The evolving classification of soft tissue tumours: an update based on the new WHO classification

Survival impact of centralization and clinical guidelines for soft tissue sarcoma (A prospective and exhaustive population-based cohort)

Purpose

The outcome of sarcoma has been suggested in retrospective and non-exhaustive studies to be better through management by a multidisciplinary team of experts and adherence to clinical practice guidelines (CPGs). The aim of this prospective and exhaustive population based study was to confirm the impact of adherence to CPGs on survival in patients with localized sarcoma.

Experimental design

Between 2005 and 2007, all evaluable adult patients with a newly diagnosis of localized sarcoma located in Rhone Alpes region (n = 634), including 472 cases of soft-tissue sarcoma (STS), were enrolled. The prognostic impact of adherence to CPGs on progression-free survival (PFS) and overall survival (OS) was assessed by multivariate Cox model in this cohort.

Results

The median age was 61 years (range 16–92). The most common subtypes were liposarcoma (n = 133, 28%), unclassified sarcoma (n = 98, 20.7%) and leiomyosarcoma (n = 69, 14.6%). In the initial management phase, from diagnosis to adjuvant treatment, the adherence to CPGs for patients with localized STS was 36% overall, corresponding to 56%, 85%, 96% and 84% for initial surgery, radiation therapy, chemotherapy and follow-up, respectively. Adherence to CPGs for surgery was the strongest independent prognostic factor of PFS, along with age, gender, grade, and tumor size. For OS, multivariate analysis adherence to CPGs for surgery was a strong independent prognostic factor, with an important interaction with a management in the regional expert centers.

Conclusions

This study demonstrates impact of CPGs and treatment within an expert center on survival for STS patients in a whole population-based cohort.

Angiomatoid fibrous histiocytoma: a series of seven cases including genetically confirmed aggressive cases and a literature review

Background

Angiomatoid fibrous histiocytoma (AFH) is a rare soft tissue tumor of intermediate biologic potential. Because of its rarity and nonspecific radiological and diverse pathological findings, AFH is often clinically misdiagnosed. However, few clinical reports have described this tumor. As reported herein, we analyzed the clinical and radiological features and clinical outcomes of AFH.

Methods

We retrospectively reviewed the medical records of seven cases histopathologically diagnosed as AFH. We examined clinical features, MRI findings, histopathological diagnoses, treatments, and outcomes.

Results

These seven cases comprised five male and two female patients with ages ranging from 8 to 50 years old. The primary locations included upper extremities in 2, lower extremities in 4, and the inguinal region in one patient. Of the tumors, 4 occurred in subcutaneous tissues and 3 occurred in deep tissues. No cases were diagnosed as AFH from MRI and needle biopsy results. All cases were diagnosed histopathologically after excision. After treatment, 2 patients (29%) had tumor recurrence and metastasis, one of whom died from disease progression. These 2 aggressive cases involved both EWSR1 and CREB1 gene rearrangements as determined by FISH. The other patients were alive and well without recurrence or metastasis.

Conclusion

AFH is a rare tumor that is difficult to diagnose. Therefore, it tends to be misdiagnosed and to be treated inadequately by referring physicians. Surgeons must therefore be mindful of the presence of AFH, learn about appropriate treatment necessary for this tumor, and conduct careful follow-up because AFH can engender poor outcomes.

Salivary gland adenoid cystic carcinoma

Malignant fibrous histiocytoma, also known as pleomorphic undifferentiated sarcoma not otherwise specified, arises in numerous organs. The first-line treatment is complete excision of the mass, but in some cases postoperative chemo- and/or radiotherapy is recommended. Only a few cases of malignant fibrous histiocytoma of the vocal fold have been previously reported in the literature. We report a new case, which originated in the true vocal fold of a 65-year-old man. The mass was removed via CO2 laser excision with preservation of the vocal fold and without the need for further treatment. At 3 years of follow-up, the patient remained recurrence-free.

Differential CT and MR imaging diagnosis between low- and high-grade malignant vascular tumors of bone

Objective

To investigate the CT and MR imaging findings and differential diagnosis of malignant vascular tumors of bone.

Materials and methods

CT and MR imaging findings of 18 patients with histopathology-proven malignant vascular tumors of bone were examined. Assessed image features included age, sex, location, CT findings, and MR imaging appearances and dynamic contrast-enhanced MR imaging.

Results

The study group comprised 18 cases, of which 7 were categorized as low-grade malignant vascular tumors (LMT), and 11 were categorized as high-grade malignant vascular tumors (HMT). Malignant vascular tumors of bone showed osteolytic lesions with heterogeneous signs and enhancement, and frequently associated with soft tissue masses and peritumorous edema. The mean age of patient was respectively 34.7 years in LMT with 3 patients younger than 20 and 49.9 years in HMT with 3 patients older than 60 years. The mean lesion diameter was 3.6 cm (range 2–7.2) in LMT with two lesions <3 cm and 7.1 cm (range 3–13) in HMT with 3 lesions greater than 10 cm. LMT showed multifocal (57.1 %) and well-defined (71.5 %) lesions with residual bone (57.1 %), peripheral sclerosis (85.7 %), and slightly hetergeneous enhancement (71.4 %), compared to those of HMT with 9.1, 45.5, 27.3, and 72.7 %, and 9.1 % respectively. Also, HMT appeared as expansive (54.5 %), ill-defined (54.5 %), macroscopic necrosis/cystic (81.8 %) or hemorrhagic (27.3 %) lesion with pathological fracture (27.3 %), and often presented with obviously hetergeneous enhancement (81.8 %), compared to those of LMT with 42.9, 28.6, 42.9, 0, 14.3 and 14.3 % respectively.

