Clinicopathological prognostic factors in soft tissue leiomyosarcoma: a multivariate analysis

Primary oral leiomyosarcoma: a clinico-pathologic study and analysis of prognostic factors

This clinico-pathologic study of primary oral leiomyosarcomas and analysis of potential prognostic factors involved a literature review of 64 cases and a report of four cases treated in the authors' unit. The demographic details, clinical presentation, diagnosis, treatment and outcome were documented for the whole group and clinico-pathologic variables analysed to detect potential prognostic factors. The most common presentation was that of a painless mass, with peak incidence in the 6th decade and a slight male predeliction (M:F=1.3:1). The maxilla was the most frequently involved site, followed by the mandible and tongue. Surgical excision was most commonly employed with radiotherapy and chemotherapy being reserved for recurrent and metastatic tumours. Local recurrence (34%) and metastasis (35%) were not uncommon and occurred most frequently to the lungs and regional lymph nodes (15%). Age, sex, size and mitotic index were not statistically related to recurrence or metastasis. Site (P=0.0125) was a predictor of metastasis. Metastasis (P=0.010) and lesions involving the maxilla and mandible (P=0.019) were associated with decreased survival. The estimated 5 year survival was 55% for the whole group and 43% and 19% for patients with bony involvement and metastasis respectively.

Clinical course of nonvisceral soft tissue leiomyosarcoma in 225 patients from the Scandinavian Sarcoma Group

BACKGROUND

Leiomyosarcoma of nonvisceral soft tissues is an uncommon malignant tumor; thus, only small numbers of cases have been reported. This study was based on a large series of patients from the Scandinavian Sarcoma Group Register acquired during a 15-year period (from 1986 to 2001). Follow-up information was available for all patients.

METHODS

The authors analyzed the clinical features of 225 patients with cutaneous, subcutaneous, or deep-seated leiomyosarcoma of the extremities, trunk wall, and superficial parts of the head and neck region to determine the natural course of the disease. Only patients who received their treatment at a specialist sarcoma center were included. Re-evaluation of histopathology was performed.

RESULTS

The age of the patients (121 women and 104 men) ranged from 20 years to 98 years (median, 70 years), and the tumors ranged in size from 0.6 cm to 35 cm (median, 4.0 cm). Eighty-two percent of the tumors were classified as high grade. The median follow-up for survivors was 5.5 years. The local treatment was adequate in 154 of 206 patients (75%) who were without metastasis at presentation. At 10 years, 84% of the 206 patients with localized disease at presentation were free from local recurrence, 66% remained metastasis free, and 49% were alive. Multivariate analysis showed that higher malignancy grade (P = .006), larger tumor size (P = .003), and deeper tumor location (P = .002) were correlated significantly with decreased metastasis-free survival, inadequate local treatment was correlated with local recurrence (P = .007), and high malignancy grade was correlated with decreased overall survival (P = .007).

CONCLUSIONS

The long-term prognosis for patients with subcutaneous and deep-seated soft tissue leiomyosarcoma remains poor despite the ability to achieve adequate local control through nonmutilating surgery with or without radiotherapy.

Retroperitoneal and Truncal Sarcomas: Prognosis Depends Upon Type Not Location

BACKGROUND

Prognostication of truncal and retroperitoneal soft tissue sarcomas has traditionally been predicated on tumor location and grade.

OBJECTIVE

To compare outcomes for patients with retroperitoneal or truncal sarcomas.

METHODS

Retrospective analysis of a prospective cancer data registry from 1977 to 2004 was performed and outcomes were determined.

RESULTS

The study group numbered 312 patients (median age 58 years, 54% male, 56% Caucasian, 14% black, 29% Hispanic). The most common tumor types were liposarcoma (35.9%), leiomyosarcoma (30.1%), and malignant fibrous histiocytoma (MFH) (19.5%). Tumor distributions were retroperitoneal (38.9%), pelvic (24.7%), abdominal (18.6%) and thoracic (17.9%). Median overall survival was 74 months. Operative resection was undertaken in 89.4% of cases and multiple surgeries (range 2-5) in 42.2%. Negative resection margins were obtained in 72.7% of patients. Univariate analysis comparing retroperitoneal versus truncal location demonstrated no significant differences in survival. Survival was improved in lower grade tumors (P < 0.02). Liposarcoma and fibrosarcoma were associated with improved survival (P < 0.0001). Multivariate analysis of pre-treatment variables showed increasing age, grade, histopathology (leiomyosarcoma and MFH) and metastasis to be associated with worse outcomes. Multivariate analysis of the treatment variables showed that surgery and negative resection margins were associated with improved survival (P < 0.001). No advantage for chemoradiotherapy could be demonstrated.

