Sarcomas of the head and neck. Prognostic factors and treatment strategies

The authors reviewed 164 cases of head and neck sarcoma from adult patients seen at the University of California, Los Angeles (UCLA), between 1955 and 1988. The median follow-up was 70 months. Multivariate analysis demonstrated that tumor grade, size, and surgical margin status were the most important independent prognostic factors. Thirty-one percent (27 of 85) of patients with high-grade lesions were free of disease versus 81% (44 of 55) with low-grade lesions at last follow-up. Sixty-seven percent (50 of 76) of patients with lesions smaller than 5 cm were free of disease versus 38% (33 of 88) with lesions larger than 5 cm. In 16 patients, low-grade lesions, measuring less than 5 cm and with negative margins histologically, were controlled with surgery alone. For the 94 patients whose primary tumors were treated at UCLA, local control was achieved in 52% (26 of 50) of patients treated with surgery alone and 90% (20 of 22) with combined therapy (surgery and radiation therapy [RT] with or without chemotherapy). Seventy-five percent (6 of 8) of patients with positive surgical margins treated with postoperative RT achieved local control versus 26% (5 of 19) of patients receiving no additional treatment. In conclusion, surgery alone appears to be adequate treatment for small, low-grade tumors and negative surgical margins. Patients with incomplete resection or high-grade tumors should receive aggressive treatment--surgery and RT.

Current management and clinical outcome of hemangiopericytomas

Hemangiopericytoma is a rare vascular tumor with variable malignant potential. We report perioperative embolization of a hemangiopericytoma and review the Virginia Mason Clinic experience with six patients during the period 1975 to 1990 with respect to demographics, diagnosis, treatment, and outcome. Our experience suggests that hemangiopericytomas have a variable but predictable malignant potential based on histology and clinical behavior. Three of six patients died of their disease. The remainder were alive and well at 1, 3.5, and 12 postoperative years. These tumors can be specifically and completely delineated preoperatively using magnetic resonance imaging and angiography, the diagnostic procedures of choice. Hemangiopericytomas are highly vascular and amenable to preoperative transarterial embolization. Our most recent case was performed without blood transfusion. This differs from literature reports of massive transfusion requirements and two cases of exsanguination following resection. Finally, recent literature has reported these tumors to respond to greater than 4,500 cGy of local postoperative radiotherapy. We conclude that this interval review of hemangiopericytomas is both timely and relevant with respect to recent developments in imaging and catheter technology. We recommend routine angiography and perioperative embolization prior to wide excision and postoperative radiotherapy.

[A case of hemangiopericytoma of the pelvis]

Haemangiopericytoma is an uncommon tumour of vascular origin. The authors report a case of one of the rarer sites of this tumour in man: paravesical pelvic haemangiopericytoma. Although modern imaging techniques have provided useful information concerning the hypervascular and clearly demarcated appearance of this tumour which displaces but does not invade adjacent organs, its diagnosis can only be established by histology. Its degree of malignancy and its invasive potential are unclear. The risk of local recurrence and metastases in more than one half of cases justifies wide surgical excision, possibly combined with adjuvant radiotherapy, and long-term follow-up.

[Neonatal malignant tumors. Apropos of 75 cases]

From 1975 to 1986, 75 neonates were treated at the Institute Gustave-Roussy for a malignant solid tumor, comprising 1.7% of the overall oncopediatric population treated during the same period of time. Of these 75 patients, 47 (62%) presented with neuroblastomas, 15 (20%) with mesenchymal tumors, 9 (12%) with germ cell tumors and 4 with various other types of tumors. Treatment consisted of surgery in 63 patients, chemotherapy in 43 and radiotherapy in 18. The 5 year crude survival rate was 77%. Neuroblastomas did the best with a crude survival rate of 89%. The young age of the patients resulted in two types of problems: immediate tolerance and long term sequelae. The therapeutic regimen should take into account the good prognosis of the majority of these tumors in order to decrease delayed effects.

Vascular soft-tissue sarcomas. An analysis of tumor-related mortality

Between 1982 and 1990, 69 adult patients were admitted to Memorial Sloan-Kettering Cancer Center with a diagnosis of angiosarcoma, lymphangiosarcoma, or malignant hemangiopericytoma. The existing literature regarding sarcomas focuses on individual histologic conditions or site-specific activity and includes pediatric patients, which makes estimates of survival difficult. We describe the clinical course of all vascular sarcomas, the survival without distant recurrence of patients with vascular sarcomas, and the overall survival of patients with vascular sarcomas. Using Cox's stepwise regression model, histologic characteristics of the tumors, tumor grade, tumor size, and other factors were assessed to determine their prognostic significance. Noncurative treatment and the presence of metastases were the only two factors influencing survival. Tumor grade approached significance. Disease recurrence was common among curatively treated patients (37% of such patients), and more than half of these recurrences involved distant sites. The survival of these patients depends on complete surgical resection and is independent of individual histologic characteristics of the tumor.