Conclusions

There are some differences in the imaging features between LMT and HMT, while unifocal/multifocal, expansive, ill-defined, necrosis/cystic, hemorrhagic features with age, lesion diameter, peripheral sclerosis, residual bone tissue, pathological fracture and slightly/obviously hetergeneous enhancement highly suggest their differential diagnosis.

Rare mimic of pedal osteomyelitis in a patient with diabetes

BACKGROUND

Diabetic foot infections are an important cause of hospitalization, health expenditure and mortality. Bone biopsy is the gold standard for diagnosing diabetic foot osteomyelitis but it is not routinely performed in most centres. Instead, a combination of history, examination, biochemical and radiological findings are used to make the diagnosis.

CASE REPORT

Here, we report a case mimicking diabetic foot osteomyelitis, where the histology was crucial in acquiring the correct diagnosis.

CONCLUSION

The absence of ulceration in cases of presumed diabetic foot osteomyelitis should raise suspicion of potential rare mimics of osteomyelitis and bone biopsy should be considered to further evaluate the underlying etiology prior to any definitive surgical management.

Treatment of orbital solitary fibrous tumour with gamma knife radiosurgery and systematic review of literature

Solitary fibrous tumours (SFTs) are relatively rare tumours that were originally thought to arise from the pleura but have thereafter been demonstrated as occurring anywhere in the body. These tumours are generally considered benign but have frequently been noted for recurrence and local invasion. Furthermore, their indolence is controversial due to increasing evidence implicating the existence of a spectrum that includes hemangiopericytoma (HPC). Stereotactic radiosurgery (SRS) has been well characterised in the treatment of benign, malignant and vascular conditions, and it appears to be a reasonable option as adjuvant or recurrent treatment for intracranial SFTs. We present in this case the first complete description of an SFT of the orbit treated by SRS as well as a systematic review of available English literature for intracranial SFTs treated by SRS. We report effective local tumour control in our case and conclude that SRS is a reasonable treatment option for recurrent SFT.

The demographic features, clinicopathologic characteristics, treatment outcome and disease-specific prognostic factors of solitary fibrous tumor: a population-based analysis

Background

Solitary fibrous tumor's (SFT) demographic features, clinicopathologic characteristics, treatment outcome and disease-specific prognostic factors were unexplored comprehensively.

Methods

SEER program was used to identify patients diagnosed with SFT from 1973 to 2012. Overall collected data were analyzed by using the SPSS 18.0.

Results

In total, 804 cases were found including 613 cases with SFT-specific mortality and 801 patients were analyzed for overall survival (OS). The 3-year disease specific survival (DSS), 5-year DSS and 10-year DSS were 73.3%, 65.7% and 53.3%. The 3-year OS, 5-year OS and 10-year OS were 71.9%, 63.3% and 47.3%. In the multivariate survival analysis, the age > 51 years (hazard ratio [HR] = 1.851 for DSS, P = 0.024 and HR = 1.652 for OS, P = 0.033; Reference [Ref] ≤ 51 years for DSS and ≤ 53 years for OS), SEER stage metastasized tumor (HR = 4.269 for DSS, P = 0.000 and HR = 2.905 for OS, P = 0.028, Ref - localized + regional tumor), pathologic grade III + IV (HR = 2.734 for DSS, P = 0.001 and HR = 2.585 for OS, P = 0.000, Ref - grade I + II) were adversely associated with DSS and OS. In addition, surgery was favorably associated with DSS (HR = 0.217, P = 0.045, Ref - surgery + radiotherapy).

Conclusions

The surgery was an independent prognostic factor for DSS. The patient's age, SEER stage and pathologic grade were SFT-specific independent prognostic indicators for DSS and OS.

Recurrent solitary fibrous tumor of lumbar spine with vertebral body involvement: imaging features and differential diagnosis with report of a case

Solitary fibrous tumors (SFTs) of the spine are exceedingly rare tumors of mesenchymal origin. Most spinal SFTs arise from the thoracic spine, followed by cervical spine, and last lumbar spine with only 6 cases reported in literature. SFTs represent a wide range of neoplasms, ranging from benign to malignant. These tumors can develop a late recurrence, even after a decade or more of initial presentation, requiring long-term follow-up. We present a case of recurrent SFT of the lumbar spine with vertebral body involvement, presenting more than a decade after initial resection. It was initially misdiagnosed as a paraganglioma. To the best of our knowledge, there have been only 3 previous cases reporting SFT with vertebral body involvement.

Predictors of residual disease after unplanned excision of soft tissue sarcomas

BACKGROUND

Unplanned excision of soft tissue sarcomas (STS) is an important quality of care issue given the morbidity related to tumor bed excision. Since not all patients harbor residual disease at the time of reexcision, we sought to determine predictors of residual STS following unplanned excision.

METHODS

We identified 76 patients from a prospective database (January 1, 2008-September 30, 2014) who received a diagnosis of primary STS following unplanned excision on the trunk or extremities. We used univariable and multivariable analyses to evaluate predictors of residual STS as the primary endpoint. We calculated the sensitivity, specificity, and accuracy of interval magnetic resonance imaging (MRI) to predict residual sarcoma at reexcision.

