Primary Bone Tumors: Epidemiologic Comparison of 9200 Patients Treated at Beijing Ji Shui Tan Hospital, Beijing, China, With 10 165 Patients at Mayo Clinic, Rochester, Minnesota

Context

Although primary bone tumors are extremely rare, the literature suggests that there are variations in the epidemiologic characteristics in different populations. The most frequently cited epidemiologic characteristics of primary bone tumors are derived from a large US series (Mayo Clinic), with no comparable study thus far performed in China.

Objective

To identify any potential epidemiologic differences between Chinese patients and a US series of patients.

Design

We performed a comparison study between 9200 patients treated at Beijing Ji Shui Tan Hospital (JST) and 10 165 patients treated at Mayo Clinic (MC), Rochester Minnesota. Detailed epidemiologic features were analyzed.

Results

We found that giant cell tumor and osteosarcoma have significantly higher incidences in the JST than the MC patients (P < .001). However, JST patients had a significantly lower incidence of Ewing sarcoma, chordoma, fibrosarcoma, myeloma, and malignant lymphoma (P < .001). For most benign and malignant bone tumors, the Chinese cohort had a more distinct male predominance than the US cohort. Malignant bone tumors had a monomodal age distribution in the JST patient group, with a bimodal age distribution in the MC cohort. Also, there were was a predilection for tumors of the femur and tibia among the JST patients (P < .001).

Conclusions

Our data confirm that epidemiologic variations of primary bone tumors exist in different populations. Factors that may contribute to these observed differences are proposed and discussed.

Gastrointestinal stromal tumors, version 2.2014

Gastrointestinal stromal tumors (GIST) are the most common soft tissue sarcoma of the gastrointestinal tract, resulting most commonly from KIT or platelet-derived growth factor receptor α (PDGFRα)-activating mutations. These NCCN Guideline Insights highlight the important updates to the NCCN Guidelines for Soft Tissue Sarcoma specific to the management of patients with GIST experiencing disease progression while on imatinib and/or sunitinib.

CYP3A isoforms in Ewing's sarcoma tumours: an immunohistochemical study with clinical correlation

Ewing's sarcoma is an aggressive malignancy of bone and soft tissue with high incidence of metastasis and resistance to chemotherapy. Cytochrome P450 (CYP) monooxygenases are a family of enzymes that are involved in the metabolism of exogenous and endogenous compounds, including anti-cancer drugs, and have been implicated in the aggressive behaviour of various malignancies. Tumour samples and clinical information including age, sex, tumour site, tumour size, clinical stage and survival were collected from 36 adult and paediatric patients with Ewing's sarcoma family tumours. Tissue microarrays slides were processed for immunohistochemical labelling for CYP3A4, CYP3A5 and CYP3A7 using liver sections as positive control. The intensity of staining was scored as negative, low or high expression and was analysed statistically for any association with patients' clinical information. Four cases were later excluded due to inadequate viable tissue. CYP3A4 staining was present in 26 (81%) cases with high expression noted in 13 (40%) of 32 cases. High expression was significantly associated with distant metastases (P < 0.05). CYP3A5 and CYP3A7 were expressed in 5 and 13 cases respectively (15.6%, 40.6%). There was no association between the expression of CYP3A isoforms and age, sex, tumour size, or location (pelvic or extra-pelvic). None of the biomarkers showed any correlation with overall or disease-free survival. In conclusion, expression of CYP3A isoforms is noted in Ewing's sarcoma tumours and high CYP3A4 expression may be associated with metastasis. Additional studies are needed to further investigate the role of CYP3A4 in the prognosis of these tumours.