CONCLUSIONS

Successful operative resection can confer prolonged disease-free survival and cure for truncal and retroperitoneal sarcomas. Histological subtype, not location, is predictive of long-term survival. Future studies should focus on histological subtype rather than tumor location for truncal and retroperitoneal sarcomas.

Do DNA copy number changes differentiate uterine from non-uterine leiomyosarcomas and predict metastasis?

DNA copy number changes were investigated in 51 (19 uterine and 32 nonuterine) primary leiomyosarcomas by comparative genomic hybridization. The aim was to evaluate whether true biological differences exist between uterine and nonuterine leiomyosarcoma and whether changes revealed by comparative genomic hybridization have prognostic value. Genomic imbalances were found in 48 (94%) cases. The most frequent DNA copy number changes were losses in 10q (35%), 13q (57%), and 16q (41%), gains in 1q (41%), and gains and high-level amplifications in 17p (39%). Gains were nearly as frequent as losses in both uterine and nonuterine leiomyosarcoma. Correlation-based tree modeling revealed two clusters that segregated significantly a group of uterine (gains at 1q11-q24) and a group of nonuterine (losses at 13q14-q34, 16q11.1-q24, and 10q21-q26) cases. The nonuterine cluster was associated with subcutaneous origin and a trend toward increased metastasis-free survival. Further explorative analyses identified aberrations associated with shorter metastasis-free survival time, including losses at 2q32.1-q37 and gains at 8q24.1-q24.3, whereas the cases with losses at 6cen-p25 showed longer metastasis-free survival time.

Evaluation of biological potential of smooth muscle tumours

Smooth muscle tumours (SMTs) have been traditionally divided into benign leiomyomas (LM) and malignant leiomyosarcomas (LMS) based on cytological atypia, mitotic activity and other criteria. In most instances, this dichotomous approach works, but in some instances the biological potential cannot be determined with certainty. This is often because some, but not all criteria for malignancy have been met or because the tumours are occurring in unusual settings for which there are sparse substantive data. Tumours falling into the latter categories are often designated as 'smooth muscle tumours of uncertain malignant potential'. For most non-hormonally influenced SMTs, the presence of significant atypia plus mitotic activity equates with a diagnosis of LMS. However, not all tumours classified as LMSs have a similar prognosis, as a number of other factors, including tumour size, depth, grade and resectability, affect outcome. For example, cutaneous SMTs, regardless of mitotic activity and atypia, have potential largely limited to local recurrence, whereas subcutaneous and deep LMSs have a definite metastatic potential. Angioleiomyoma is the most common SMT of peripheral soft tissues, but deep peripheral LMs are distinctly rare and should be approached with caution. Hormonally influenced oestrogen- and progesterone receptor-positive uterine and extrauterine SMTs in women have unique criteria, including the allowance of higher mitotic activity for the benign LM designation. SMTs of female genital tract can be assessed with criteria similar to uterine tumours. Because of the rarity of these tumours, experience is more limited, and more caution is needed to assess the potential of tumours with mitotic activity and atypia. This review summarizes the current knowledge, guidelines, prognostic data and controversies for the classification of SMTs of soft tissue and most visceral sites.

Prognostic factors of myxofibrosarcomas: implications of margin status, tumor necrosis, and mitotic rate on survival

BACKGROUND

Myxofibrosarcomas (MFS) are characterized by tumor progression with increased metastases after local recurrences (LR). Few series had appropriately addressed what parameters independently affect prognosis.

METHODS

Seventy primary localized MFS were analyzed for local recurrence-free survival (LRFS), metastasis-free survival (MeFS), and disease-specific survival (DSS). Follow-up was obtained in 61 cases.