RESULTS

Mean age was 52 y, and 63.2% were male. 50% had fragmented unplanned excision. Among patients undergoing reexcision, residual STS was identified in 70%. On univariable analysis, MRI showing gross disease and fragmented excision were significant predictors of residual STS (odds ratio, 10.59; 95% CI, 2.14-52.49; P = 0.004 and odds ratio, 3.61; 95% CI, 1.09-11.94; P = 0.035, respectively). On multivariable analysis, tumor size predicted distant recurrence and overall survival. When we combined equivocal and positive MRI, the sensitivity and specificity of MRI for predicting residual STS were 86.7% (95% CI, 73.2%-95.0%) and 57.9% (95% CI, 33.5%-79.8%), with an overall accuracy of 78.1% (95% CI, 66.0%-87.5%).

CONCLUSIONS

About 70% of patients undergoing repeat excision after unplanned excision of STS harbor residual sarcoma. Although interval MRI and fragmented excision appear to be the most significant predictors of residual STS, the accuracy of MRI remains modest, especially given the incidence of equivocal MRI.

Primary pulmonary artery sarcoma: a close associate of pulmonary embolism-20-year observational analysis

BACKGROUND

Primary pulmonary artery sarcoma (PPAS) is a rare tumor that mimics pulmonary thromboembolism (PE). Similarities to PE can delay the diagnosis and misguide the treatment of PPAS. This study aimed to evaluate tumor characteristics and outcome predictors among those diagnosed with PPAS and misdiagnosed as PE.

METHODS

From 1991-2010, 10 PPAS cases were available from the Cleveland Clinic (CC) institutional database and another 381 cases were reported in the literature. Patient characteristics, tumor subtypes, diagnostic testing & timing, interventions and clinical outcomes were analyzed. We also noted effects of misdiagnosis as PE and clinical outcome as a result of inappropriate intervention.

RESULTS

Among 391 confirmed cases of PPAS, the mean age at diagnosis was 52±14 years; 55% were male. The median duration of symptoms prior to diagnosis was 100 [interquartile range (IQR), 30-210] days. Nearly half (47%) of PPAS were originally misdiagnosed as PE including 39% that received thrombolytic and/or anticoagulation therapy. For every doubling of time from symptom onset to diagnosis, the odds of death increased by 46% (OR: 1.46, 95% CI: 1.21-1.82; P<0.001). The odds of death (OR: 2.66, 95% CI: 1.58-4.54; P=0.0003) and occurrence of distant metastasis (OR: 2.30, 95% CI: 1.30-4.15; P=0.049) were increased among those who did not receive chemotherapy but chemotherapy did not impact local recurrence. Those with complete resection had a better survival.

CONCLUSIONS

PPAS has a radiological appearance similar to PE, which makes accurate and timely diagnosis challenging. More rapid diagnosis may lead to earlier, appropriate surgical treatment and improved outcomes, when combined with adjuvant treatment.

Head and neck sarcomas: clinical and histopathological presentation, treatment modalities, and outcomes

BACKGROUND

Sarcoma of the head and neck is a rare condition that poses significant challenges in management and often requires radical multimodality treatment.

OBJECTIVES

This study aimed to analyse current clinical presentation, evaluation, management dilemmas and oncological outcomes.

METHODS

Computer records and case notes were analysed, and 39 patients were identified. Variables were compared using Pearson's chi-square test and the log-rank test, while survival outcomes were calculated using the Kaplan-Meier method.

RESULTS

The histopathological diagnosis was Kaposi sarcoma in 20.5 per cent of cases, chondrosarcoma in 15.3 per cent and osteosarcoma in 10.2 per cent. A range of other sarcomas were diagnosed in the remaining patients. The site of disease was most commonly sinonasal, followed by the oral cavity and larynx.

CONCLUSION

Wide local excision with clear resection margins is essential to achieve local control and long-term survival. There is a need for cross-specialty collaboration in order to accrue the evidence which will be necessary to improve long-term outcomes.

Primary undifferentiated pleomorphic sarcoma of the breast in a young female: a case report

BACKGROUND

Undifferentiated pleomorphic sarcoma is a rare entity and requires extensive immunohistochemical markers to differentiate it from other tumors of the breast.

CASE PRESENTATION

We present a 29-year-old female with a left breast lump for 2 months. Initial diagnosis of malignant spindle cell tumor was done on core biopsy following which total mastectomy was done. After extensive sampling, on histology, highly pleomorphic spindle cells palisading the area of geographic necrosis with very high atypical mitosis were seen. As there was diagnostic difficulty, immunohistochemical antibody panel was used and diagnosis of undifferentiated pleomorphic sarcoma of the breast was made by exclusion.

CONCLUSIONS

Core biopsy with immunostaining is possibly superior to FNA as an initial diagnostic modality for breast masses with atypical features.

Malignant Solitary Fibrous Tumor of the Scalp

Solitary fibrous tumors are an uncommon slow growing benign neoplasm originally described as a pleural neoplasm but can also be found in the lung, mediastinum, peritoneum, or any other sites including the head and neck. Malignant solitary fibrous tumors (MSFT) are extremely rare and only few cases have been published in the literature. There have been 19 cases reported of MSFT in the head and neck, but there are no reports of MSFT located within the scalp in the English language literature. We present a case of MSFT arising in the scalp and describe our experience with the clinical presentation, surgical management, and outcome in this pathological condition.

