Cytogenetic findings in a malignant fibrous histiocytoma of the gallbladder

We report the cytogenetic findings in a rare tumor, a malignant fibrous histiocytoma of the gallbladder. Four related clones, two near-diploid and two near-tetraploid, which appeared to have been formed by a doubling of the near-diploid clones, were present. Numerous structural and numerical abnormalities characterized the tumor. Structural rearrangements included reciprocal translocations, translocations of unidentified material onto chromosomes, and deletions. Chromosomes involved in the rearrangements included 1, 3, 10, 12, 14, 16, and 19. Numerical changes included trisomy of chromosomes 2, 8, 10, and 20. Double minute chromatin bodies ranging in number from 5 to several were present in over a third of the cells.

Treatment of unknown primary melanoma

Sixty-four patients with unknown primary melanoma were identified among 1045 new patients with melanoma (6%) seen during an 11-year period. Their mean age was 44.5 years (median age, 42.7 years). Of these, 39 (59%) were men, and 25 (38%) were women. In 34, only one site was involved. Common single sites were the axilla (29%), groin (24%), and neck (32%). Most of the melanomas (88%) were melanotic. Patients with localized melanoma surgically treated (n = 34) had a median survival of 53 months, and a 5-year survival rate of 45%. The respective rates for disseminated melanoma were 7 months and 10% (P = 0.00001). Localized, unknown primary melanoma should be treated with radical excision because a substantial proportion of patients so treated survive 5 years.

Axillary node dissection in malignant melanoma

Axillary node dissection was performed in 212 patients with malignant melanoma. For 212 initial dissections plus 49 repeat procedures (261 operations), wound infection occurred in 25 (10%) and arm edema in 10 (4%), with other complications being infrequent. The arm edema resolved promptly and completely six (2%) patients after elevation of the arm, while four (2%) patients have had permanent, moderate edema. The estimated 5-year survival rate for patients with clinically and histologically negative nodes was 74%. Among those with histologically positive nodes, when the nodes were not palpable, this rate was 73%; when the nodes were palpable and less than 2 cm in diameter, it was 46%; when they were palpable and 2 to 4 cm in diameter, it was 22%; when the nodes were larger than 4 cm in diameter, it was 18%; and when the nodes were fixed, it was 13%. The 5-year survival rate for 17 patients with positive nodes above the level of the axillary vein was 18%; 1 of 6 patients with resection of the axillary vein due to involvement is disease-free 57 months later. In patients who developed recurrence, further resection when feasible resulted in 13% of these patients being disease-free 5 years after the original axillary dissection.

Attributes and survival patterns of multiple primary cutaneous malignant melanoma

From a series of 1495 patients with primary cutaneous malignant melanoma (PCMM), 26 patients (1.73%) had multiple primary cutaneous malignant melanoma (MPCMM). This report describes the attributes and survival patterns in this small, but important, subgroup of patients with PCMM. Of 26 patients, 23 had two primaries, two had three primaries, and one had six primaries. Five patients had synchronous and 21 patients had metachronous MPCMM. The median interval between the occurrence of the first and subsequent PCMM in these patients was 1.93 years. The estimated 5-year survival rate from the first melanoma was 83.5%; that from the last melanoma was 53.1%. In summary, MPCMM is a distinct biologic phenomenon. A second or subsequent malignant melanoma should be treated like a primary melanoma.

Trisomy 8 as a nonrandom secondary change in myxoid liposarcoma

We report the cytogenetic findings in 5 cases of myxoid liposarcoma following short-term culture. In all 5 tumors a t(12:16)(q13:p11), characteristic of the myxoid form of liposarcoma, was observed. Trisomy 8 was present in two tumors as the only additional change and in a third in addition to other abnormalities. In the other two tumors the t(12:16) was present as the sole change. Three other myxoid liposarcomas with trisomy 8 as an additional aberration have been reported, suggesting that it could represent a non-random secondary event in these tumors.

Limb salvage in soft tissue sarcomas with selective combination of modalities

One hundred and seventy-one consecutive patients with soft tissue sarcomas were treated in the period 1977-1986. Of 144 patients with extremity sarcomas, only eight (6%) were managed with amputation. The overall estimated 5-year survival rate is 64%, and that for patients with extremity tumors is 71%. The 5-year local recurrence rate in extremity sarcomas was 6% for patients with minimum surgical margins 2 cm or greater and no further local therapy, and 6% for those with narrower surgical margins and adjuvant postoperative radiation; 80 patients (56%) were in the former group and 64 (44%) in the latter. With a selective combination of modalities, limb salvage can now be practiced in 94% of the patients with acceptable local control and survival rates.

