Retroperitoneal sarcomas: patterns of care at diagnosis, prognostic factors and focus on main histological subtypes: a multicenter analysis of the French Sarcoma Group

BACKGROUND

Retroperitoneal sarcomas (RPS) are heterogeneous. No previous study has investigated the impact of specialized surgery, evaluated locoregional relapse (LRR), abdominal sarcomatosis and distant metastatic relapse as separate events, or considered histological subtypes separately. This study addresses these specific points in a homogeneous cohort of patients with completely resected primary RPS.

PATIENTS AND METHODS

We conducted a retrospective analysis of adult patients diagnosed with a RPS between 1 January 1988 and 31 December 2008 and eventually referred to one of 12 centers of the French Sarcoma Group. All cases were centrally reviewed by an expert pathologist.

RESULTS

Five hundred eighty-six patients were included. Median follow-up was 6.5 years [95% confidence interval (CI) 5.9-7.1]. Five hundred thirty-seven patients had localized disease and 389 patients (76%) had macroscopically complete resection of the tumor. In this latter group, the 5-year LRR-free survival rate was 46% [41-52] and the 5-year overall survival (OS) rate was 66% [61-71]. In multivariate analysis, gender, adjacent organ involvement, specialization of the surgeon, piecemeal resection and perioperative radiotherapy were independently associated with LRR. Specialization of the surgeon and piecemeal resection were independently associated with abdominal sarcomatosis whereas histology and adjacent organ involvement were independently associated with distant metastasis. Age, gender, grade, adjacent organ involvement and piecemeal resection were significantly associated with OS. Prognostic factors for LRR and OS were analyzed in well-differentiated and dedifferentiated liposarcomas and leiomyosarcomas. Grade 3 was an independent prognostic factor for OS of dedifferentiated liposarcomas.

CONCLUSION

This study underlines the crucial role of pretherapeutic assessment and meticulous histological examination of RPS as well as the need to consider histological subtypes separately. Surgery in a specialized center and avoidance of piecemeal resection stand out as the two most important prognostic factors for RPS and highlight the importance of treating these patients in specialized centers.

Three-dimensional computational analysis of optical coherence tomography images for the detection of soft tissue sarcomas

We present a three-dimensional (3-D) computational method to detect soft tissue sarcomas with the goal of automatic surgical margin assessment based on optical coherence tomography (OCT) images. Three parameters are investigated and quantified from OCT images as the indicators for the tissue diagnosis including the signal attenuation (A-line slope), the standard deviation of the signal fluctuations (speckles), and the exponential decay coefficient of its spatial frequency spectrum. The detection of soft tissue sarcomas relies on the combination of these three parameters, which are related to the optical attenuation characteristics and the structural features of the tissue. Pilot experiments were performed on ex vivo human tissue samples with homogeneous pieces (both normal and abnormal) and tumor margins. Our results demonstrate the feasibility of this computational method in the differentiation of soft tissue sarcomas from normal tissues. The features of A-line-based detection and 3-D quantitative analysis yield promise for a computer-aided technique capable of accurately and automatically identifying resection margins of soft tissue sarcomas during surgical treatment.

[The role of 18F-fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography (PET/CT) in liposarcoma of the chest wall]

18F-fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography (PET/CT)imaging is valuable in biopsy guidance, response assessment, grading, follow-up and prognostication for soft-tissue sarcoma. In liposarcoma, the maximum standardized uptake value (SUVmax) on PET/CT scan is correlated with the histological subtypes. We briefly review the role of FDG PET/CT in liposarcoma, and describe a case of chest wall liposarcoma treated based on the assessment with PET/CT. A 76-year-old man, with a 10-cm tumor at the thoracic outlet of the right chest wall, underwent the complete resection of the tumor according to the assessment with PET/CT that showed high FDG uptakeonly in the central area of the tumor with SUVmax of 5.89, but low uptake in the peripheral area. In accordance with the PET/CT findings, pathological examination revealed dedifferentiated liposarcoma in the central area and well-differentiated liposarcoma in the peripheral area. Pretherapy PET/CT should be performed for the appropriate treatment of liposarcoma.

Intramuscular lipoma of the subscapularis muscle

CONTEXT

Intramuscular lipomas are benign tumors that infiltrate the muscles.

CASE REPORT

We describe the case of a 58-year-old female patient with an axillary lump. The lump was a lipoma inside the subscapularis muscle. It is important to differentiate these lesions from liposarcomas and from other diseases that may present as axillary lumps. The most accurate imaging method for differentiating benign lipomatous tumors from liposarcomas is magnetic resonance imaging, but surgical removal of these intramuscular lesions to confirm the diagnosis is recommended.

CONCLUSION

Intramuscular lipomas are a rare cause of benign axillary lumps and should be considered in making differential diagnoses on axillary masses.

[A man with a swelling in the palm of his hand]

A 41-year-old man had a palpable mass on the volar side of his hand. X-ray, ultrasound and MRI showed an inhomogeneous tumour with calcification. Histologic examination ruled out the suspicion of a liposarcoma. The surgeon successfully excised the ossifying lipoma, which is a rare variant of a common lipoma and can clinically and radiologically mimic malignant neoplasms.