Long non-coding RNAs (LncRNA) regulated by transforming growth factor (TGF) β: LncRNA-hit-mediated TGFβ-induced epithelial to mesenchymal transition in mammary epithelia

Long noncoding RNAs (lncRNAs) are emerging as key regulators in various biological processes. Epithelial-to-mesenchymal transition (EMT) is a developmental process hijacked by tumor cells to depart from the primary tumor site, invade surrounding tissue, and establish distant metastases. Transforming growth factor β (TGFβ) signaling has been shown to be a major inducer of EMT and to facilitate breast cancer metastasis. However, the role of lncRNAs in this process remains largely unknown. Here we report a genome-wide lncRNA profile in mouse mammary epithelial NMuMG cells upon TGFβ induction of EMT. Among 10,802 lncRNAs profiled, over 600 were up-regulated and down-regulated during the EMT, respectively. Furthermore, we identify that lncRNA-HIT (HOXA transcript induced by TGFβ) mediates TGFβ function, i.e. depletion of lncRNA-HIT inhibits TGFβ-induced migration, invasion, and EMT in NMuMG. LncRNA-HIT is also significantly elevated in the highly metastatic 4T1 cells. Knockdown of lncRNA-HIT in 4T1 results in decrease of cell migration, invasion, tumor growth, and metastasis. E-cadherin was identified as a major target of lncRNA-HIT. Moreover, lncRNA-HIT is conserved in humans and elevated expression associates with more invasive human primary breast carcinoma. Collectively, these data suggest that a subset of lncRNAs such as lncRNA-HIT play a significant role in regulation of EMT and breast cancer invasion and metastasis, and could be potential therapeutic targets in breast cancers.

Beta-catenin expression patterns in matched pre- and post-neoadjuvant chemotherapy-resistant breast cancer

BACKGROUND

β-catenin is a critical component of the cadherin cell-to-cell adhesion pathway and a key participant in the Wnt signaling pathway. Activation of β-catenin signaling in the Wnt pathway is a known contributor to tumor cancer progression and metastasis and may result in resistance to chemotherapeutic agents. The aim of this study is to evaluate the patterns of expression of β-catenin in breast carcinoma cells before and after neoadjuvant chemotherapy. Discovery of the molecular mechanisms responsible for resistance to chemotherapy treatment could result in more effective therapy, and improve outcome and survival.

DESIGN

Twenty-nine matched pre-treatment and post-neoadjuvant chemotherapy breast carcinomas were subjected to immunohistochemical study using anti-β-catenin antibody. Normal staining was defined as crisp membrane staining in >90% tumor cells; aberrant expression was nuclear staining in >5% tumor cells.

RESULTS

Of the 29 included cases, five cases of invasive lobular carcinoma lacked β-catenin immunoreactivity pre- and post-treatment. Mildly reduced membranous staining was seen in two post-treatment samples. One case of triple-negative ductal carcinoma had reduced pre- and post-treatment staining. All other cases showed normal pre- and post-treatment β-catenin expression. No aberrant staining was identified.

CONCLUSION

In our study, there was no difference in the expression of β-catenin in pre- and post-neoadjuvant chemotherapy specimens. These results do not suggest that β-catenin plays a role in conferring neoadjuvant chemotherapy resistance.

Histopathological and immunophenotypical features of intestinal-type adenocarcinoma of the gallbladder and its precursors

BACKGROUND

Intestinal-type adenocarcinoma of the gallbladder is an unusual malignancy associated with low- and high-grade intraepithelial neoplasms. The literature on the clinicopathologic characteristics of the precursor lesions of gallbladder cancer is limited, due in part to the variability in its definition and terminology.

METHODS

Here we report one case of intestinal-type adenocarcinoma of the gallbladder with distinctive morphology and associated precursor lesions. All of the hematoxylin and eosin stained slides were reviewed. Immunostains were performed using the avidin-biotin complex method for CK20, CK7, CDX2, MUC1, MUC2, and MUC-5AC. We also reviewed the literature discussing the current terminology from the World Health Organization for these lesions.

RESULTS

A 70-year-old man presented with epigastric abdominal pain and bloating. Computed tomography demonstrated a large heterogeneous gallbladder mass. Macroscopically, the gallbladder was 7.5 x 5.5 x 4.5 cm with smooth serosa. The lumen was occupied by a 5.0 x 4.5 x 3.0 cm irregular friable exophytic mass. The remaining mucosa had a tan brown to pink color with granular/papillary excrescences of up to 0.7 cm in thickness. Histologically, the tubulopapillary adenoma was lined by pseudostratified columnar epithelium with low and extensive high-grade dysplasia. Goblet cell and cystic dilatation were present in some glands. Immunohistochemistry showed that the intestinal type was positive for CK20, CK7, and CDX2, focally positive for MUC1/2, and negative for MUC-5AC.