Characterization of a Rat Subcutaneous Malignant Fibrous Histiocytoma and Its Tumor Lines, with Reference to Histiocytic Features

Malignant fibrous histiocytoma (MFH) is regarded as soft tissue-derived undifferentiated pleomorphic sarcoma, of which the histogenesis remains to be proven. To investigate the cellular characteristics, a homotransplantable tumor line (KJ) was established from a spontaneous MFH that developed in the subcutis of an aged F344 rat. KJ tumors have been produced in syngeneic rats by serial subcutaneous implantation of tissue fragments. The original and KJ tumors consisted of oval and fusiform cells arranged in interlacing bundles with fibrous stroma. Occasional giant cells with bizarre nuclei were observed. Enzyme/immunohistochemically, neoplastic cells reacted to ED1 and ED2 (antibodies specific for rat histiocytes/macrophages), and showed a positive reaction to vimentin and lysosomal enzyme markers such as acid phosphatase (ACP) and nonspecific esterase (Non-SE). Electron microscopically, neoplastic cells possessed lysosomal granules in cytoplasm. A cloned cell line (KJ-A) was isolated from a KJ tumor. KJ-A cells showed positive reactions to ED1, ED2, ACP, and Non-SE, and had cytoplasmic lysosomal granules. Tumors induced by KJ-A cells exhibited histologic and enzyme/immunohistochemical findings similar to those of KJ tumors. Lipopolysaccharide (LPS) treatment increased the number of ED1-positive cells and the expression of tumor necrosis factor-α mRNA by reverse transcription-polymerase chain reaction. Collectively, it is likely that rat MFH cells originally possess histiocyte/macrophage-like features that may be enhanced by LPS. Because tumor lines are useful for in vivo and in vitro studies concerning different characteristics of the original neoplasms. KJ and KJ-A should prove useful for studies concerning the morphogenesis of MFH.

Solitary Fibrous Tumor/Hemangiopericytoma Dichotomy Revisited: A Restless Family of Neoplasms in the CNS

Solitary fibrous tumor (SFT) and hemangiopericytoma (HPC) both entered the literature as separate entities in the early to mid 1900s. In contrast to their central nervous system (CNS) counterparts, there has been a tendency to consider these 2 entities as 1 since the early 1990s, as soft tissue SFT gradually included the tumors previously diagnosed as HPC. The most recent World Health Organization (WHO) classification of the tumors of soft tissue considered the term HPC obsolete, and places all such tumors within the extrapleural SFT category. In contrast, CNS SFT and HPC continue to be regarded as different entities in the latest version of the WHO CNS tumor classification. A change in this approach is currently being considered for the upcoming revision of the WHO scheme, but it is not quite clear whether such a change will be as drastic as the one adopted by the soft tissue and bone tumor working group. This article focuses on the historical evolution of these 2 labels as primary CNS neoplasms, and reviews their differences and similarities in terms of clinical, pathologic, and molecular features.

Giant Solitary Fibrous Tumor of Orbit

Solitary fibrous tumors (SFTs) have been reported in various locations in the body. Solitary fibrous tumors are extremely rare tumors, especially when located in the orbit. Diagnosis of SFT cannot be made based on histopathology only because it exhibits a variable microscopic appearance, and necessitates immunohistochemistry to confirm the diagnosis. A 51-year-old man was admitted to our clinic for the evaluation of a mass bulging in his left eye. Clinical examination revealed a painless mass extruding out of the orbital cavity with dimensions of 8 × 7  cm. Exenteration of the left eye including the upper and lower eyelid and reconstruction of the orbital cavity using a temporoparietal fascia flap and a temporal muscle flap was performed. SFT of orbital region is known as a slow growing and painless tumor. Based on previous studies, increased mitotic rate of the tumor gives the impression that the tumor has a malignant nature. Until now a small number or orbital SFTs were reported and none of them presented with a giant mass protruding out of the orbital cavity. We present a unique case of orbital SFT filling the whole orbital cavity and protruding outward as a giant mass. This case has been reported to expand our knowledge in this debated entity.

Diffusion-weighted magnetic resonance imaging for the initial characterization of non-fatty soft tissue tumors: correlation between T2 signal intensity and ADC values

OBJECTIVE

To evaluate the performance of quantitative diffusion-weighted imaging (DWI) correlated with T2 signal in differentiating non-fatty benign from malignant tumors.

MATERIAL AND METHODS

A total of 76 patients with a histologically confirmed non-fatty soft tissue tumors (46 benign and 30 malignant) were prospectively included in this ethics committee approved study. All patients signed an informed consent and underwent MRI with DWI with two b values (0 and 600). ADC values from the solid components of these tumors were obtained and were correlated with the lesion's signal intensity on T2-weighted fat-saturated sequences. ADC values were obtained from adjacent normal muscle to allow calculation of tumor/muscle ADC ratios.

RESULTS

There were 58 hyperintense and 18 iso or hypointense lesions. All hypointense lesions were benign. The mean ADC values for benign and malignant tumors were 1.47 ± 0.54 × 10(-3) and 1.17 ± 0.38 × 10(-3) mm(2)/s respectively (p < 0.005). The mean ADC ratio in benign iso or hypointense tumors was significantly lower than that of hyperintense ones (0.76 ± 0.21 versus 1.58 ± 0.82 - p < 0.0001). An ADC ratio lower than 0.915 was highly specific for malignancy (96.4 %), whereas an ADC ratio higher than 1.32 was highly sensitive for benign lesions (90 %).

CONCLUSION

ADC analysis can be useful in the initial characterization of T2 hyperintense non-fatty soft tissue masses, although this technique alone is not likely to change patient management.

Transsphincteric tumor resection in case of a pararectal solitary fibrous tumor

Transsphincteric resection of rectal tumors was first described about 120 years ago. Nowadays, this approach faded into obscurity due to standardized guidelines and practice in surgical oncology including lymphadenectomy, mesorectal excision and radical dissection of veins. However, transsphincteric resection seems reasonable in some cases, especially if an abdominal approach can be avoided. In the following, we will present and describe the technique of the transsphincteric approach with its variations in rectal surgery in the case of a rare pararectal tumor.