RESULTS

Thirty-eight males and 32 females had primary tumors ranging from 1.5 to 24 cm. Thirty and 40 tumors were superficial and deep, respectively, with 26 cases (38%) having positive margins. The 5-year LRFS-, MeFS-, and DSS-rates were 30%, 60%, and 73%. Positive margins (P = 0.0003) were the only inferior LRFS predictor. High grade (FNCLCC 2 and 3) was a negative factor of both MeFS (P = 0.0078) and DSS (P = 0.0174), and high stage (AJCC stage 3) was predictive of MeFS (P = 0.0470). However, both grading and staging were not prognostically independent. In multivariate analyses, mitoses >or=20/10 HPF (P = 0.0009, RR = 9.71) and positive margins (P = 0.0203, RR = 4.27) were independent adverse DSS predictor. However, tumor necrosis >or=10% (P = 0.0092, RR = 3.91) independently correlated with worse MeFS, together with mitoses >or=20/10 HPF (P = 0.0176, RR = 3.80) and positive margins (P = 0.0121, RR = 3.41).

CONCLUSIONS

Margin status and histologic property both affect the prognosis of MFS. The former correlates with improved LRFS and translates into final survival benefits.

Addicted to death: invasive cancer and the immune response to unscheduled cell death

The development of an invasive cancer involves a progressive switch from predominantly apoptotic (scheduled) to necrotic (unscheduled) tumor cell death. This switch is associated with chronic and increasing release of intracellular factors that in turn promote reactive angiogenesis and stromal proliferation and mediates the disordered tumor microenvironment associated with local immune suppression. The authors review the relevant immunobiology of these factors, including the nuclear protein HMGB1; the products of purine metabolism (uric acid, ATP, and adenosine); the S100 family members; and the heat shock proteins, which we believe drive futile cycles of cell death followed by reparative cell growth. The authors also present a novel and provocative hypothesis that suggests that most of the derangements that we associate with progression of cancer and the associated immunologic consequences can indeed be ascribed to the consequences of disordered tumor cell death rather than cell growth. Thus the fundamental defect in invasive human cancers, in the authors' view, is not one of cell growth but rather one of disordered cell death, resulting in turn in a tumor microenvironment that encourages tumor growth, progression, and local immunosuppression, a condition the authors have termed "addicted to death." This new understanding could inform and drive the development of more effective biologic therapies for patients with cancer.

[Varying characteristics of subcutaneous and dermal leiomyosarcomas. Two case reports and literature review]

Cutaneous leiomyosarcomas (LMS) originating from smooth muscle of the skin are rare malignant neoplasms. Preferential sites are hair-bearing areas, especially the legs. We report two patients in their 5th and 7th decade, in whom leiomyosarcomas were encountered in the lower leg and the capillitium, respectively. Histologically, the former was found to be a dermal leiomyosarcoma with subcutaneous infiltration, the latter an exclusively dermal tumor. The LMS of the lower leg had been excised three years previously in a different institution and had been diagnosed as a leiomyoma. Both lesions were excised with adequate safety margins in our institution and within a two-year postoperative observation period no recurrences were encountered. Dermal leiomyosarcomas have a 33% recurrence rate while that of subcutaneous leiomyosarcomas show is 50%. In contrast to exclusively dermal tumors, subcutaneous LMS show a tendency for hematogenic and lymphogenic metastases. Therapy of choice is excision with wide safety margins.

Workshop on Cancer Biometrics: Identifying Biomarkers and Surrogates of Cancer in Patients

The current excitement about molecular targeted therapies has driven much of the recent dialog in cancer diagnosis and treatment. Particularly in the biologic therapy of cancer, identifiable antigenic T-cell targets restricted by MHC molecules and the related novel stress molecules such as MICA/B and Letal allow a degree of precision previously unknown in cancer therapy. We have previously held workshops on immunologic monitoring and angiogenesis monitoring. This workshop was designed to discuss the state of the art in identification of biomarkers and surrogates of tumor in patients with cancer, with particular emphasis on assays within the blood and tumor. We distinguish this from immunologic monitoring in the sense that it is primarily a measure of the tumor burden as opposed to the immune response to it. Recommendations for intensive investigation and targeted funding to enable such strategies were developed in seven areas: genomic analysis; detection of molecular markers in peripheral blood and lymph node by tumor capture and RT-PCR; serum, plasma, and tumor proteomics; immune polymorphisms; high content screening using flow and imaging cytometry; immunohistochemistry and tissue microarrays; and assessment of immune infiltrate and necrosis in tumors. Concrete recommendations for current application and enabling further development in cancer biometrics are summarized. This will allow a more informed, rapid, and accurate assessment of novel cancer therapies.

Prognostic factors in soft tissue leiomyosarcoma of the extremities: a retrospective analysis of 42 cases

AIMS

Soft tissue leiomyosarcomas (LMS) are rare tumours which are associated with a poor prognosis. The goals of the present study were to describe the clinico-pathological and prognostic features of 42 patients affected by soft tissue LMS of the extremities.