CONCLUSION

This case showed the complete spectrum of the progression of intestinal-type intracholecystic papillary-tubular neoplasms of the gallbladder.

Cutaneous leiomyosarcoma: treatment and outcomes with a standardized margin of resection

BACKGROUND

Cutaneous leiomyosarcoma is primarily a low-grade malignancy that affects elderly male Caucasians. It is a rare dermal-based tumor for which treatment algorithms have been poorly defined.

METHODS

We retrospectively reviewed the use of a median 1-cm margin for resection to treat patients with cutaneous leiomyosarcoma referred for treatment between 2005 and 2010.

RESULTS

Thirty-three patients with cutaneous leiomyosarcoma were treated. Of these, 76% were male, 97% were Caucasian (median age: 63.5 years), and 67% of tumors were located on the extremities. Preoperative staging was negative for distant metastasis in all patients. A majority of the tumors (88%) were low grade (median size: 1.3 cm). All of the tumors were positive for smooth-muscle actin. A total of 94% of patients underwent primary surgical resection with a median margin of 1 cm. Final resection margin was negative in 97% of patients. Adjuvant radiotherapy was used in 15%. No metastatic spread or recurrences were present, and 100% of patients were alive at last follow-up (median: 15.5 months).

CONCLUSIONS

Good oncological control and excellent outcomes are possible with a 1-cm resection margin in most cases of cutaneous leiomyosarcoma.

Vascular measurements correlate with estrogen receptor status

Background

Breast carcinoma can be classified as either Estrogen Receptor (ER) positive or negative by immunohistochemical phenotyping, although ER expression may vary from 1 to 100% of malignant cells within an ER + tumor. This is similar to genetic variability observed in other tumor types and is generally viewed as a consequence of intratumoral evolution driven by random genetic mutations. Here we view cellular evolution within tumors as a classical Darwinian system in which variations in molecular properties represent predictable adaptations to spatially heterogeneous environmental selection forces. We hypothesize that ER expression is a successful adaptive strategy only if estrogen is present in the microenvironment. Since the dominant source of estrogen is blood flow, we hypothesized that, in general, intratumoral regions with higher blood flow would contain larger numbers of ER + cells when compared to areas of low blood flow and in turn necrosis.

Methods

This study used digital pathology whole slide image acquisition and advanced image analysis algorithms. We examined the spatial distribution of ER + and ER- cells, vascular density, vessel area, and tissue necrosis within histological sections of 24 breast cancer specimens. These data were correlated with the patients ER status and molecular pathology report findings.

Results

ANOVA analyses revealed a strong correlation between vascular area and ER expression and between high fractional necrosis and absent ER expression (R² = 39%; p < 0.003 and R² = 46%; p < 0.001), respectively). ER expression did not correlate with tumor grade or size.

Conclusion

We conclude that ER expression can be understood as a Darwinian process and linked to variations in estrogen delivery by temporal and spatial heterogeneity in blood flow. This correlation suggests strategies to promote intratumoral blood flow or a cyclic introduction of estrogen in the treatment schedule could be explored as a counter-intuitive approach to increase the efficacy of anti-estrogen drugs.

Pleomorphic liposarcoma: a cytologic study of five cases

Pleomorphic liposarcoma represents one of the rarest variants of liposarcoma. It has a poor prognosis and unlike other variants of liposarcoma, lacks a molecular or genetic signature. Histologic studies of pleomorphic liposarcoma have defined this lesion as a high grade sarcoma, which contains a variable number of lipoblasts. We describe the cytologic features of five cases of pleomorphic liposarcoma, all of which had histologic confirmation. We consistently identified numerous lipoblasts as well as micro and macrovesicular fat vacuoles in the background of cellular, pleomorphic sarcomatoid neoplasms. The appearance of the aspirates differs substantially form other variants of liposarcoma.