Assessing the role of ¹⁸F-FDG PET and ¹⁸F-FDG PET/CT in the diagnosis of soft tissue musculoskeletal malignancies: a systematic review and meta-analysis

PURPOSE

Twelve years ago a meta-analysis evaluated the diagnostic performance of (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in assessing musculoskeletal soft tissue lesions (MsSTL). Currently, PET/CT has substituted PET imaging; however, there has not been any published meta-analysis on the use of PET/CT or a comparison of PET/CT with PET in the diagnosis of MsSTL. Therefore, we conducted a meta-analysis to identify the current diagnostic performance of (18)F-FDG PET/CT and determine if there is added value when compared to PET.

METHODS

A systematic review of English articles was conducted, and MEDLINE PubMed, the Cochrane Library, and Embase were searched from 1996 to March 2015. Studies exploring the diagnostic accuracy of (18)F-FDG PET/CT (or dedicated PET) compared to histopathology in patients with MsSTL undergoing investigation for malignancy were included.

RESULTS

Our meta-analysis included 14 articles composed of 755 patients with 757 soft tissue lesions. There were 451 (60 %) malignant tumors and 306 benign lesions. The (18)F-FDG PET/CT (and dedicated PET) mean sensitivity, specificity, accuracy, positive predictive value, and negative predictive value for diagnosing MsSTL were 0.96 (0.90, 1.00), 0.77 (0.67, 0.86), 0.88 (0.85, 0.91), 0.86 (0.78, 0.94), and 0.91 (0.83, 0.99), respectively. The posterior mean (95 % highest posterior density interval) for the AUC was 0.92 (0.88, 0.96). PET/CT had higher specificity, accuracy, and positive predictive value when compared to a dedicated PET (0.85, 0.89, and 0.91 vs 0.71, 0.85, and 0.82, respectively).

CONCLUSION

(18)F-FDG PET/CT and dedicated PET are both highly accurate in the diagnosis of MsSTL. PET/CT is more accurate and specific and has a higher positive predictive value than PET.

Benign nerve tumours of the hand (excluding wrist)

INTRODUCTION

Hand tumours of neural origin are rare in clinical practice. The aim of this work is to present our experience in operative treatment of benign nerve tumours located in the hand. Special emphasis has been put on determining the occurrence rates of particular tumour types characterized by their unique histopathological patterns and describing detailed location of the lesions. The obtained results of treatment were assessed.

MATERIALS AND METHODS

The study comprised of 26 patients, both female (19) and male (7). The mean age and age range of the female and male patients were 44.8 years (range, 21-73 years) and 39.6 years (range, 21-74 years), respectively. The patients underwent operative treatment for tumours of neurogenic origin located in the hand between the years 1990 and 2013. In total, 31 tumours in 26 patients were removed. The most common site of tumour origin was small cutaneous branches and only exceptionally the tumours arose from common digital nerves (2 patients). No patient was lost to postoperative follow-up. The shortest period of postoperative follow-up covered 1 year.

RESULTS

No tumour recurrence was detected during postoperative follow-up examinations. The patients reported neither pain nor presence of paraesthesias. Neurofibromas (17 tumours) predominated in the gathered clinical material, while the second most common group of tumours were schwannomas (12 tumours).

CONCLUSIONS

(1) Benign nerve tumours of the hand are rare. Neurofibromas and schwannomas predominate among them. Tumours having other histopathological patterns are extremely uncommon. (2) The prognosis after resection of benign nerve tumours located in the hand is good and the risk of postoperative complications and recurrence is low.

Solitary Fibrous Tumor of the Lower Leg: A Rare and Difficult Diagnosis

Solitary fibrous tumor (SFT) is a rare neoplasm that commonly originates in the pleura. Extrapleural locations are rare and for this reason sometimes difficult to diagnose. Malignant forms with local recurrence or distant metastases have been reported, also as a consequence of inappropriate treatment. In this article, we report the case of an SFT of the lower leg in a 37-year-old man. Leg SFT is a rare occurrence, and differential diagnosis may be difficult because they can mimic a variety of benign and malignant mesenchymal tumors; immunohistochemical analysis for CD34, CD99, vimentin, and Bcl-2 is necessary. Misdiagnosis carries a significant risk of inadequate removal with subsequent increased risk of recurrence and distant metastases.

Evaluation of prognostic factors in localized high-grade undifferentiated pleomorphic sarcoma: report of a multi-institutional experience of Anatolian Society of Medical Oncology

Most data on prognostic factors for patients with high-grade undifferentiated pleomorphic sarcoma (HGUPS) is obtained from analyses of soft tissue sarcomas. The purpose of this study was to evaluate the clinicopathologic features and their impact on outcomes specifically in patients diagnosed with HGUPS. In this multicenter trial, we retrospectively analyzed 112 patients who were diagnosed and treated at 12 different institutions in Turkey. We collected data concerning the patients, tumor characteristics, and treatment modalities. There were 69 males (61.6 %) and 43 females (38.4 %). Median age was 56 years (19-90). The most common anatomic site of tumor origin was the upper extremity. Pleomorphic variant was the predominant histological subtype. Median tumor size was 8.2 cm (0.6-30 cm). Tumors were mainly deeply seated (57.1 %). Fifty-seven patients (50.9 %) were stage II and the remainder were stage III at the time of diagnosis. Median follow-up was 30 months (2-160). The primary site of distant metastasis was the lung (73.5 %) and the second most common site was the liver (11.7 %). The 5-year overall survival, distant metastasis-free survival, and local recurrence-free survival rates were 56.3, 53.4, and 67.2 %, respectively. Multivariate analysis showed that Eastern Cooperative Oncology Group (ECOG) performance score of II (p = 0.033), deep tumor location (p = 0.000), and development of distant metastasis (p = 0.004) were negatively correlated with overall survival, and perioperative radiotherapy and negative microscopic margins were significant factors for local control rates (p = 0.000 for each). Deep tumor location (p = 0.003) was the only adverse factor related to distant metastasis-free survival. Deep tumor location, ECOG performance score of II, and development of distant metastasis carry a poor prognostic implication on overall survival. These will aid clinicians in predicting survival and treatment decision.