Survival after groin dissection for malignant melanoma

Groin dissection was performed in 158 patients with malignant melanoma (superficial dissection, 76 patients; radical dissection, 82 patients). Of 63 patients with palpable nodes, 57 patients (90%) had histologic involvement. Of 93 patients with nonpalpable nodes, 31 patients (33%) had histologically positive nodes. The 5-year survival rate for patients with histologically negative nodes (n = 69) was 77%; the 5-year survival rate for patients with histologically positive nodes (n = 89) was 43%. The respective 5-year disease-free survival rates were 72% and 34%. Of 57 patients with palpable, positive inguinal nodes, 21 patients (37%) had involvement of the deep nodes. Of 31 patients with nonpalpable, histologic involvement of the inguinal nodes, six patients (19%) had or developed involvement of the deep nodes. One of two patients with uncertain clinical status of the nodes preoperatively had positive deep nodes. In prophylactic node dissection, frozen section of the inguinal group of the nodes does not provide a reliable method, because of sampling errors, in determining microscopic involvement of the nodes and in deciding whether a superficial or radical groin dissection is to be done. For patients with positive nodes the 5-year survival rate was 48% when only the inguinal group was involved and was 28% when both inguinal and deep nodes were involved; the respective 5-year disease-free survival rates were 39% and 20%. Survival after therapeutic groin dissection may partly depend on the thoroughness of the procedure. Patients who have positive, deep nodes and who are undergoing an incontinuity dissection of the inguinal, iliac, and obturator nodes have an appreciable 5-year survival rate.

Cytogenetic profile of 109 lipomas

Cytogenetic analysis of short-term cultures was carried out on 109 lipomas from 92 patients. Clonal chromosomal abnormalities were present in 50% of the tumors analyzed. Based on the results, three main cytogenetic groups were identified and included: (a) tumors with normal karyotypes, (b) tumors with abnormalities involving region q13-15 on chromosome 12, and (c) tumors with other clonal aberrations. Within each of these groups, cytogenetic subgroups could be identified, each characterized by a specific anomaly. Tumors with abnormalities of 12q included specific subgroups with t/ins(1;12)(p32-33;q13-15), t(2;12)(p21-22;q13-14), t(3;12)(q28;q14), t(12;21)(q13;q21), complex, and nonrecurrent aberrations. The group containing heterogeneous clonal aberrations included subgroups with del(13)(q12q22), der(6)(p21-23), der(11)(q13), and nonspecific aberrations. Chromosome bands 1p36, 1p32-33, 2p21-22, 3q27-28, 6p21-23, 11q13, 12q13-15, 13q12, 13q22, 17p13, 17q21, and 21q21-22 were preferentially involved in structural rearrangements in lipomas. The identification of these sites of nonrandom rearrangements may serve to identify genes (at or near the junctions of chromosomal aberrations) involved in normal cellular growth control. Statistical analysis of the data revealed a correlation among karyotypic abnormalities and clinical data, such as age and sex of the patient, and tumor depth, site, and size.

Modified anterior compartment resection

In the majority of patients with soft tissue sarcomas of the anterior compartment of the thigh, it is possible to preserve a small portion of the quadriceps with intact nerve supply without compromising on the radicality of the procedure or the local control rate. The distal one-third of the vastus medialis can usually be spared with a long, slender branch providing its innervation. Dissection of the femoral nerve below the inguinal ligament and its branch(es) to an uninvolved area of the quadricepts the farthest from the location of the tumor is essential. This modified anterior compartment resection improves dramatically the function of the extremity.

Axillary node dissection in malignant melanoma: results and complications

Axillary node dissection was performed in 133 patients with malignant melanoma. The nodes were histologically negative for disease in 67 patients and positive in 66 patients. Disease-free survival rate varied according to the histologic and clinical status of the nodes and to the number of the nodes involved by tumor. The lymphocele rate was 7%; the wound infection rate was 5%; and the skin edge necrosis rate was 0.8%. One patient (0.8%) experienced both lymphocele and wound infection. Neurapraxia developed in the distribution of the musculocutaneous nerve in two patients (2%); this resolved completely in 3 to 4 weeks and was not observed again, since hyperextension of the arm has been carefully avoided during the procedure. Transient arm edema was noted postoperatively in five patients (4%), and the edema responded promptly and completely to elevation of the arm for 1 to 2 weeks. There was no permanent edema even after ligation and resection of the distal portion of the axillary vein (six patients). Permanent arm edema has not developed in any of the 133 patients, indicating that axillary node dissection as performed for malignant melanoma is not associated with the long-term complications occurring after mastectomy and axillary node dissection.

