. 18 cases had malignant features on histological examination. Locoregional recurrent disease was more common in those with malignant histopathological findings compared to those with benign histopathology (6/18 vs 0/15 p 0.021). Distant metastatic disease was more common in those with malignant histopathological findings (7/18 vs 1/15 p 0.046) and these patients were at increased risk of death (10/18 vs 0/15 p<0.01). The presence of malignant histopathology was the only factor to affect survival with no benign cases dying of disease and malignant cases having a median survival of 59 months (p 0.003).

CONCLUSION

In our experience ESFTs have a higher rate of malignant behaviour than that classically described. Those tumours with atypical or malignant features on histological examination have poor prognosis and should be managed and followed up in the same manner as other high-grade soft tissue tumours.

Treatment and outcome of radiation-induced soft-tissue sarcomas at a specialist institution

BACKGROUND

Radiation-induced sarcoma (RIS) is a rare late complication of therapeutic irradiation with a reputation for aggressive pathology and poor outcome.

METHODS

We retrospectively reviewed histopathological features, surgery and outcome in 67 patients with RIS treated between 1990 and 2005 at a single tertiary referral center.

RESULTS

Previous breast cancer was the most common indication for radiotherapy. The median interval from irradiation to development of RIS of was 11 years (3-36 years). Median tumour size was 7 cm with 56% classified as high grade, 31% intermediate grade and 13% low grade. The commonest histology was leiomyosarcoma. The only relationship for histology with site was for angiosarcoma (n=9), all of which developed on the chest wall/breast after irradiation for breast cancer. Of 67 patients, 34 underwent potentially curative surgery, and microscopically clear margins were achieved in 75% of cases. Pedicled or free tissue transfer was required in 12 patients and abdominal or chest wall mesh reconstructions were required in 8 patients. No patient received adjuvant radiotherapy but 7 received adjuvant/neoadjuvant chemotherapy. Median follow up is 53 months. Median sarcoma specific survival was 54 months (2- & 5-year survival: 75% & 45%). The local relapse rate was 65%. Negative histopathological margins were a significant predictor of sarcoma specific survival (HR 3.0 95% CI 1.1-8.6 p=0.04). Grade and size of tumour approached, but did not attain significance.

CONCLUSION

RIS is a biologically aggressive tumour with high rates of local relapse despite aggressive attempts at curative surgery.

The myofibroblast and its tumours

Tumours and tumour-like lesions of myofibroblasts may present diagnostic difficulty because of their rarity and because of uncertainties in identifying the myofibroblast. The objectives of this review are to provide a definition of the myofibroblast and an account of its biology for facilitating an understanding of the cell and of myofibroblastic lesions; and to describe, in the context of common diagnostic problems, the features of benign and malignant myofibroblastic lesions. The main characteristics of the myofibroblast include a spindled or stellate morphology; immunostaining for alpha-smooth muscle actin and the extra domain A variant of cellular fibronectin; and an ultrastructure of rough endoplasmic reticulum, peripheral contractile filaments and the cell-to-matrix junction known as the fibronexus. On this basis, lesions traditionally regarded as myofibroblastic are shown to vary in their level of differentiation, and some appear to be smooth muscle rather than myofibroblastic. Immunohistochemistry and electron microscopy, used together, are emphasised as being important for maximum diagnostic confidence in some myofibroblastic lesions.

Epithelioid perineurioma: an unusual variant

An unusual epithelioid variant of perineurioma of the groin occurring in a 53-year-old man is described. The lesion appeared to be associated with a femoral nerve branch. The tumour was characterised by the presence of a syncytial proliferation of epithelioid cells, mimicking a meningioma of syncytial type. In addition there was a minor component of a conventional perineurioma. The tumour cells were EMA+, claudin-1+ and collagen type IV+. Bcl 2 was focally expressed. This case highlights the possibility of a common histogenetic pathway for meningiomas and perineuriomas. Although ultrastructural evidence of possible meningiomatous differentiation within an otherwise histologically typical perineurioma has been described, this is the first reported case of an unconventional epithelioid variant of perineurioma, histologically resembling meningioma.

Liposarcoma of the thyroid

Liposarcoma of the thyroid gland is rare with only 3 cases reported in the English literature. We present a further two patients whom we have recently treated: a 49 year old lady with a myxoid liposarcoma and a 71 year old man with a pleomorphic liposarcoma. Both underwent macroscopic excision of tumour but had positive margins, so were then treated with external beam radiotherapy. The former patient died from metastases 10 months after presentation, the latter remains alive but has developed metastatic disease on follow up at 24 months.

We recommend the use of high dose radiotherapy following radical surgery as margins of excision are usually narrow in this most difficult region. The role of chemotherapy is yet to be established.