Angiogenesis, cell differentiation and cell survival in tissue engineering and cancer research

Recent medical advances lead to a growing demand for tissue engineering and regenerative medicine in the future. Tissue engineering and regenerative medicine aim to create substitute tissue or restore lost or impaired tissue by combining biological science with engineering techniques, whereas cancer research faces the challenge to identify and hinder aberrant and uncontrolled cell growth.

These two seemingly opposing fields of research share fundamental communalities.

This review focuses on the shared underlying biological processes. Exploring these mechanisms of tissue growth and homeostasis from different angles will allow for creative novel approaches for both areas of research.

A large retroperitoneal malignant solitary fibrous tumor

We report on a large, retroperitoneal, malignant, solitary fibrous tumor (SFT) with high proliferation activity. A 43-year-old man was admitted to our department complaining of a palpable mass. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a large retroperitoneal tumor occupying the entire abdominal cavity. A laparotomy was performed for diagnosis and treatment, which revealed a tumor in the retroperitoneum but with no invasion to the surrounding organs, thereby allowing safe macroscopic excision. Histologically, the tumor was composed of spindle-shaped cells with patternless pattern and a hemangiopericytomatous appearance. Moreover, immunohistochemical staining was positive for CD34, vimentin, Bcl-2, and CD99 and negative for desmin, S-100p, and smooth muscle actin (AMA). The tumor exhibited high cellularity, moderate mitotic activity, pleomorphism, necrosis, and hemorrhagic changes. In addition, the Ki-67 labeling index was 37%. These findings confirmed the diagnosis of malignant SFT with high proliferation activity. Subsequently, adjuvant doxorubicin plus ifosfamide chemotherapy was performed. No signs of recurrence were observed 12 months after the surgery.

Elevated expression of HSP90 and the antitumor effect of an HSP90 inhibitor via inactivation of the Akt/mTOR pathway in undifferentiated pleomorphic sarcoma

BACKGROUND

Undifferentiated pleomorphic sarcoma (UPS) is a heterogeneous tumor group, and little is known about molecular target therapy for UPS. Heat shock protein 90 (HSP90) is an expressed chaperone that refolds certain denatured proteins under stress conditions. One of these proteins is Akt. The disruption of Akt signaling plays an important role in tumor progression. The present study's purpose was to analyze the HSP90 expression, Akt/mTOR pathway activation and the correlation between HSP90 expression and its pathway activation in UPS.

METHODS

The status of HSP90 and the profiles of the Akt/ mTOR pathway were assessed by immunohistochemistry in 79 samples of UPS, and these data were compared with clinicopathological and histopathological findings. The expressions of indicated proteins were assessed by Western blotting in five frozen samples. After treating UPS cells with the HSP90 inhibitor, we assessed the antitumor effect of the inhibitor.

RESULTS

Immunohistochemically, phosphorylated Akt (p-Akt), p-mTOR, p-S6RP and p-4EBP were positive in 57.3, 51.9, 54.5 and 57.1% of the UPS samples, respectively. The expressions of those phosphorylated proteins were correlated with each other. HSP90 expression was elevated in 56.4% of the samples and was correlated with p-Akt, p-mTOR and p-S6RP. The immunohistochemical results were confirmed by Western blotting. The HSP90 inhibitor led to decreased viability and invasiveness of the cells and inactivated the AKT/mTOR pathway in vitro.

CONCLUSION

Elevated expression of HSP90 is a poor-prognosis factor and is involved in the activation of the Akt/mTOR pathway in UPS. HSP90 inhibition is a potential treatment option for UPS.

Ocular Inflammatory Myofibroblastic Tumor in the Left Eye with Phthisis Right Eye: A Rare Occurrence in a Child

Inflammatory myofibroblastic tumor (IMT) is a benign pseudoneoplastic inflammatory condition with the potential for persistent local growth and recurrence that rarely affects the orbit. We report a very rare case of anterior orbital IMT in a child who presented with gradually progressive mass in left eye for 16 months. Ocular examination showed a cauliflower like exophytic mass at 360 degrees of the perilimbal area covering the entire cornea and obscuring the visualization of anterior and posterior segments. The right eye was phthisical. CT scan showed a lobulated exophytic soft tissue mass in the preseptal region and along the anterior portion of the left globe extending from medial canthus to the lateral canthus. Enucleation of the left eye was performed and the histopathological examination confirmed the diagnosis of IMT. This report aims to raise awareness about this rare ocular entity and emphasizes its early treatment as delay can result in loss of the eye.

Clinical, pathological and unusual MRI features of five synovial sarcomas in head and neck

Objective:

Synovial sarcoma (SS) of the head and neck is an unusual malignancy. This article documents five SSs in this region.

Methods:

All the patients underwent MR examinations. Four lesions received surgical ablation; one was treated with radiotherapy before surgery. The clinical, pathological and MRI features were reviewed.