Soft-tissue sarcomas of the proximal lower extremity

Of 54 patients with soft-tissue sarcomas of the proximal part of the lower extremity, 2 patients (4%) were treated with amputation, while 52 patients (96%) were treated with limb-preserving resection. Adjuvant postoperative irradiation was applied selectively when the minimum margin was less than 2 cm (22 patients). Technical improvements in exposure, resection of involved vessels or nerve, and preservation of function permitted a high rate of limb salvage with satisfactory function. At a median follow-up of 30 months for those subjects still alive, the 5-year disease-free survival rate was 65%, and only 3 patients (6%) had had a local recurrence.

Variants of hemipelvectomy and their complications

In the period from 1976 through 1986, 62 procedures were performed. Of these, 42 were posterior flap hemipelvectomies, 5 anterior flap hemipelvectomies, and 15 internal hemipelvectomies. The median duration of these procedures was 6.5 hours, and the median blood loss was 2,541 ml. Postoperatively, there were no wound problems in 38 procedures (61 percent). The overall rate of flap necrosis was 15 percent, and the overall rate of wound infection, 17 percent. The viability of the posterior flap was not dependent on the level of division of the iliac vessels. By leaving the gluteus maximus muscle attached to the posterior flap, the rate of flap necrosis, initially 55 percent, was eliminated completely in the last 38 patients. Including 11 recently performed procedures, the operative mortality rate was 1 percent (1 of 73 procedures). For patients operated on with curative intent, the estimated 5-year survival rate was 43 percent.

Tumor thickness and prognosis in clinical stage I malignant melanoma

The current grouping of patients with malignant melanoma into thin, intermediate, and thick melanomas provides a convenient but arbitrary classification which, although providing "average" survival values for each group, offers crude prognostication for the individual patient. A review of 371 patients with clinical Stage I malignant melanoma, treated during the period 1970 to 1985, was conducted. The estimated 5-year survival rate for female patients with melanomas 1.0 mm thick was 94%; for each 1-mm increment in thickness the survival rate declined by about 3%, up to the 6 mm mark, the survival rate declining thereafter by about 8% for each additional millimeter in the range of 7 to 15 mm of thickness. The estimated 5-year survival rate for male patients with melanomas 1.0 mm thick was 80%; for each 1-mm increment the survival rate declined by about 9%, up to the 10 mm mark. The proposed method of estimating the expected survival according to the patient's sex and the thickness of the primary lesion hopefully provides a more accurate and convenient method of prognostication for the clinician dealing with specific patients with intermediate or thick melanomas.

Clinical factors and treatment parameters affecting prognosis in adult high-grade soft tissue sarcomas: a retrospective review of 267 cases

Data on 267 adults with high-grade soft tissue sarcomas were reviewed. Male sex, large tumor size, Stage IIIC, IV A and sarcomatous skin invasion, as well as marginal excision, amputation, postoperative fever and wound infection, were found to be associated with shorter survival time. Head and neck location, multifocal growth of sarcoma. Stage IIIC, malignant skin infiltration, locally recurrent tumor as well as marginal excision and limb-sparing resection, were found to influence local control unfavorably in single factor analyses. Each of the significant variables were entered into a multivariate proportional hazards model in a stepwise manner. Stage, postoperative fever, the surgical margin and type of surgery, and sarcomatous skin changes significantly affected survival time. Local recurrence was significantly affected by the surgical margin and type of surgery, the status of tumor (primary or recurrent), stage and malignant skin infiltration.

Cytogenetic subtype involving chromosome 13 in lipoma. Report of three cases

We report three lipomas with rearrangements of chromosome 13. The karyotype of the tumors studied were 45,XX,-8,+der(8)t(8;13)(q22;q12),del(10)(p12),-13; 46,XY,del(13)(q12q22), and 46,XY,t(11;12)(q23;q13),del(13)(q12q22), respectively, revealing common involvement of band 13q12 in the rearrangement. Three other lipomas with aberrations of bands 13q12-q13 have been reported, suggesting that such tumors with abnormalities of chromosome 13 could represent a subgroup of lipoma in addition to those already reported with abnormalities of chromosomes 12q and 6p. The rearrangements of #13 in all these cases also involved loss of the band 13q14 to which the antioncogene associated with retinoblastoma and osteosarcoma is localized. Detailed clinical, histopathologic, and molecular studies should help to further characterize the various cytogenetically defined subgroups of lipoma.