Tenosynovial giant cell tumors lacking giant cells: report of diagnostic pitfalls

Tenosynovial giant cell tumors are a group of neoplastic disorders that involve synovium-lined tendon sheaths, synovial joints, and adjacent soft tissue. They are divided into localized and diffuse subtypes. TSGCTs have well-established clinical and histological diagnostic criteria; however, the subtypes and nomenclature can be confusing. They also pose diagnostic challenges when they occur in atypical locations or without multinucleated giant cells. With the possibility for systemic targeted therapy in relapsing pigmented villonodular tenosynovitis and diffuse-type giant cell tumor, accurate diagnosis and subtyping of TSGCTs is increasingly important. We report two cases of TSGCTs in order to elucidate the diagnostic nomenclature, clinicopathological features, differential diagnosis, and diagnostic pitfalls. Recent advancements in the pathogenesis and targeted therapy of TSGCTs are also discussed.

Co-existing adenoid cystic carcinoma and invasive squamous cell carcinoma of the uterine cervix: a rare case report and literature review

Adenoid cystic carcinoma (ACC) is a rare cervical malignancy, and its coexistence with other malignancies in the uterine cervix is extremely rare. Here, we present a case of coexistence of ACC and invasive squamous cell carcinoma (SCC) of the uterine cervix, as well as a literature review. A 68-year-old Chinese woman with vaginal bleeding underwent a cervical cytology screening, cervical biopsy, and finally cervical conization. Subsequent pathological diagnoses of coexisting ACC and invasive SCC were rendered with a positive margin. Her status post-radiation therapy showed no recurrence or metastasis after a follow-up of 7 months. Immunohistochemical studies of the surgical specimen revealed that the ACC component exhibited a pattern distinct from the SCC component. ACC was collagen IV, S-100 and CK7 positive, and p63 and CK34βE12 (CK903) patchy positive; SCC was p63 and CK34βE12 (CK903) strongly and diffusely positive, while negative for collagen IV, S-100, and CK7. Both components were positive for high-risk human papilloma virus types 16 and 18, detected by in situ hybridization. This case is among very few previously described cases of coexisting ACC with invasive SCC in the uterine cervix.

Carbonic anhydrase IX as an imaging and therapeutic target for tumors and metastases

Carbonic anhydrase IX (CAIX) which is a zinc containing metalloprotein, efficiently catalyzes the reversible hydration of carbon dioxide. It is constitutively up-regulated in several cancer types and has an important role in tumor progression, acidification and metastasis. High expression of CAIX generally correlates with poor prognosis and is related to a decrease in the disease-free interval following successful therapy. Therefore, it is considered as a prognostic indicator in oncology.In this review, we describe CAIX regulation and its role in tumor hypoxia, acidification and metastasis. In addition, the molecular imaging of CAIX and its potential for use in cancer detection, diagnosis, staging, and for use in following therapy response is discussed. Both antibodies and small molecular weight compounds have been used for targeted imaging of CAIX expression. The use of CAIX expression as an attractive and promising candidate marker for systemic anticancer therapy is also discussed.

Diagnostic digital cytopathology: Are we ready yet?

Background:

The cytology literature relating to diagnostic accuracy using whole slide imaging is scarce. We studied the diagnostic concordance between glass and digital slides among diagnosticians with different profiles to assess the readiness of adopting digital cytology in routine practice.

Materials and Methods:

This cohort consisted of 22 de-identified previously screened and diagnosed cases, including non-gynecological and gynecological slides using standard preparations. Glass slides were digitalized using Aperio ScanScope XT (×20 and ×40). Cytopathologists with (3) and without (3) digital experience, cytotechnologists (4) and senior pathology residents (2) diagnosed the digital slides independently first and recorded the results. Glass slides were read and recorded separately 1-3 days later. Accuracy of diagnosis, time to diagnosis and diagnostician's profile were analyzed.

Results:

Among 22 case pairs and four study groups, correct diagnosis (93% vs. 86%) was established using glass versus digital slides. Both methods more (>95%) accurately diagnosed positive cases than negatives. Cytopathologists with no digital experience were the most accurate in digital diagnosis, even the senior members. Cytotechnologists had the fastest diagnosis time (3 min/digital vs. 1.7 min/glass), but not the best accuracy. Digital time was 1.5 min longer than glass-slide time/per case for cytopathologists and cytotechnologists. Senior pathology residents were slower and less accurate with both methods. Cytopathologists with digital experience ranked 2^nd fastest in time, yet last in accuracy for digital slides.