Results:

Four of all five cases were monophasic fibrous-type SS, and the other one was biphasic type that was the fourth documented SS located in the nasopharynx. The symptoms were varied. All the masses were well defined, mainly homogeneous and solid; three of them arose adjacent to the minor joint. The mass parenchyma showed isointense signal on T₁ weighted imaging similar to that of the skeletal muscle and hyperintense signal on T₂ weighted imaging with remarkable enhancement. Two cases were found with fibrous septum, one with haemorrhage and one with cystic degeneration. Epithelial membrane antigens (EMAs) were all positive. The positive rate of cytokeratin (CK), part pan-CK antibody (AE1/3) and vimentin (Vim) were 50%, 75%, 75%, respectively.

Conclusion:

Well-defined head and neck masses frequently arise adjacent to the minor joint, which are mainly homogeneous and solid, with isointense signal on T₁ weighted MRI and hyperintense signal on T₂ weighted MRI, and remarkable enhancement should evoke the diagnosis of SS. The positive staining of Vim\AE1/3\EMA and CK facilitates the final diagnosis.

Advances in knowledge:

The article documents the fourth SS involving the nasopharynx; other locations were also uncommon; three of them arose adjacent to the minor joint. The clinical, pathology and uncommon MR features of SS in the head and neck are also documented.

Topotecan plus cyclophosphamide in adults with relapsed or refractory pediatric-type sarcoma: a retrospective analysis from the German Sarcoma Medical Oncology Group (AIO)

BACKGROUND

To assess the efficacy and safety of topotecan and cyclophosphamide (TC) in adult patients with pediatric-type sarcoma subtypes who failed induction chemotherapy.

PATIENTS AND METHODS

Patients with pediatric sarcoma subtypes, refractory to or relapsed after at least one prior induction chemotherapy, inoperable, ECOG PS 0-2, with measurable, progressive disease (PD), adequate organ functions, who have been treated with TC combination were retrospectively analysed within the AIO and SAREZ/BMBF network.

RESULTS

Thirty-nine patients, median age 28 years (18-58), 14 females, 25 males, have been identified. All patients had received induction treatment according to (inter)national study protocols. Second-line TC was applied in 33 patients (≥3rd-line in 6 patients). Twenty-three patients had refractory disease (evidence of PD during induction chemotherapy); 8 patients experienced an early relapse within 6 months as well as 8 patients after more than 24 months (late relapse). A median of 3 cycles (range, 1-6) had been applied and antitumor activity was: CR 2.6 %, PR 7.9 %, and disease stabilisation (SD) 26.3 %. PR lasted 32.8 months and median duration in patients with SD was 5 months (range, 2.0-14.7). The 3/6-months progression-free rates were 43.2 and 18.9 %.

CONCLUSIONS

Limited activity was seen in adult pts with refractory or relapsed pediatric-type sarcomas with the regimen which has proven activity in pediatric patients. Adults with refractory small cell sarcoma appear to have a similar dismal outcome as seen in pts with common adult-type histologies; however, a subset of patients has achieved long-lasting remissions on TC resulting in long-term survival.

Lipomatous hemangiopericytoma in a child: A case report with immunohistochemical evaluation

Lipomatous hemangiopericytomas are rare soft-tissue tumors that show areas of hemangiopericytoma like vascular pattern admixed with lipid containing cells. It is now considered a subtype of solitary fibrous tumor due to histopathological and immunohistochemical similarities. To date, only a few cases have been adequately reported in the medical literature. A case of lipomatous hemangiopericytoma in an 11-year-old female patient is presented and the clinical, histopathological and immunohistochemical features are discussed, along with a literature review. To the best of our knowledge, this is the first known case of a lipomatous hemangiopericytoma in a pediatric patient. Our case report further emphasizes that a number of studies should be evaluated to delineate hemangiopericytomas from solitary fibrous tumors.

Cutaneous Metastatic Undifferentiated Pleomorphic Sarcoma from a Mediastinal Sarcoma

Undifferentiated pleomorphic sarcoma, known as malignant fibrous histiocytoma, is a malignant neoplasm that arises in both soft tissue and bones. In 2002, the World Health Organization declassified malignant fibrous histocytoma as a formal diagnostic entity and renamed it 'undifferentiated pleomorphic sarcoma not otherwise specified.' It most commonly occurs in the lower extremities and rarely metastasizes cutaneously. We report a case of cutaneous metastatic undifferentiated pleomorphic sarcoma of the buttocks occurring in a 73-year-old man diagnosed with mediastinal sarcoma 4 years previously. He first noticed the mass approximately 2 months previously. Histological findings with immunomarkers led to a final diagnosis of cutaneous metastatic sarcoma from mediastinal undifferentiated pleomorphic sarcoma.

Malignant fibrous histiocytoma of maxillary sinus- a diagnostic challenge

Malignant fibrous histiocytoma (MFH) is a malignant mesenchymal tumor uncommonly seen in head and neck region and even rarer in maxillary sinus with less than thirty cases reported in literature. Microscopic diagnosis at this rare site may be challenging because of the spectrum of features, which frequently overlap with other benign and malignant tumors. We herein report a case of malignant fibrous histiocytoma of the maxillary sinus in a 40-year-old man who presented with epistaxis. The initial biopsy appeared benign whereas histopathology of wide surgical excision was consistent with MFH. In view of the deep location, the diagnosis may be missed on a small biopsy, which can appear deceptive leading to diagnostic errors. This case report highlights the histopathological difficulties and pitfalls of this tumor at this rare site.