Selective arterial embolization in orthopaedic pathology. Analysis of long-term results

9 patients with tumorous and tumor-like skeletal lesions are examined; the patients were treated by selective arterial embolization, therapeutic, adjuvant and palliative, with follow-up ranging from 2 to 10 years. For therapeutic purposes 12 cases were constituted by aneurysmal bone cyst of large size and which was difficult to treat surgically (pelvis: 5; spine: 3; limbs: 4). For the purposes of assisting the excision procedure, selective arterial embolization was used in 2 patients with giant cell tumor of bone, the first localized in the right iliac wing and the second in the sacrum; in one patient with retroperitoneal teratoma and in 1 with hemangiopericytoma of the soft tissues of the thigh. Furthermore, in 3 patients with inoperable multiple bone metastasis, selective arterial embolization was used in order to relieve pain as palliative SAE. The authors emphasize that complete healing of aneurysmal bone cyst is possible, with no recurrence after more than 10 years; they also stress the role played by selective arterial embolization as an adjuvant particularly in the pre-surgical treatment of large giant cell tumor of bone.

Intracranial cystic hemangiopericytoma--case report

A rare case of intracranial hemangiopericytoma associated with a large cyst was treated by gross total removal and local irradiation. The tumor has not recurred for 16 months, although the effectiveness of radiation therapy for hemangiopericytoma is unclear. Histological examination of the tumor specimen showed aggregation of the microcystic components, possibly contributing to the cyst formation. Hemangiopericytoma should not be classified as meningioma because of the different neoplastic and cytological properties. Complete surgical removal is essential for this tumor because of its malignancy.

Malignant hemangiopericytoma of the pelvis. Report of a case with urological implications and immunohistochemical analysis

A case of a malignant hemangiopericytoma located in the pelvic fossa of a 50-year old man is reported. The tumor displaced the urinary bladder and caused bilateral hydronephrosis. Light microscopic diagnosis was followed by immunohistochemistry. After surgery the patient was successfully treated by chemotherapy and irradiation. This paper reviews clinicopathological features in respect of prognosis and a possible treatment.

[Clinico-morphological substantiation of the selection of optimal variants of therapeutic tactics in non-epithelial tumors of the nasal cavity and paranasal sinuses]

Out of 227 cases of nonepithelial tumors of the nasal cavity and paranasal sinuses, 147 patients with benign neoplasms had a good prognosis while 80 patients with malignant neoplasms had a poor prognosis. The efficacy of their therapy can be enhanced on the basis of a differential approach, measurement of tissue radiosensitivity and adequate surgical intervention.

Pelvic hemangiopericytomas: a report of five cases and literature review

Five cases of pelvic hemangiopericytomas are reported. One of these tumors arose from the uterus, and four patients had extrauterine, pelvic hemangiopericytomas. The patient with a primary uterine hemangiopericytomas had only simple excision, and, after 6 years, is alive and free of disease. All four patients with extrauterine, pelvic hemangiopericytomas had incomplete resection of their tumors because of hemorrhage. However, pelvic radiation therapy was then employed in these patients and produced a complete regression in one patient and partial regression in two patients with minimal shrinkage in another patient. The latter patients were reexplored after pelvic radiation and underwent complete resection of their disease. Two patients developed pelvic recurrences at 2 and 9 years, respectively, and these were effectively resected. All four patients are all alive and free of disease 5 to 18 years later. If this lesion is unexpectedly discovered at laparotomy, our experience suggests that the resection should be discontinued and that they should be treated with pelvic radiation and delayed resection of persistent and recurrent pelvic tumors.

Hemangiopericytoma of the spleen

Hemangiopericytomas are rare vascular tumors, most frequently found in the muscles of the lower extremities. A parenchymatous origin is extremely uncommon. We present here what we believe is the first case ever reported of an hemangiopericytoma of the spleen.

Interventional angiography in neuropediatrics

Since the introduction of non-invasive imaging techniques (CT, US, MRI), superselective cerebrospinal angiography has been playing a major role as a diagnostic tool as well as a therapeutic procedure prior to surgery or as an alternative. Surgical neuroangiography is now also a well-established therapeutic technique in neuropediatrics. Lesions fed by the external carotid artery and spinal cord lesions are the main indications. The first group consists of maxillofacial vascular malformations, nasopharyngeal angiofibromas, and vascularized tumors of the facioorbital area (hemangiopericytoma, angiosarcoma ...). Spinal lesions for which embolization can be considered are benign tumors of the vertebral column (vertebral hemangioma, aneurysmal bone cyst ...) and vascular malformations intrinsic to the spinal cord. Particles (Ivalon, dura) are the safest embolization materials and have a wide range of possible applications; glues such as IBC have defined but limited indications. Digital subtraction angiography is crucial during the procedure and in determining the overall doses of contrast medium to be administered. Furthermore, decisions can be made more rapidly and precisely, with a definite improvement in the therapeutic results.