Primary spermatic cord tumors: disease characteristics, prognostic factors, and treatment outcomes

INTRODUCTION

Experience with management of spermatic cord tumors (SCTs) is uncommon. We utilized a large population-based cancer registry to characterize the demographic, pathological, treatment characteristics, and outcomes of SCTs.

MATERIAL AND METHODS

The Surveillance, Epidemiology, and End Results database (1973-2007) was queried.

RESULTS

From the database, 362 patients were identified with SCT. The annual incidence of SCT was 0.3 cases per million and did not change over time. The most common histologic types were liposarcoma (46%), leiomyosarcoma (20%), histiocytoma (13%), and rhabdomyosarcoma (9%). The median age of diagnosis for rhabdomyosarcomas was (26.3 y), whereas for other SCTs, it was (64.7 y) (P<0.001). On multivariate analysis, a worse outcome was observed with undifferentiated tumor grade, distant disease, positive lymph nodes, and leiomyosarcoma or histiocytoma cell histology.

CONCLUSION

We describe the largest cohort of SCT studied to date. Liposarcoma was most common, while leiomyosarcoma and histiocytoma histologic subtypes were observed to be the most aggressive. Multivariate analysis revealed that tumor grade, stage, histologic type, and lymph node involvement were independently predictive of prognosis.

Encapsulated fat necrosis mimicking subcutaneous liposarcoma: radiologic findings on MR, PET-CT, and US imaging

We present a case of a subcutaneous encapsulated fat necrosis of the upper extremity that mimicked subcutaneous liposarcoma because of heterogeneous signal intensity, its relatively large size, and pronounced enhancement on magnetic resonance imaging (MRI). For this case, we present the radiologic findings including MRI, positron emission tomography-computed tomography (PET-CT), ultrasonography, and radiography. We emphasize the imaging features of this lesion, which has a fibrous capsule and briefly discuss its nomenclature and pathophysiology.

[Rare solid pancreatic tumors]

The most common tumor of the pancreas is cancer, which constitutes 85% of all pancreatic neoplasms. Cystic pancreatic tumors comprise 10% of malignancies. No more than 5% of pancreatic tumors are rare solid tumors as: neuroendocrine tumors, gastrointestinal stromal tumors, solid pseudopapillary tumors, pecomas, lymphomas, granulocytic sarcomas, schwannomas, lipomas, liposarcomas and metastases to pancreas. Nowadays, these tumors are diagnosed more commonly due to the developement and accessibility of the diagnostic imaging techniques. Moreover, the treatment and management of rare solid pancreatic tumors often differs from the management in pancreatic cancer what makes the differential diagnosis difficult and responsible challenge. The main purpose of this article is to present an actual data of epidemiology, clinical presentation, management and treatment of rare solid pancreatic tumors according to recent literature and self experience.

Giant pedunculated esophageal liposarcoma associated with Hurthle cell thyroid neoplasia

Giant pedunculated liposarcoma of the esophagus is considered a rare entity. They impose difficulties in management, especially the surgical approach. We report a case of giant pedunculated liposarcoma of the esophagus in a 62-year-old male who underwent cervical excision of this large tumor, and made a full recovery. Hurthle cell thyroid cancer was found during the work-up, which was managed accordingly.

Inguinal canal tumors of adulthood

AIM

To review benign and malignant paratesticular lesions.

MATERIALS AND METHODS

A non-systematic review of the English literature in the National Library of Medicine Database (MEDLINE) was performed using the key words "spermatic cord", "inguinal canal", "neoplasms" (focusing on soft tissue sarcomas). The 74 most significant contributions were selected.

RESULTS

Although generally benign (lipoma is the most frequent), paratesticular tumors have a high incidence of malignancy (30%). Ultrasonography, computed tomography and magnetic resonance imaging represent the main tools in the evaluation of a solid paratesticular mass. Most malignant tumors are sarcomas and commonly spread via local invasion to adjacent structures. The definitive diagnosis is made postoperatively. Surgical excision in the form of radical orchiectomy and wide local resection of tumor margins is mandatory and represents the mainstay of treatment options.

CONCLUSION

Surgical treatment of paratesticular tumors is fundamental in order to determine the histology so as to define the correct follow-up for each patient.

Huge mesenteric liposarcoma

Primary mesenteric liposarcoma is extremely rare and is treated by aggressive surgical management i.e. wide excision with adequate margins (in the absence of distant metastases). We report a case of huge slow-growing primary mesenteric liposarcoma in a 52-year-old man, who presented with gross abdominal distension. He was anaemic with pre-operative imaging demonstrating a well-encapsulated huge solid tumour filling the whole abdomen, abutting the anterior abdominal wall without any evidence of distance metastasis or ascites. The patient underwent successful resection of the tumour which weighed 22 kilograms. Histopathology confirmed a well-differentiated liposarcoma with rare mitoses. The patient received full eight cycles of adjuvant chemotherapy. After five years of clinical and imaging follow-up, there was no evidence of metastasis or recurrence of the disease.