Primary and secondary bone lymphomas

Recent studies have contributed to the enhancement of clinical and molecular knowledge on bone lymphomas, a group of rare malignancies with particular characteristics. Nevertheless, several questions remain unanswered and the level of evidence supporting some diagnostic and therapeutic decisions remains low. Currently, three different forms of bone lymphomas can be distinguished: the primary bone lymphoma, consisting of a single bone lesion with or without regional lymphadenopathies; the polyostotic lymphoma, consisting of multifocal disease exclusively involving the skeleton; and the disseminated lymphoma with secondary infiltration of the skeleton. The first two forms exhibit a good prognosis, requiring treatments similar to those commonly used for nodal lymphomas of the same category, but several issues regarding the role of surgery and local control of the disease, the sequence of treatment, radiation volumes and doses, management of pathological fractures and prevention of late sequelae deserve particular attention. Due to its rarity, prospective trials exclusively focused on bone lymphomas appear unrealistic, thus, critical revision of our own experience and analyses of large cumulative series as well as molecular studies on archival cases remain valid alternatives to improve our knowledge on this obscure lymphoproliferative malignancy. The present review is based on the analysis of the largest available database of bone lymphomas established under the sponsorship of the International Extranodal Lymphoma Study Group (IELSG) as well as on the critical revision of related literature. We provide recommendations for diagnosis, staging, treatment, and response assessment of these patients in everyday practice as well as for the management of special conditions like pathological fractures, indolent forms and central nervous system prophylaxis.

Dermatofibrosarcoma protuberans, a rare but locally aggressive tumor on finger: clinical and aeromedical considerations

Dermatofibrosarcoma protuberans (DFSP) is a rare, slow growing, locally infiltrative tumor of intermediate malignancy. It is mostly found on the trunk and head, rarely on hands. The course of evaluation and treatment of a young pilot with DFSP on left middle finger is reported. The clinical issues and aeromedical considerations of this rare tumor is discussed.

A rare case of malignant fibrous histiocytoma/ pleomorphic undifferentiated sarcoma of the kidney

Malignant Fibrous Histiocytoma (MFH) usually arises from the extremities with the retroperitoneum being the second most common site. We present the case report of a 58-year-old man presenting with fever and was detected to have a renal mass on evaluation. He underwent a radical nephrectomy with a preoperative diagnosis of renal cell carcinoma. But the final histopathological report was MFH. Primary renal MFH is extremely rare and is usually diagnosed on histopathology with the aid of immunohistochemistry.

Malignant fibrous histiocytoma of visceral organs: clinicopathologic features and diagnostic value of ezrin and HMG-CoA reductase

Malignant fibrous histiocytoma (MFH) of the breast and visceral organs is extremely rare. There is an incomplete understanding of the clinical pathology of the primary MFH originating from the breast and visceral organs, especially in comparison with other soft tissue sarcomas. As a consequence we searched and analyzed the clinical and pathological records of all the nine patients with diagnosed breast and visceral MFH in our hospital. Immunohistochemical staining was performed for ezrin and HMG-CoA reductase in these MFH cases and relevant mesenchymal sarcomas. The 9 MFH cases presented with nonspecific symptoms and imaging manifestations. 6 cases were classified as storiform-pleomorphic MFH, 2 cases as inflammatory MFH, and the remaining 1 case as giant cell MFH. The results showed that ezrin expression, as well as HMG-CoA reductase expression, was significantly stronger in MFH cases than other non-MFH sarcomas. Poor prognosis seemed to be associated with younger age. Certain characteristics and clinicopathologic features can help us making the diagnosis of MFH. In conclusion, our study provided the potential value of ezrin and HMG-CoA reductase for diagnosis and differential diagnosis of MFH located in the breast and visceral organs. More accurate prognostic information of this rare disease needed to be further investigated.

Towards the lean lab: the industry challenge

In anatomic pathology, the current state encompassing the pre-analytic processes of tissue collection, handling, examination, preparation, processing, and storage are largely uncontrolled, inconsistently performed, and/or not standardized according to the sound scientific data. Pre-analytic defects result in nearly three-quarters of the problems in laboratory diagnostics. This is evident in quality surveys from well-respected institutions that document high miss rates in the required basics of information related to patient and tissue identity, let alone parameters documenting quality aspects related to the surgical specimen and its preservation. This talk will describe the historical approach to tissue processing and identify gaps from worldwide observations in current laboratory practices. It will also offer potential methodological and technological solutions and process improvements that laboratories may consider in serving the ultimate users of pathology information: the clinician and the patient. It illustrates the need for scientifically validated specimen guidelines and a performance based, standardized and documented "chain of custody" of the pre-analytical steps from the patient's body through fixation. For thought leaders and professional standard setters, opportunities for optimizing molecular studies exist in specimen collection, transfer, grossing, fixation, and decalcification protocols. In this evolving era of molecular profiling and personalized therapeutic decision-making, a well-reasoned and coordinated focus on pre-analytic processes that optimizes specimens for subsequent testing will result in: Improved specimen quality for molecular testing Improved accuracy of diagnostic and molecular test results Reduced Turnaroundtimes for same-day diagnosis Enhanced satisfaction of clinicians and patients.

Incidence of soft tissue sarcomas in an Italian area affected by illegal waste dumping sites

The aim of the present study was to investigate the possible association between occurrence of soft tissue sarcomas (STS) and residence in an Italian area affected by illegal practices of dumping and setting fire to both hazardous and solid urban wastes. Standardized incidence ratios (SIRs) were computed separately for STS and some specific STS subtypes. The analysis was performed for the total population and for specific age groups, namely, children, adolescents, and adults. In adults, no significant increase in STS was found other than for gastrointestinal stromal tumors in males. A nonsignificant increase in incidence of STS was observed for male children and female adolescents. The results of the present study do not allow conclusions for a causal association. In the absence of previous epidemiological studies on this issue, further investigations are needed.