Axillary compression syndrome with neurapraxia due to operative positioning

A 20-year-old man underwent a 9-hour operation in a left lateral position for the removal of an osteoblastoma involving the pedicles of thoracic vertebrae T-11 and T-12 and for fixation with bond grafting. Immediately after the operation, extensive swelling of the left shoulder area was noted. The radial pulse on the left was intact, and there was movement of the fingers of the left hand, which ceased completely by the following morning. A computerized axial tomographic scan showed extensive swelling of the pectoral, deltoid, and other muscles around the shoulder. An emergency decompression procedure was carried out by dividing the pectoral and anterior scalene muscles; prompt return of some motor activity in the left hand followed, and this gradually returned to normal. This case of what may be termed "axillary" compression syndrome suggests that extra care should be taken to use an adequate axillary roll and to avoid lengthy operations in a lateral position, and indicates a method for decompression.

The effect of local recurrence on survival time in adult high-grade soft tissue sarcomas

Data gathered on 262 adults with high-grade soft tissue sarcoma, operated on at the same institution for curative intent, were used to study formally, and to quantitate for the first time, the relationship between local recurrence of the tumor and survival time. Using Cox's proportional hazards model with a time-dependent covariate representing the local recurrence of the tumor, it was found that local recurrence is significantly associated with a shorter survival time (estimated relative risk (relative hazard) = 2.5, p less than 0.0001). The estimated 5 yr survival rate and median survival time for patients without a local recurrence were 44% and 42 months, respectively, while the corresponding figures for patients with a local recurrence were only 26% and 28 months. Hence, a local recurrence resulted in a relative decline in the estimated 5 yr survival rate of 41%. This strong relationship continued to hold even after adjusting for several other important, time-independent prognostic variables (stage, type of surgery, type of resection, signs of sarcomatous skin invasion, and presence of postoperative fever) in a multivariable analysis. Local control of high-grade soft tissue sarcomas is vitally important for successful management of these patients.

Tumor size/symptom duration ratio as a prognostic factor in patients with high-grade soft tissue sarcomas

Two hundred sixty-seven patients with high-grade (G2,G3) soft tissue sarcomas but without distant metastases, were studied retrospectively with respect to their duration of symptoms and size of tumor. Prognosis was significantly related to the size of the tumor (P = 0.0039). Small tumors (5 cm or less) had a 5-year survival rate of 49% compared to 28% for large tumors (more than 5 cm in diameter). Symptom duration was not related significantly to survival time (P = 0.2490). The ratio of the size of the tumor (greatest diameter, recorded in cm) to duration of symptoms (recorded in months), reflecting the growth rate of the tumor, is introduced as a potentially important prognostic variable. Analysis revealed a highly significant relation between an increasing size/duration ratio and shorter overall survival time (P less than 0.0001) and time to distant metastases (P = 0.0034). Moreover, an optimal cut-off point of 1.0 for the size/duration ratio offers prognostic information independent of the G-TNM classification and other prognostic factors.

Prognostic significance of lymph node metastasis and bone, major vessel, or nerve involvement in adults with high-grade soft tissue sarcomas

Two hundred sixty-seven patients with high-grade (G2 or G3) soft tissue sarcomas (STS) were examined. All tumors were removed by resection (marginal or wide) or amputation. Seventy-four patients had T3 primary tumors invading neurovascular structures (n = 41) or bone (n = 33), and 29 patients had histologically confirmed metastases to the regional nodes removed at the time of definitive surgery. The estimated 5-year and 10-year survival rates for patients in Stage IIa, b or IIIa, b were 44% and 37%, respectively. For patients with neurovascular or bone invasion the survival rates were 24% and 15%, respectively. For patients with lymph node metastases the survival rates were 10% and 3%, respectively. Survival of patients with primary sarcomas invading the nerve, vessel, or bone was significantly better than that of patients with lymph node metastases (P = 0.002). Survival also was distinctly different between patients with nerve or vessel invasion who had a 5-year survival rate of 32%, and patients with bone invasion who had a 5-year survival rate of 15% (P = 0.002). These findings suggest that the current staging system for STS should be reexamined. Also, patients with nerve or vessel invasion should be assigned a IIIc1 position, those with bone invasion a IIIc2 position, and those with lymph node metastases a IVa position in the staging system.