Primary liposarcoma of the duodenum: a first case presentation

A 55-year-old man suffering from melena was admitted to our hospital. A blood test showed severe anemia. Contrast-enhanced computed tomography (CT) revealed a huge lesion in the duodenum and dilatation of the common bile duct. Upper gastrointestinal endoscopy also identified hemorrhaging from the tumor in the duodenum. Due to the low density of the tumor mass, we performed emergency pylorus-preserving pancreaticoduodenectomy. Histology revealed an area of well-differentiated liposarcoma as well as an area of high-grade spindle cells and pleomorphic sarcoma without obvious differentiation. The final pathological diagnosis was dedifferentiated liposarcoma. This is the first case report of primary liposarcoma of the duodenum.

[Current idea of the morphogenetic features of liposarcomas]

The paper considers the current aspects of the morphology, immunohistochemistry, molecular biology of liposarcomas. Particular attention is given to the embryogenesis of liposarcomas and to problems in the immunohistochemical diagnosis of these neoplasms. There is evidence that TLS-CHOP is involved in the PNA processing of liposarcoma cells. Prospects for the diagnosis and treatment of malignant mesenchymal tumors are discussed.

Correlation of different imaging modalities in pre-surgical evaluation of pericardial metastasis of liposarcoma

A patient presented with a large pericardial tumor of uncertain etiology. Five years earlier, she had been treated for myxoid liposarcoma of the thigh. For pre-surgical evaluation, conventional radiography, positron emission tomography/computed tomography (PET/CT), magnetic resonance imaging (MRI), CT of the heart, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were performed. The final histopathologic diagnosis was metastatic liposarcoma. Each of the imaging modalities used had advantages and disadvantages, and their coordination was necessary for optimal evaluation.

Primary orbital liposarcoma misdiagnosed as thyroid associated orbitopathy

Orbital malignancy can mimic thyroid associated orbitopathy (TAO) due to overlap of clinical and radiographic findings, which include proptosis, extraocular muscle (EOM) enlargement on imaging, and EOM restriction with diplopia. We report a case of primary orbital liposarcoma masquerading as TAO which required exenteration.

Malignant renal tumours in adults in Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria

BACKGROUND

Malignant renal tumour is the third commonest urological tumour after prostate and bladder cancer. It is however the urological tumour with the highest mortality/incidence ratio.

OBJECTIVE

To review the frequency, mode of presentation and histological pattern of patients with malignant renal tumours in Nnamdi Azikiwe University Teaching Hospital.

METHOD

A 7 year retrospective review of all our renal tumour folders in theinstitution.

RESULTS

19 patients qualified for the study with a male/female ratio of 1:2.8 and a mean age of 52.6 +/- 15.8 years. The peak age was in the seventh decade. Most patient present late (78.9%). Renal cell cancer was the commonest tumour type with the commonest mode of presentation being abdominal mass and pain.

CONCLUSION

Malignant renal tumours present very ate in our environment and patients hesitate in accepting available treatment option which is surgery. There is need for increased patient awareness and high index of suspicion by the clinician, particularly during imaging procedures, as this would significantly enhance the early detection of these patients.

[Chest wall lipoma mimicking a well differentiated liposarcoma; report of two cases]

We experienced 2 cases of chest wall lipoma mimicking a well differentiated liposarcoma. The 1st case was a 60-year-old female. She admitted to our hospital with abnormal shadow detected by chest X-ray. Positron emission tomography combined with computed tomography (PET-CT) revealed fatty tumor penetrating left chest wall without significant accumulation of fluoro-2-deoxy-D-glucose (FDG). Resection of the tumor with partial resection of the 6th and 7th ribs with were performed, because the tumor was suspected to invade surrounding tissues by surgical findings. The other case was a 41-year-old male. He admitted to our hospital with abnormal shadow detected by chest X-ray. PET-CT revealed fatty tumor penetrating left chest wall and its standard uptake value (SUV) was 1.2. The tumor was resected with surrounding periosteum and intercostal muscle without thoracotomy. Both cases were diagnosed as lipoma by pathology.

Giant retroperitoneal liposarcoma. Report of 5 cases

BACKGROUND

Liposarcoma is the most frequent histopathological variety of the retroperitoneum, surgery is the gold standard for treatment.

CLINICAL SERIES

We report, retrospectively over 7 years (2000-2006), 5 cases (four men and one woman, the mean age was 48 years) of giant retroperitoneal liposarcomas and study their clinical characteristics intra operatively findings and course evolution. None of our patients had a percutaneous biopsy of his tumour. Surgery was indicated to all patients. Resection was performed in 4 cases (we performed a bloc resection in three cases and a simple tumour resection in one case), and in one case, abstention was decided. None of patients had an adjuvant therapy Three of the patients still alive after the follow up of 2, 3 and 4 years.

CONCLUSION

Retroperitoneal liposarcomas represent a unique situation and require a more aggressive surgical approach including multiple resections for recurrences. Based on the ability of the patient to tolerate the procedure, surgery is suggested to evaluate resectability of the tumor. We must take into consideration whether prolonged survival will be attained and tumor removal will result in palliation of symptoms.