Conclusions:

There was good overall diagnostic agreement between the digital whole-slide images and glass slides. Although glass slide diagnosis was more accurate and faster, the results of technologists and pathologists with no digital cytology experience suggest that solid diagnostic ability is a strong indicator for readiness of digital adoption.

Cutaneous angiosarcoma: a single-institution experience

BACKGROUND

Cutaneous angiosarcoma (CAS) is a rare, aggressive vascular sarcoma with a poor prognosis, historically associated with 5-year overall survival (OS) rates between 10 and 30 %.

METHODS

This is a single-institution retrospective review of patients treated for CAS from 1999-2011. Demographics, primary tumor characteristics, treatment, and outcomes were analyzed.

RESULTS

A total of 88 patients were identified (median age 70 years and 57 % female). Median tumor size was 3 cm. Median follow-up was 22 months. The 5-year OS and recurrence-free survival (RFS) were 35.2 and 32.3 %, respectively; median was 22.1 months. Also, 36 patients (41 %) received surgery alone, 7 (8 %) received XRT alone, and 41 (47 %) received surgery and XRT. Of the 67 of 88 patients who were disease-free after treatment, 33 (50 %) recurred (median of 12.3 months). Surgery alone had the highest 5-year OS (46.9 %) and RFS (39.9 %) (p = ns). Four presentation groups were identified: (1) XRT-induced, n = 30 (34 %), 26 of 30 occurred in females with a prior breast cancer, (2) sporadic CAS on head and neck (H/N), n = 38, (3) sporadic CAS on trunk/extremities, n = 13, and (4) Stewart-Treves n = 7. Those with trunk/extremity CAS had the highest 5-year OS (64.8 %), with H/N CAS having the worst 5-year OS (21.5 %). On MV analysis, only tumor size <5 cm correlated with improved OS (p = 0.014).

DISCUSSION

In this large series, there appears to be a better overall prognosis than historically reported, especially in Stewart-Treves and CAS on trunk or extremities. While surgery alone was associated with better OS and RFS compared with other treatment modalities, this was not statistically significant. Tumor size was a significant prognostic factor for OS.

Ethnicity and age disparities in Ewing sarcoma outcome

This institutional retrospective review studied Ewing sarcomas from 1987-2011. Among 135 patients, 127 (19 Hispanic and 108 white/non-Hispanic) were analyzed (excluding small sample sized groups) finding 15% Hispanic, 85% non-Hispanic, 27% <18 years, 21% >40 years and 1-272 months follow-up (median 41). Age was significantly associated with overall survival (OS) (p = 0.01), whereby <18 years had a higher probability of 5-year survival (OS 61%) than >40 years (OS 37.6%). Ethnicity was marginally statistically significant (OS, p = 0.065); whereby median survival was clinically significant (white non-Hispanic 63 months and Hispanic 23 months). Hispanic ethnicity and older age are independent poor prognostic factors.

Abstract 415: Cytochrome CYP3A4 expression may predict metastasis in Ewing's sarcoma family of tumors

Background: Ewing's sarcoma family tumor (EFT) is an aggressive malignancy of bone and soft tissue with high incidence of metastasis and resistance to chemotherapy in metastatic disease. Cytochrome P450 (CYP) monooxygenases are a multigene family of enzymes that are involved in phase I reactions of metabolism of a wide range of endogenous compounds and xenobiotics, including anticancer drugs. Expression of CYP isoforms may influence tumor development, progression and resistance to therapy. Overexpression of CYP3A isoforms was associated with more aggressive behavior in breast cancer, osteosarcoma and other tumors. The purpose of this study is to define the expression CYP3A isoforms in EFT and establish its prognostic significance.