Prognostic significance of lymph node metastasis and bone, major vessel, or nerve involvement in adults with high-grade soft tissue sarcomas

Two hundred sixty-seven patients with high-grade (G2 or G3) soft tissue sarcomas (STS) were examined. All tumors were removed by resection (marginal or wide) or amputation. Seventy-four patients had T3 primary tumors invading neurovascular structures (n = 41) or bone (n = 33), and 29 patients had histologically confirmed metastases to the regional nodes removed at the time of definitive surgery. The estimated 5-year and 10-year survival rates for patients in Stage IIa, b or IIIa, b were 44% and 37%, respectively. For patients with neurovascular or bone invasion the survival rates were 24% and 15%, respectively. For patients with lymph node metastases the survival rates were 10% and 3%, respectively. Survival of patients with primary sarcomas invading the nerve, vessel, or bone was significantly better than that of patients with lymph node metastases (P = 0.002). Survival also was distinctly different between patients with nerve or vessel invasion who had a 5-year survival rate of 32%, and patients with bone invasion who had a 5-year survival rate of 15% (P = 0.002). These findings suggest that the current staging system for STS should be reexamined. Also, patients with nerve or vessel invasion should be assigned a IIIc1 position, those with bone invasion a IIIc2 position, and those with lymph node metastases a IVa position in the staging system.

Intraoperative photodynamic therapy for retroperitoneal sarcomas

A pilot study was done to determine the feasibility of adjuvant photodynamic therapy (PDT) in recurrent retroperitoneal sarcomas. Ten patients, who had recurrences after conventional methods of treatment, had repeated resections of the tumor and intraoperative photodynamic treatment to the tumor bed. The methods and equipment used are detailed. In eight of ten patients, a complete resection was possible, and two patients are alive without recurrence at 28 and 24 months. There were no complications from the therapy. Tumors elicited red fluorescence, which helped in identifying residual tumor areas. Adjuvant PDT is a feasible alternative although its effectiveness should be evaluated further.

Selective combination of modalities in soft tissue sarcomas: limb salvage and survival

One hundred fifty-two consecutive patients with soft tissue sarcomas were operated in the period 1977 through 1985. Eighty-seven patients with minimum resection margin of 2 cm or greater had no further local therapy, whereas 65 patients with minimum margin less than 2 cm had adjuvant postoperative radiation. Of 121 patients with extremity sarcomas, only 5 (4%) were managed with amputation. The overall 5-year survival rate is 58%, and for patients with extremity tumors, 67%. The 5-year local recurrence rate in extremity sarcomas was 10% for patients with minimum surgical margins 2 cm or greater and no further local therapy, and 6% for those with lesser surgical margins and adjuvant postoperative radiation. With selective combination of modalities limb salvage can now be practiced in 96% of the patients with acceptable local control and survival rates.

Adjuvant treatment of malignant melanoma with DTIC + estracyt or BCG

Eighty-two patients with invasive malignant melanoma and no distant metastases were prospectively randomized following their surgical treatment to 1) observation; 2) chemotherapy with Dacarbazine (DTIC) 200 mg/M2 I.V. daily X 5 every 4 weeks and Estracyt 15 mg/kg orally daily for 1 year; and 3) immunotherapy with TICE BCG 1 ml to an area of scarification near the primary site, every 4 weeks for 1 year. At a median follow-up of 73.4 months 31 patients (38%) have relapsed. There was no significant difference in survival according to the treatment, but a weak effect on the course of the disease by either of the treatment protocols cannot be ruled out due to the small sample of patients. Survival and disease-free interval varied significantly according to the histologic status of the regional nodes. The estimated 5-year disease-free rate of patients with negative nodes was 85% and for those with positive nodes it was 35% (P less than 0.0001).

Chromosomal changes in soft-tissue sarcomas. A new diagnostic parameter

A cytogenetic study was performed on short-term cultures from fresh surgical specimens obtained from 41 patients with soft-tissue sarcomas of various histologic origins. The results demonstrated that myxoid liposarcomas (five tumors) were associated with a specific translocation between chromosomes 12 and 16 and that synovial sarcomas (six tumors) were associated with a specific translocation between the X chromosome and chromosome 18. These chromosomal data have been used to differentiate myxoid liposarcoma from other myxoid tumors exhibiting a non-characteristic histologic picture, as well as to ascertain the diagnosis of synovial sarcoma in undifferentiated soft-tissue sarcomas. The results to date indicate that identification of specific chromosomal changes in sarcomas may provide a new diagnostic criterion for these tumors and possibly improve prognostication with regard to survival and response to treatment.