METHODS

The following clinical and pathological parameters were analysed: age, sex, site, size, depth, previous surgical procedures, stage, histological type, nuclear atypia, grade, mitotic activity, necrosis, surgical margins, therapy. Disease-free survival rates were calculated.

RESULTS

The overall 2-year and 5-year disease free survival rates were 42.3% and 32.6%, respectively. By univariate analysis, tumour size (< or =10 cm vs. >10 cm; p = 0.01), average mitotic rate (< or =19/10 HPF vs. >19/10 HPF; p = 0.05), type of excision (wide vs. marginal or intralesional; p = 0.001) and adjuvant radiotherapy (none vs. brachytherapy+external beam radiotherapy vs. external beam radiotherapy; p = 0.02) were significantly correlated with disease progression. By multivariate analysis, the only factor that was found to be an independent predictor of disease relapse was type of excision (p = 0.001).

CONCLUSIONS

Large tumour size and high mitotic rate resulted adverse prognostic factors. Adjuvant radiation therapy, in combination with wide surgical excision, allowed the best chance of cure.

A rare case of leiomyosarcoma of the penis with a reappraisal of the literature

Primary leiomyosarcomas arising in the penis are rare, with only 29 reported cases to date. We review the published records on this entity and describe an additional case of penile leiomyosarcoma occurring in a 53-year-old patient who underwent postectomy for a firm nodule in the prepuce. Four years later he experienced local recurrence which was successfully treated with partial penectomy.

Mechanisms of inactivation of the p16INK4a gene in leiomyosarcoma of soft tissue: decreased p16 expression correlates with promoter methylation and poor prognosis

The p16INK4a tumour suppressor gene, encoding p16 protein, plays a crucial role in regulation of the G1 cell-cycle phase. To investigate the potential role of p16 in soft tissue leiomyosarcoma (LMS), an immunohistochemical analysis was performed of 77 LMSs for p16 expression. Decreased expression of the p16 protein was identified in 25 of 77 LMSs (32%). Decreased expression of p16 correlated significantly with large tumour size (p=0.0038). In a univariate analysis, large tumour size and decreased expression of p16 were statistically significant adverse prognostic factors (p=0.025 and p=0.0021, respectively). In a multivariate analysis including conventional clinicopathological parameters, decreased expression of p16 protein was revealed as the only independent unfavourable prognostic factor (p=0.012). To elucidate the mechanisms of inactivation of the p16INK4a gene, 49 LMSs for which genomic DNA was available were examined; analysis for homozygous deletion, mutation, and promoter hypermethylation was conducted using differential PCR, PCR-SSCP, and methylation-specific PCR, respectively. Promoter hypermethylation was detected in 11 of 49 LMS cases (22%); homozygous deletion was detected in 3 of 49 cases (6%); and mutation was not recognized in any of the cases studied. Eight of 15 cases (53%) with decreased expression of p16 protein revealed methylation of the p16INK4a gene promoter. Promoter hypermethylation correlated closely with decreased expression and poor prognosis (p=0.0014 and p=0.0088, respectively). These results suggest that decreased expression of p16 protein can be considered as an independent reliable prognostic parameter in patients with soft tissue LMS. Furthermore, promoter methylation was more frequent than either homozygous deletion or mutation in this tumour, and promoter methylation was also shown to have a strong association with inactivation of the p16INK4a gene.

Cytogenetic and clinicopathological analysis of soft-tissue leiomyosarcomas

To identify a characteristic cytogenetic aberration and cytogenetic-morphological correlation in soft-tissue leiomyosarcomas, a karyotypic and clinicopathological analysis of 15 cases of leiomyosarcoma was performed. The histological type was classical in nine cases, pleomorphic in three cases and myxoid in three cases. The histological grade was 1 in three cases, 2 in 10 cases and 3 in two cases. Nine of 15 tumors displayed an abnormal karyotype, whereas the other six tumors displayed a normal karyotype. The relative consistency of involvement of 3p, 3q, 6q, 7p, 7q, 9p, 10p, 11p, 11q, 12p, 16q, 17p and 19q was recognized, although characteristic chromosomal rearrangements were not detected. All six tumors that had a normal karyotype were of the classical type, whereas those displaying an abnormal karyotype contained another morphological type along with the classical type. The results of the present study suggest that chromosomal aberrations contribute to morphological changes in soft-tissue leiomyosarcomas.