Design: Archived EFT cases and pertinent clinical data were compiled to include patient's age, sex, tumor location, tumor size, overall survival, disease-free survival and clinical stage. Two representative histologic sections of the tumors were selected for tissue microarray construction. Sections were processed for immunohistochemical labeling with CYP3A4, CYP3A5, and CYP3A7. Liver sections were used as positive control. The intensity of the staining was scored as negative, low (weak staining less than the positive control) or high (equal to or stronger than the positive control). The staining intensity was correlated with clinical data and the significance of any associations was statistically analyzed by one tailed and two tailed t-tests.

Results: 36 cases of Ewing sarcoma family of tumors were selected, 22 were males and 12 females. Age ranged from 12-72 years. 4 cases were excluded from immunohistochemical interpretation due inadequate viable tissue. CYP3A4 staining was present in 27 (84%) cases with high expression noted in 6 (19%) of 32 cases. High expression was significantly associated with distant metastases (p&lt; 0.05). There was no association of high CYP3A4 expression with age, sex, tumor size, or location (pelvic or extrapelvic). CYP3A5 and CYP3A7 were expressed in 5 and 13 cases (15.6%, 40.6%) respectively, and were not associated with age, sex, tumor size, metastasis or location. None of the studied biomarkers showed any correlation with overall or disease free survival.

Conclusion: CYP3A4, CYP3A5 and CYP3A7 are variably expressed in EFTs. High CYP3A4 expression may predict metastasis in EFT. Additional studies with higher number of cases are needed to further investigate the role of CYP3A4 in the prognosis of Ewing's sarcoma family tumors.

Citation Format: Atif Ahmed, Hamid Zia, Graeme I. Murray, Carrie A. Vyhlidal, J. Steven Leeder, Marilyn M. Bui. Cytochrome CYP3A4 expression may predict metastasis in Ewing's sarcoma family of tumors. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 415. doi:10.1158/1538-7445.AM2013-415

Wee1 inhibition by MK-1775 leads to tumor inhibition and enhances efficacy of gemcitabine in human sarcomas

Sarcomas are rare and heterogeneous mesenchymal tumors affecting both pediatric and adult populations with more than 70 recognized histologies. Doxorubicin and ifosfamide have been the main course of therapy for treatment of sarcomas; however, the response rate to these therapies is about 10-20% in metastatic setting. Toxicity with the drug combination is high, response rates remain low, and improvement in overall survival, especially in the metastatic disease, remains negligible and new agents are needed. Wee1 is a critical component of the G2/M cell cycle checkpoint control and mediates cell cycle arrest by regulating the phosphorylation of CDC2. Inhibition of Wee1 by MK1775 has been reported to enhance the cytotoxic effect of DNA damaging agents in different types of carcinomas. In this study we investigated the therapeutic efficacy of MK1775 in various sarcoma cell lines, patient-derived tumor explants ex vivo and in vivo both alone and in combination with gemcitabine, which is frequently used in the treatment of sarcomas. Our data demonstrate that MK1775 treatment as a single agent at clinically relevant concentrations leads to unscheduled entry into mitosis and initiation of apoptotic cell death in all sarcomas tested. Additionally, MK1775 significantly enhances the cytotoxic effect of gemcitabine in sarcoma cells lines with different p53 mutational status. In patient-derived bone and soft tissue sarcoma samples we showed that MK1775 alone and in combination with gemcitabine causes significant apoptotic cell death. Magnetic resonance imaging (MRI) and histopathologic studies showed that MK1775 induces significant cell death and terminal differentiation in a patient-derived xenograft mouse model of osteosarcoma in vivo. Our results together with the high safety profile of MK1775 strongly suggest that this drug can be used as a potential therapeutic agent in the treatment of both adult as well as pediatric sarcoma patients.

Fibrous dysplasia

Fibrous dysplasia is an uncommon bone disease. The diagnosis is usually not difficult, given the symptoms, radiology, and histology. The gene involved is the α subunit of the G-protein receptor. Recent innovation in molecular pathology has helped us understand the mechanism of disease pathogenesis. The treatment of fibrous dysplasia is limited to maintenance of maximum bone density. Surgical reinforcement is used to treat bowing deformities and fractures as they occur. Malignant transformation of fibrous dysplasia is rare. Currently, there is no therapy for preventing the disease from advancing or for malignant transformation.