Treatment of hemangiopericytoma in a dog, using surgical excision, radiation, and a thoracic pedicle skin graft

A dog with hemangiopericytoma of the left forelimb underwent surgical excision followed by radiation therapy and thoracic pedicle skin grafting. Recurrence of the neoplasm was not observed 3.5 years after surgery. Hemangiopericytoma is an uncommon neoplasm that seldom metastasizes but has a high recurrence rate. In this dog, complete surgical excision was not possible because of the location and invasiveness of the neoplasm. The combination of surgery, radiotherapy, and skin grafting was a viable alternative to limb amputation.

Radio-Hyperthermia for Subcutaneous Metastasis of Hemangiopericytoma of the Mediastinum: Case Report

Hemangiopericytoma is a rare type of neoplasia originating from the Zimmermann pericytes and can arise in numerous sites. As it is difficult to correlate the histologic aspect with the prognosis, it was considered advisable to take account of other factors such as age and tumoral site. Aggressive surgery followed by irradiation therapy is suggested as the most suitable management. Hyperthermia also was adopted in treating subcutaneous metastasis, but its role has yet to be fully defined.

Hemangiopericytoma of the kidney: a case with preoperative ethanol embolization

We report a case of a giant renal hemangiopericytoma that was embolized preoperatively with ethanol. Ultrasound and computerized tomography showed multiple smooth-walled cysts within the tumor. The tumor itself was hypervascular and a vascular pattern specific for hemangiopericytoma was noted upon reinterpretation of the angiograms. The diagnostic and therapeutic aspects are discussed, and the literature is reviewed.

Tumours of the mastoid temporal bone: with interesting cases in the paediatric age group

Tumours of the mastoid temporal bone are interesting clinical entities owing to their rarity. A wide variety of benign and malignant tumours occur in and around the temporal bone reflecting the complicated embryological origin and resultant diversity of tumours found in the area. Friedmann (1974), in a classification of tumours of the ear, has grouped some tumours as intermediate in variety, e.g. glomus jugulare tumour, in addition to various benign and malignant tumours. Metastatic deposits from various distant organs such as the lung, breast and kidney can occur in the mastoid bone (Schucknecht, 1968). Invasive tumours can spread to the mastoid bone from adjacent areas such as neoplasms of the parotid and cranium.

Hemangiopericytoma-induced osteomalacia: tumor transplantation in nude mice causes hypophosphatemia and tumor extracts inhibit renal 25-hydroxyvitamin D 1-hydroxylase activity

Although more than 50 patients with the tumor-induced osteomalacia syndrome, characterized by remission of unexplained osteomalacia after resection of a coexisting tumor, have been reported, the pathogenesis of this syndrome is still not clear. We investigated the cause of biopsy-confirmed osteomalacia which was resistant to treatment with 1 alpha-hydroxyvitamin D3 in a 54-yr-old man. He had severe hypophosphatemia, a high serum alkaline phosphatase level, a low plasma 1,25-dihydroxyvitamin D level, and remarkably increased urinary phosphorus excretion. A tumor, with histological characteristics of a hemangiopericytoma, was found on his left thigh. After surgical removal of this tumor, his plasma 1,25-dihydroxyvitamin D and serum phosphorus levels increased to normal levels, and his bone pain subsided. The tumor was transplanted to athymic nude mice. A nodule formed in each mouse, with histological features identical to those of the original tumor, and the tumor-bearing mice had hypophosphatemia, high serum alkaline phosphatase levels, and increased urinary phosphorus excretion. When extracts of the original tumor were added to primary cultures of renal tubular cells, renal cAMP levels did not change, but 25-hydroxyvitamin D-1 alpha-hydroxylase activity was significantly inhibited. These data indicate tumoral production of some humoral factor(s) inhibiting 25-hydroxyvitamin D-1 alpha-hydroxylase activity and phosphorus reabsorption unrelated to adenylate cyclase-cAMP production in proximal renal tubules.

Clinical features of malignant haemangiopericytomas and haemangioendotheliosarcomas

The clinical features of 23 patients with malignant vascular tumours, referred for treatment in the period 1968-85, are described. The tumours consisted of 15 haemangioendotheliosarcomas (angiosarcomas) and 8 malignant haemangiopericytomas. Ten haemangioendotheliosarcomas were located in skin or mucous membranes and 5 in viscera and deep soft tissues. None of the 8 haemangiopericytomas were superficially located. One cutaneous haemangioendotheliosarcoma arose in a lymphoedematous leg, while 4 others occurred in previously irradiated areas. There was one case of a Thorotrast-induced hepatic haemangioendotheliosarcoma. No predisposing factors could be demonstrated in the cases of malignant haemangiopericytoma. Median survival was 11 months for the haemangioendotheliosarcomas and 19 months for the haemangiopericytomas. Patients who were operable at the time of admission had a longer median survival (37 months) than those who presented with advanced disease (5 months). Local control was obtained by surgery in 3 cases and by radiation therapy in 2. No complete responses were seen on chemotherapeutic regimens.